|
PROSTATOLITHOTOMY
|
Facility
|
OP
|
$7,912.00
|
|
| Hospital Charge Code |
2960324
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,215.36 |
| Max. Negotiated Rate |
$31,648.00 |
| Rate for Payer: Aetna Commercial |
$7,120.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,804.32
|
| Rate for Payer: Aetna Managed Medicare |
$2,215.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,142.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,956.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,797.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,193.36
|
| Rate for Payer: Cash Price |
$2,373.60
|
| Rate for Payer: Cigna Commercial |
$7,279.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,427.56
|
| Rate for Payer: Health EOS Commercial |
$7,041.68
|
| Rate for Payer: HFN Commercial |
$7,279.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,934.00
|
| Rate for Payer: Multiplan Commercial |
$6,329.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,747.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,279.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,876.88
|
| Rate for Payer: Quartz Commercial |
$5,142.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,747.20
|
| Rate for Payer: The Alliance Commercial |
$31,648.00
|
| Rate for Payer: WEA Trust Commercial |
$4,351.60
|
| Rate for Payer: WPS Commercial |
$5,860.42
|
|
|
PROSTHESIS 20fr 14mm #IN2014IR
|
Facility
|
OP
|
$2,891.00
|
|
| Hospital Charge Code |
2973278
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$809.48 |
| Max. Negotiated Rate |
$11,564.00 |
| Rate for Payer: Aetna Commercial |
$2,601.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,486.26
|
| Rate for Payer: Aetna Managed Medicare |
$809.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,879.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,445.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,387.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,532.23
|
| Rate for Payer: Cash Price |
$867.30
|
| Rate for Payer: Cigna Commercial |
$2,659.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,617.80
|
| Rate for Payer: Health EOS Commercial |
$2,572.99
|
| Rate for Payer: HFN Commercial |
$2,659.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,168.25
|
| Rate for Payer: Multiplan Commercial |
$2,312.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,734.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,659.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,416.59
|
| Rate for Payer: Quartz Commercial |
$1,879.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,734.60
|
| Rate for Payer: The Alliance Commercial |
$11,564.00
|
| Rate for Payer: WEA Trust Commercial |
$1,590.05
|
| Rate for Payer: WPS Commercial |
$2,141.36
|
|
|
PROSTHESIS 20fr 14mm #IN2014IR
|
Facility
|
IP
|
$2,891.00
|
|
| Hospital Charge Code |
2973278
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,416.59 |
| Max. Negotiated Rate |
$2,659.72 |
| Rate for Payer: Aetna Commercial |
$2,601.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,486.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,532.23
|
| Rate for Payer: Cash Price |
$867.30
|
| Rate for Payer: Cigna Commercial |
$2,659.72
|
| Rate for Payer: Health EOS Commercial |
$2,572.99
|
| Rate for Payer: HFN Commercial |
$2,659.72
|
| Rate for Payer: Multiplan Commercial |
$2,312.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,734.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,659.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,416.59
|
| Rate for Payer: Quartz Commercial |
$1,734.60
|
| Rate for Payer: WEA Trust Commercial |
$1,590.05
|
| Rate for Payer: WPS Commercial |
$2,141.36
|
|
|
PROSTHESIS EAR 0.25M x 10MM
|
Facility
|
IP
|
$5,088.00
|
|
| Hospital Charge Code |
2965321
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,493.12 |
| Max. Negotiated Rate |
$4,680.96 |
| Rate for Payer: Aetna Commercial |
$4,579.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,375.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,696.64
|
| Rate for Payer: Cash Price |
$1,526.40
|
| Rate for Payer: Cigna Commercial |
$4,680.96
|
| Rate for Payer: Health EOS Commercial |
$4,528.32
|
| Rate for Payer: HFN Commercial |
$4,680.96
|
| Rate for Payer: Multiplan Commercial |
$4,070.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,052.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,680.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,493.12
|
| Rate for Payer: Quartz Commercial |
$3,052.80
|
| Rate for Payer: WEA Trust Commercial |
$2,798.40
|
| Rate for Payer: WPS Commercial |
$3,768.68
|
|
|
PROSTHESIS EAR 0.25M x 10MM
|
Facility
|
OP
|
$5,088.00
|
|
| Hospital Charge Code |
2965321
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,424.64 |
| Max. Negotiated Rate |
$20,352.00 |
| Rate for Payer: Aetna Commercial |
$4,579.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,375.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,424.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,307.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,544.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,442.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,696.64
|
| Rate for Payer: Cash Price |
$1,526.40
|
| Rate for Payer: Cigna Commercial |
