|
TOGA T7 PLUS PEEL-AWAY 2X 0416-841-100
|
Facility
OP
|
$1,363.00
|
|
| Hospital Charge Code |
6181771
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$381.64 |
| Max. Negotiated Rate |
$5,452.00 |
| Rate for Payer: Aetna Commercial |
$1,226.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,172.18
|
| Rate for Payer: Aetna Managed Medicare |
$381.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$885.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$681.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$654.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$722.39
|
| Rate for Payer: Cash Price |
$408.90
|
| Rate for Payer: Cigna Commercial |
$1,253.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$762.73
|
| Rate for Payer: Health EOS Commercial |
$1,213.07
|
| Rate for Payer: HFN Commercial |
$1,253.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,022.25
|
| Rate for Payer: Multiplan Commercial |
$1,090.40
|
| Rate for Payer: NAPHCARE Commercial |
$817.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,253.96
|
| Rate for Payer: Quartz Beloit One Network |
$667.87
|
| Rate for Payer: Quartz Commercial |
$885.95
|
| Rate for Payer: Quartz Medicare Advantage |
$817.80
|
| Rate for Payer: The Alliance Commercial |
$5,452.00
|
| Rate for Payer: WEA Trust Commercial |
$749.65
|
| Rate for Payer: WPS Commercial |
$1,009.57
|
|
|
TOGA T7 PLUS PEEL-AWAY 2X 0416-841-100
|
Facility
IP
|
$1,363.00
|
|
| Hospital Charge Code |
6181771
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$667.87 |
| Max. Negotiated Rate |
$1,253.96 |
| Rate for Payer: Aetna Commercial |
$1,226.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$722.39
|
| Rate for Payer: Cash Price |
$408.90
|
| Rate for Payer: Cigna Commercial |
$1,253.96
|
| Rate for Payer: Health EOS Commercial |
$1,213.07
|
| Rate for Payer: HFN Commercial |
$1,253.96
|
| Rate for Payer: Multiplan Commercial |
$1,090.40
|
| Rate for Payer: NAPHCARE Commercial |
$817.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,253.96
|
| Rate for Payer: Quartz Beloit One Network |
$667.87
|
| Rate for Payer: Quartz Commercial |
$817.80
|
| Rate for Payer: WEA Trust Commercial |
$749.65
|
| Rate for Payer: WPS Commercial |
$1,009.57
|
|
|
TOGA ZIPPERED REGULAR T5 0400-830-000
|
Facility
OP
|
$1,075.00
|
|
| Hospital Charge Code |
2966092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$4,300.00 |
| Rate for Payer: Aetna Commercial |
$967.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$924.50
|
| Rate for Payer: Aetna Managed Medicare |
$301.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$698.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$537.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$516.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$569.75
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cigna Commercial |
$989.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$601.57
|
| Rate for Payer: Health EOS Commercial |
$956.75
|
| Rate for Payer: HFN Commercial |
$989.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$806.25
|
| Rate for Payer: Multiplan Commercial |
$860.00
|
| Rate for Payer: NAPHCARE Commercial |
$645.00
|
| Rate for Payer: Preferred Network Access Commercial |
$989.00
|
| Rate for Payer: Quartz Beloit One Network |
$526.75
|
| Rate for Payer: Quartz Commercial |
$698.75
|
| Rate for Payer: Quartz Medicare Advantage |
$645.00
|
| Rate for Payer: The Alliance Commercial |
$4,300.00
|
| Rate for Payer: WEA Trust Commercial |
$591.25
|
| Rate for Payer: WPS Commercial |
$796.25
|
|
|
TOGA ZIPPERED REGULAR T5 0400-830-000
|
Facility
IP
|
$1,075.00
|
|
| Hospital Charge Code |
2966092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.75 |
| Max. Negotiated Rate |
$989.00 |
| Rate for Payer: Aetna Commercial |
$967.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$569.75
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cigna Commercial |
$989.00
|
| Rate for Payer: Health EOS Commercial |
$956.75
|
| Rate for Payer: HFN Commercial |
$989.00
|
| Rate for Payer: Multiplan Commercial |
$860.00
|
| Rate for Payer: NAPHCARE Commercial |
$645.00
|
| Rate for Payer: Preferred Network Access Commercial |
$989.00
|
| Rate for Payer: Quartz Beloit One Network |
$526.75
|
| Rate for Payer: Quartz Commercial |
$645.00
|
| Rate for Payer: WEA Trust Commercial |
$591.25
|
| Rate for Payer: WPS Commercial |
$796.25
|
|
|
TOGA ZIPPERED X-LARGE T-5 0400-850-000
|
Facility
IP
|
$1,117.00
|
|
| Hospital Charge Code |
2966093
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$547.33 |
| Max. Negotiated Rate |
$1,027.64 |
| Rate for Payer: Aetna Commercial |
$1,005.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$592.01
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cigna Commercial |
$1,027.64
|
| Rate for Payer: Health EOS Commercial |
$994.13
|
| Rate for Payer: HFN Commercial |
$1,027.64
|
| Rate for Payer: Multiplan Commercial |
$893.60
|
| Rate for Payer: NAPHCARE Commercial |
$670.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,027.64
|
| Rate for Payer: Quartz Beloit One Network |
$547.33
|
| Rate for Payer: Quartz Commercial |
