|
Ped Combo Pad
|
Facility
|
IP
|
$55.00
|
|
| Hospital Charge Code |
3040334
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$50.60 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
Pediasure
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS B4160
|
| Hospital Charge Code |
3031448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.88
|
| Rate for Payer: Aetna Managed Medicare |
$2.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.48
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$5.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4.80
|
| Rate for Payer: The Alliance Commercial |
$32.00
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$5.93
|
|
|
Pediasure
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS B4160
|
| Hospital Charge Code |
3031448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$4.80
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$5.93
|
|
|
Pediatric airway stabilization collar - Endotracheal Tube Status
|
Facility
|
IP
|
$1,291.00
|
|
|
Service Code
|
HCPCS L0174
|
| Hospital Charge Code |
3025910
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$632.59 |
| Max. Negotiated Rate |
$1,187.72 |
| Rate for Payer: Aetna Commercial |
$1,161.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,110.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$684.23
|
| Rate for Payer: Cash Price |
$387.30
|
| Rate for Payer: Cigna Commercial |
$1,187.72
|
| Rate for Payer: Health EOS Commercial |
$1,148.99
|
| Rate for Payer: HFN Commercial |
$1,187.72
|
| Rate for Payer: Multiplan Commercial |
$1,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$774.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,187.72
|
| Rate for Payer: Quartz Beloit One Network |
$632.59
|
| Rate for Payer: Quartz Commercial |
$774.60
|
| Rate for Payer: WEA Trust Commercial |
$710.05
|
| Rate for Payer: WPS Commercial |
$956.24
|
|
|
Pediatric airway stabilization collar - Endotracheal Tube Status
|
Facility
|
OP
|
$1,291.00
|
|
|
Service Code
|
HCPCS L0174
|
| Hospital Charge Code |
3025910
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$206.13 |
| Max. Negotiated Rate |
$5,164.00 |
| Rate for Payer: Aetna Commercial |
$1,161.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,110.26
|
| Rate for Payer: Aetna Managed Medicare |
$361.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$206.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$206.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$206.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$684.23
|
| Rate for Payer: Cash Price |
$387.30
|
| Rate for Payer: Cash Price |
$387.30
|
| Rate for Payer: Cigna Commercial |
$1,187.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$722.44
|
| Rate for Payer: Health EOS Commercial |
$1,148.99
|
| Rate for Payer: HFN Commercial |
$1,187.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$968.25
|
| Rate for Payer: Multiplan Commercial |
$1,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$774.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,187.72
|
| Rate for Payer: Quartz Beloit One Network |
$632.59
|
| Rate for Payer: Quartz Commercial |
$839.15
|
| Rate for Payer: Quartz Medicare Advantage |
$774.60
|
| Rate for Payer: The Alliance Commercial |
$5,164.00
|
| Rate for Payer: WEA Trust Commercial |
$710.05
|
| Rate for Payer: WPS Commercial |
$956.24
|
|
|
Pediatric Cannuals
|
Facility
|
IP
|
$9.00
|
|
| Hospital Charge Code |
3040336
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$8.28 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.77
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: Health EOS Commercial |
$8.01
|
| Rate for Payer: HFN Commercial |
$8.28
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: NAPHCARE Commercial |
$5.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8.28
|
| Rate for Payer: Quartz Beloit One Network |
$4.41
|
| Rate for Payer: Quartz Commercial |
$5.40
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$6.67
|
|
|
Pediatric Cannuals
|
Facility
|
OP
|
$9.00
|
|
| Hospital Charge Code |
3040336
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Aetna Managed Medicare |
$2.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.77
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.04
|
| Rate for Payer: Health EOS Commercial |
$8.01
|
| Rate for Payer: HFN Commercial |
$8.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.75
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: NAPHCARE Commercial |
$5.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8.28
|
| Rate for Payer: Quartz Beloit One Network |
$4.41
|
| Rate for Payer: Quartz Commercial |
$5.85
|
| Rate for Payer: Quartz Medicare Advantage |
$5.40
|
| Rate for Payer: The Alliance Commercial |
$36.00
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$6.67
|
|
|
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
|
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
|
|
|
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
|
|
|
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
|
|