$4,680.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,847.24
|
| Rate for Payer: Health EOS Commercial |
$4,528.32
|
| Rate for Payer: HFN Commercial |
$4,680.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,816.00
|
| Rate for Payer: Multiplan Commercial |
$4,070.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,052.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,680.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,493.12
|
| Rate for Payer: Quartz Commercial |
$3,307.20
|
| Rate for Payer: Quartz Medicare Advantage |
$3,052.80
|
| Rate for Payer: The Alliance Commercial |
$20,352.00
|
| Rate for Payer: WEA Trust Commercial |
$2,798.40
|
| Rate for Payer: WPS Commercial |
$3,768.68
|
|
|
PROSTHESIS EAR LIPPY
|
Facility
|
IP
|
$2,490.00
|
|
| Hospital Charge Code |
2965335
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,220.10 |
| Max. Negotiated Rate |
$2,290.80 |
| Rate for Payer: Aetna Commercial |
$2,241.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,141.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,319.70
|
| Rate for Payer: Cash Price |
$747.00
|
| Rate for Payer: Cigna Commercial |
$2,290.80
|
| Rate for Payer: Health EOS Commercial |
$2,216.10
|
| Rate for Payer: HFN Commercial |
$2,290.80
|
| Rate for Payer: Multiplan Commercial |
$1,992.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,494.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,290.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,220.10
|
| Rate for Payer: Quartz Commercial |
$1,494.00
|
| Rate for Payer: WEA Trust Commercial |
$1,369.50
|
| Rate for Payer: WPS Commercial |
$1,844.34
|
|
|
PROSTHESIS EAR LIPPY
|
Facility
|
OP
|
$2,490.00
|
|
| Hospital Charge Code |
2965335
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$697.20 |
| Max. Negotiated Rate |
$9,960.00 |
| Rate for Payer: Aetna Commercial |
$2,241.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,141.40
|
| Rate for Payer: Aetna Managed Medicare |
$697.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,618.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,245.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,195.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,319.70
|
| Rate for Payer: Cash Price |
$747.00
|
| Rate for Payer: Cigna Commercial |
$2,290.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,393.40
|
| Rate for Payer: Health EOS Commercial |
$2,216.10
|
| Rate for Payer: HFN Commercial |
$2,290.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,867.50
|
| Rate for Payer: Multiplan Commercial |
$1,992.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,494.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,290.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,220.10
|
| Rate for Payer: Quartz Commercial |
$1,618.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,494.00
|
| Rate for Payer: The Alliance Commercial |
$9,960.00
|
| Rate for Payer: WEA Trust Commercial |
$1,369.50
|
| Rate for Payer: WPS Commercial |
$1,844.34
|
|
|
PROSTHESIS EAR STAPES PISTON 1133005
|
Facility
|
OP
|
$2,318.00
|
|
| Hospital Charge Code |
2973976
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.04 |
| Max. Negotiated Rate |
$9,272.00 |
| Rate for Payer: Aetna Commercial |
$2,086.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,993.48
|
| Rate for Payer: Aetna Managed Medicare |
$649.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,506.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,159.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,112.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,228.54
|
| Rate for Payer: Cash Price |
$695.40
|
| Rate for Payer: Cigna Commercial |
$2,132.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,297.15
|
| Rate for Payer: Health EOS Commercial |
$2,063.02
|
| Rate for Payer: HFN Commercial |
$2,132.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,738.50
|
| Rate for Payer: Multiplan Commercial |
$1,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,132.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,135.82
|
| Rate for Payer: Quartz Commercial |
$1,506.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,390.80
|
| Rate for Payer: The Alliance Commercial |
$9,272.00
|
| Rate for Payer: WEA Trust Commercial |
$1,274.90
|
| Rate for Payer: WPS Commercial |
$1,716.94
|
|
|
PROSTHESIS EAR STAPES PISTON 1133005
|
Facility
|
IP
|
$2,318.00
|
|
| Hospital Charge Code |
2973976
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,135.82 |
| Max. Negotiated Rate |
$2,132.56 |
| Rate for Payer: Aetna Commercial |
$2,086.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,993.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,228.54
|
| Rate for Payer: Cash Price |
$695.40
|
| Rate for Payer: Cigna Commercial |
$2,132.56
|
| Rate for Payer: Health EOS Commercial |
$2,063.02
|
| Rate for Payer: HFN Commercial |
$2,132.56
|
| Rate for Payer: Multiplan Commercial |
$1,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,132.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,135.82
|
| Rate for Payer: Quartz Commercial |
$1,390.80
|
| Rate for Payer: WEA Trust Commercial |
$1,274.90
|
| Rate for Payer: WPS Commercial |
$1,716.94
|
|
|
PROSTHESIS EAR STAPES PISTON 1133007
|
Facility
|
OP
|
$2,318.00
|
|
| Hospital Charge Code |
2990960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.04 |
| Max. Negotiated Rate |
$9,272.00 |
| Rate for Payer: Aetna Commercial |
$2,086.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,993.48
|
| Rate for Payer: Aetna Managed Medicare |
$649.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,506.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,159.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,112.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,228.54
|
| Rate for Payer: Cash Price |
$695.40
|
| Rate for Payer: Cigna Commercial |
$2,132.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,297.15
|
| Rate for Payer: Health EOS Commercial |
$2,063.02
|
| Rate for Payer: HFN Commercial |
$2,132.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,738.50
|
| Rate for Payer: Multiplan Commercial |
$1,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,132.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,135.82
|
| Rate for Payer: Quartz Commercial |
$1,506.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,390.80
|
| Rate for Payer: The Alliance Commercial |
$9,272.00
|
| Rate for Payer: WEA Trust Commercial |
$1,274.90
|
| Rate for Payer: WPS Commercial |
$1,716.94
|
|
|
PROSTHESIS EAR STAPES PISTON 1133007
|
Facility
|
IP
|
$2,318.00
|
|
| Hospital Charge Code |
2990960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,135.82 |
| Max. Negotiated Rate |
$2,132.56 |
| Rate for Payer: Aetna Commercial |
$2,086.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,993.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,228.54
|
| Rate for Payer: Cash Price |
$695.40
|
| Rate for Payer: Cigna Commercial |
$2,132.56
|
| Rate for Payer: Health EOS Commercial |
$2,063.02
|
| Rate for Payer: HFN Commercial |
$2,132.56
|
| Rate for Payer: Multiplan Commercial |
$1,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,132.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,135.82
|
| Rate for Payer: Quartz Commercial |
$1,390.80
|
| Rate for Payer: WEA Trust Commercial |
$1,274.90
|
| Rate for Payer: WPS Commercial |
$1,716.94
|
|
|
PROSTHESIS VOICE DUAL 20fr 12mm #DV 2012-NS
|
Facility
|
OP
|
$4,442.00
|
|
| Hospital Charge Code |
2973516
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,243.76 |
| Max. Negotiated Rate |
$17,768.00 |
| Rate for Payer: Aetna Commercial |
$3,997.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,820.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,243.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,887.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,221.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,132.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,354.26
|
| Rate for Payer: Cash Price |
$1,332.60
|
| Rate for Payer: Cigna Commercial |
$4,086.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,485.74
|
| Rate for Payer: Health EOS Commercial |
$3,953.38
|
| Rate for Payer: HFN Commercial |
$4,086.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,331.50
|
| Rate for Payer: Multiplan Commercial |
$3,553.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,665.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,086.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,176.58
|
| Rate for Payer: Quartz Commercial |
$2,887.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,665.20
|
| Rate for Payer: The Alliance Commercial |
$17,768.00
|
| Rate for Payer: WEA Trust Commercial |
$2,443.10
|
| Rate for Payer: WPS Commercial |
$3,290.19
|
|
|
PROSTHESIS VOICE DUAL 20fr 12mm #DV 2012-NS
|
Facility
|
IP
|
$4,442.00
|
|
| Hospital Charge Code |
2973516
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,176.58 |
| Max. Negotiated Rate |
$4,086.64 |
| Rate for Payer: Aetna Commercial |
$3,997.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,820.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,354.26
|
| Rate for Payer: Cash Price |
$1,332.60
|
| Rate for Payer: Cigna Commercial |
$4,086.64
|
| Rate for Payer: Health EOS Commercial |
$3,953.38
|
| Rate for Payer: HFN Commercial |
$4,086.64
|
| Rate for Payer: Multiplan Commercial |
$3,553.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,665.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,086.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,176.58
|
| Rate for Payer: Quartz Commercial |
$2,665.20
|
| Rate for Payer: WEA Trust Commercial |
$2,443.10
|
| Rate for Payer: WPS Commercial |
$3,290.19
|
|
|
PROSTHESIS VOICE INDWELLING 20fr 12mm #IN 2012IR
|
Facility
|
IP
|
$2,780.00
|
|
| Hospital Charge Code |
2973256
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.20 |
| Max. Negotiated Rate |
$2,557.60 |
| Rate for Payer: Aetna Commercial |
$2,502.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,390.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,473.40
|
| Rate for Payer: Cash Price |
$834.00
|
| Rate for Payer: Cigna Commercial |
$2,557.60
|
| Rate for Payer: Health EOS Commercial |
$2,474.20
|
| Rate for Payer: HFN Commercial |
$2,557.60
|
| Rate for Payer: Multiplan Commercial |
$2,224.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,668.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,557.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,362.20
|
| Rate for Payer: Quartz Commercial |
$1,668.00
|
| Rate for Payer: WEA Trust Commercial |
$1,529.00
|
| Rate for Payer: WPS Commercial |
$2,059.15
|
|
|
PROSTHESIS VOICE INDWELLING 20fr 12mm #IN 2012IR
|
Facility
|
OP
|
$2,780.00
|
|
| Hospital Charge Code |
2973256
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$778.40 |
| Max. Negotiated Rate |
$11,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,390.80
|
| Rate for Payer: Aetna Managed Medicare |
$778.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,807.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,390.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,334.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,473.40
|
| Rate for Payer: Cash Price |
$834.00
|
| Rate for Payer: Cigna Commercial |
$2,557.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,555.69
|
| Rate for Payer: Health EOS Commercial |
$2,474.20
|
| Rate for Payer: HFN Commercial |
$2,557.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,085.00
|
| Rate for Payer: Multiplan Commercial |
$2,224.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,668.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,557.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,362.20
|
| Rate for Payer: Quartz Commercial |
$1,807.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,668.00
|
| Rate for Payer: The Alliance Commercial |
$11,120.00
|
| Rate for Payer: WEA Trust Commercial |
$1,529.00
|
| Rate for Payer: WPS Commercial |
$2,059.15
|
|
|
PROSTHESIS VOICE INDWELLING 20FR 6mm #IN 2006-NS
|
Facility
|
IP
|
$2,869.00
|
|
| Hospital Charge Code |
2973134
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,405.81 |
| Max. Negotiated Rate |
$2,639.48 |
| Rate for Payer: Aetna Commercial |
$2,582.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,467.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,520.57
|
| Rate for Payer: Cash Price |
$860.70
|
| Rate for Payer: Cigna Commercial |
$2,639.48
|
| Rate for Payer: Health EOS Commercial |
$2,553.41
|
| Rate for Payer: HFN Commercial |
$2,639.48
|
| Rate for Payer: Multiplan Commercial |
$2,295.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,721.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,639.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,405.81
|
| Rate for Payer: Quartz Commercial |
$1,721.40
|
| Rate for Payer: WEA Trust Commercial |
$1,577.95
|
| Rate for Payer: WPS Commercial |
$2,125.07
|
|
|
PROSTHESIS VOICE INDWELLING 20FR 6mm #IN 2006-NS
|
Facility
|
OP
|
$2,869.00
|
|
| Hospital Charge Code |
2973134
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$803.32 |
| Max. Negotiated Rate |
$11,476.00 |
| Rate for Payer: Aetna Commercial |
$2,582.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,467.34
|
| Rate for Payer: Aetna Managed Medicare |
$803.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,864.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,434.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,377.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,520.57
|
| Rate for Payer: Cash Price |
$860.70
|
| Rate for Payer: Cigna Commercial |
$2,639.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,605.49
|
| Rate for Payer: Health EOS Commercial |
$2,553.41
|
| Rate for Payer: HFN Commercial |
$2,639.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,151.75
|
| Rate for Payer: Multiplan Commercial |
$2,295.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,721.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,639.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,405.81
|
| Rate for Payer: Quartz Commercial |
$1,864.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,721.40
|
| Rate for Payer: The Alliance Commercial |
$11,476.00
|
| Rate for Payer: WEA Trust Commercial |
$1,577.95
|
| Rate for Payer: WPS Commercial |
$2,125.07
|
|
|
PROSTHESIS VOICE INDWELLING 20fr 8mm #IN 2008-IR
|
Facility
|
OP
|
$2,780.00
|
|
| Hospital Charge Code |
2973255
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$778.40 |
| Max. Negotiated Rate |
$11,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,390.80
|
| Rate for Payer: Aetna Managed Medicare |
$778.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,807.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,390.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,334.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,473.40
|
| Rate for Payer: Cash Price |
$834.00
|
| Rate for Payer: Cigna Commercial |
$2,557.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,555.69
|
| Rate for Payer: Health EOS Commercial |
$2,474.20
|
| Rate for Payer: HFN Commercial |
$2,557.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,085.00
|
| Rate for Payer: Multiplan Commercial |
$2,224.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,668.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,557.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,362.20
|
| Rate for Payer: Quartz Commercial |
$1,807.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,668.00
|
| Rate for Payer: The Alliance Commercial |
$11,120.00
|
| Rate for Payer: WEA Trust Commercial |
$1,529.00
|
| Rate for Payer: WPS Commercial |
$2,059.15
|
|
|
PROSTHESIS VOICE INDWELLING 20fr 8mm #IN 2008-IR
|
Facility
|
IP
|
$2,780.00
|
|
| Hospital Charge Code |
2973255
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.20 |
| Max. Negotiated Rate |
$2,557.60 |
| Rate for Payer: Aetna Commercial |
$2,502.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,390.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,473.40
|
| Rate for Payer: Cash Price |
$834.00
|
| Rate for Payer: Cigna Commercial |
$2,557.60
|
| Rate for Payer: Health EOS Commercial |
$2,474.20
|
| Rate for Payer: HFN Commercial |
$2,557.60
|
| Rate for Payer: Multiplan Commercial |
$2,224.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,668.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,557.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,362.20
|
| Rate for Payer: Quartz Commercial |
$1,668.00
|
| Rate for Payer: WEA Trust Commercial |
$1,529.00
|
| Rate for Payer: WPS Commercial |
$2,059.15
|
|
|
PROSTHESIS VOICE INDWELLING 20FR 8mm #IN 2008-NS
|
Facility
|
OP
|
$2,869.00
|
|
| Hospital Charge Code |
2973135
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$803.32 |
| Max. Negotiated Rate |
$11,476.00 |
| Rate for Payer: Aetna Commercial |
$2,582.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,467.34
|
| Rate for Payer: Aetna Managed Medicare |
$803.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,864.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,434.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,377.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,520.57
|
| Rate for Payer: Cash Price |
$860.70
|
| Rate for Payer: Cigna Commercial |
$2,639.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,605.49
|
| Rate for Payer: Health EOS Commercial |
$2,553.41
|
| Rate for Payer: HFN Commercial |
$2,639.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,151.75
|
| Rate for Payer: Multiplan Commercial |
$2,295.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,721.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,639.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,405.81
|
| Rate for Payer: Quartz Commercial |
$1,864.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,721.40
|
| Rate for Payer: The Alliance Commercial |
$11,476.00
|
| Rate for Payer: WEA Trust Commercial |
$1,577.95
|
| Rate for Payer: WPS Commercial |
$2,125.07
|
|
|
PROSTHESIS VOICE INDWELLING 20FR 8mm #IN 2008-NS
|
Facility
|
IP
|
$2,869.00
|
|
| Hospital Charge Code |
2973135
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,405.81 |
| Max. Negotiated Rate |
$2,639.48 |
| Rate for Payer: Aetna Commercial |
$2,582.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,467.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,520.57
|
| Rate for Payer: Cash Price |
$860.70
|
| Rate for Payer: Cigna Commercial |
$2,639.48
|
| Rate for Payer: Health EOS Commercial |
$2,553.41
|
| Rate for Payer: HFN Commercial |
$2,639.48
|
| Rate for Payer: Multiplan Commercial |
$2,295.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,721.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,639.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,405.81
|
| Rate for Payer: Quartz Commercial |
$1,721.40
|
| Rate for Payer: WEA Trust Commercial |
$1,577.95
|
| Rate for Payer: WPS Commercial |
$2,125.07
|
|
|
Protamine Sulfate 50mg/5ml vial [Med]
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
HCPCS J2720
|
| Hospital Charge Code |
2974976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Aetna Managed Medicare |
$27.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.81
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.50
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$63.70
|
| Rate for Payer: Quartz Medicare Advantage |
$58.80
|
| Rate for Payer: The Alliance Commercial |
$392.00
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$5.32
|
|
|
Protamine Sulfate 50mg/5ml vial [Med]
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS J2720
|
| Hospital Charge Code |
2974976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.02 |
| Max. Negotiated Rate |
$90.16 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$58.80
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
PROTECTIVE TIP CAP 3MM BROWN 5047-1-030
|
Facility
|
OP
|
$430.00
|
|
| Hospital Charge Code |
6165644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$120.40 |
| Max. Negotiated Rate |
$1,720.00 |
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.80
|
| Rate for Payer: Aetna Managed Medicare |
$120.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$279.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$215.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$206.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.63
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$322.50
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$258.00
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$279.50
|
| Rate for Payer: Quartz Medicare Advantage |
$258.00
|
| Rate for Payer: The Alliance Commercial |
$1,720.00
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
PROTECTIVE TIP CAP 3MM BROWN 5047-1-030
|
Facility
|
IP
|
$430.00
|
|
| Hospital Charge Code |
6165644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$210.70 |
| Max. Negotiated Rate |
$395.60 |
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$258.00
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$258.00
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