$670.20
|
| Rate for Payer: WEA Trust Commercial |
$614.35
|
| Rate for Payer: WPS Commercial |
$827.36
|
|
|
TOGA ZIPPERED X-LARGE T-5 0400-850-000
|
Facility
OP
|
$1,117.00
|
|
| Hospital Charge Code |
2966093
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$312.76 |
| Max. Negotiated Rate |
$4,468.00 |
| Rate for Payer: Aetna Commercial |
$1,005.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$960.62
|
| Rate for Payer: Aetna Managed Medicare |
$312.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$726.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$558.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$536.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$592.01
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cigna Commercial |
$1,027.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$625.07
|
| Rate for Payer: Health EOS Commercial |
$994.13
|
| Rate for Payer: HFN Commercial |
$1,027.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$837.75
|
| Rate for Payer: Multiplan Commercial |
$893.60
|
| Rate for Payer: NAPHCARE Commercial |
$670.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,027.64
|
| Rate for Payer: Quartz Beloit One Network |
$547.33
|
| Rate for Payer: Quartz Commercial |
$726.05
|
| Rate for Payer: Quartz Medicare Advantage |
$670.20
|
| Rate for Payer: The Alliance Commercial |
$4,468.00
|
| Rate for Payer: WEA Trust Commercial |
$614.35
|
| Rate for Payer: WPS Commercial |
$827.36
|
|
|
TONSIL BLEED
|
Facility
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960437
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TONSIL BLEED
|
Facility
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960437
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TONSILLECTOMY
|
Facility
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960540
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| 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
|
|
|
TONSILLECTOMY
|
Facility
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960540
|
|
Hospital Revenue Code
|
360
|
| 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
|
|
|
TONSILLECTOMY/ADENOIDECTOMY
|
Facility
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960402
|
|
Hospital Revenue Code
|
360
|
| 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
|
|
|
TONSILLECTOMY/ADENOIDECTOMY
|
Facility
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960402
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| 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
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER
|
Facility
OP
|
$11,838.12
|
|
|
Service Code
|
CPT 42821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$11,838.12 |
| Rate for Payer: Aetna Managed Medicare |
$3,182.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,182.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,182.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,182.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,182.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,339.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,182.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,838.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,182.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,182.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,182.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,182.29
|
| Rate for Payer: NAPHCARE Commercial |
$4,773.44
|
| Rate for Payer: Quartz Medicare Advantage |
$3,182.29
|
| Rate for Payer: The Alliance Commercial |
$7,251.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,182.29
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$3,182.29
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12
|
Facility
OP
|
$21,532.40
|
|
|
Service Code
|
CPT 42820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,240.00 |
| Max. Negotiated Rate |
$21,532.40 |
| Rate for Payer: Aetna Managed Medicare |
$5,788.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,238.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,914.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,367.00
|
| Rate for Payer: Anthem Medicare Advantage |
$5,788.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,788.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,788.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,788.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,339.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,788.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,532.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,788.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,788.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,788.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,788.28
|
| Rate for Payer: NAPHCARE Commercial |
$8,682.42
|
| Rate for Payer: Quartz Medicare Advantage |
$5,788.28
|
| Rate for Payer: The Alliance Commercial |
$7,251.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,788.28
|
| Rate for Payer: United Healthcare PPO |
$4,240.00
|
| Rate for Payer: Wellcare Medicare |
$5,788.28
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER
|
Facility
OP
|
$39,231.04
|
|
|
Service Code
|
CPT 42826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$39,231.04 |
| Rate for Payer: Aetna Managed Medicare |
$3,182.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,182.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,182.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,182.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,182.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,795.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,182.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,838.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,182.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,182.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,182.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,182.29
|
| Rate for Payer: NAPHCARE Commercial |
$4,773.44
|
| Rate for Payer: Quartz Medicare Advantage |
$3,182.29
|
| Rate for Payer: The Alliance Commercial |
$39,231.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,182.29
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$3,182.29
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12
|
Facility
OP
|
$21,532.40
|
|
|
Service Code
|
CPT 42825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,240.00 |
| Max. Negotiated Rate |
$21,532.40 |
| Rate for Payer: Aetna Managed Medicare |
$5,788.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,238.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,914.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,367.00
|
| Rate for Payer: Anthem Medicare Advantage |
$5,788.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,788.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,788.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,788.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,788.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,532.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,788.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,788.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,788.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,788.28
|
| Rate for Payer: NAPHCARE Commercial |
$8,682.42
|
| Rate for Payer: Quartz Medicare Advantage |
$5,788.28
|
| Rate for Payer: The Alliance Commercial |
$7,251.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,788.28
|
| Rate for Payer: United Healthcare PPO |
$4,240.00
|
| Rate for Payer: Wellcare Medicare |
$5,788.28
|
|
|
TOPAZ EZ IFS ACH4041-01
|
Facility
IP
|
$4,399.00
|
|
| Hospital Charge Code |
5611610
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,155.51 |
| Max. Negotiated Rate |
$4,047.08 |
| Rate for Payer: Aetna Commercial |
$3,959.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,331.47
|
| Rate for Payer: Cash Price |
$1,319.70
|
| Rate for Payer: Cigna Commercial |
$4,047.08
|
| Rate for Payer: Health EOS Commercial |
$3,915.11
|
| Rate for Payer: HFN Commercial |
$4,047.08
|
| Rate for Payer: Multiplan Commercial |
$3,519.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,639.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,047.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,155.51
|
| Rate for Payer: Quartz Commercial |
$2,639.40
|
| Rate for Payer: WEA Trust Commercial |
$2,419.45
|
| Rate for Payer: WPS Commercial |
$3,258.34
|
|
|
TOPAZ EZ IFS ACH4041-01
|
Facility
OP
|
$4,399.00
|
|
| Hospital Charge Code |
5611610
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,231.72 |
| Max. Negotiated Rate |
$17,596.00 |
| Rate for Payer: Quartz Medicare Advantage |
$2,639.40
|
| Rate for Payer: Aetna Commercial |
$3,959.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,783.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,231.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,859.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,199.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,111.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,331.47
|
| Rate for Payer: Cash Price |
$1,319.70
|
| Rate for Payer: Cigna Commercial |
$4,047.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,461.68
|
| Rate for Payer: Health EOS Commercial |
$3,915.11
|
| Rate for Payer: HFN Commercial |
$4,047.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,299.25
|
| Rate for Payer: Multiplan Commercial |
$3,519.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,639.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,047.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,155.51
|
| Rate for Payer: Quartz Commercial |
$2,859.35
|
| Rate for Payer: The Alliance Commercial |
$17,596.00
|
| Rate for Payer: WEA Trust Commercial |
$2,419.45
|
| Rate for Payer: WPS Commercial |
$3,258.34
|
|
|
Topiramate Level
|
Facility
IP
|
$340.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
978080
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$166.60 |
| Max. Negotiated Rate |
$312.80 |
| Rate for Payer: Aetna Commercial |
$306.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.20
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$312.80
|
| Rate for Payer: Health EOS Commercial |
$302.60
|
| Rate for Payer: HFN Commercial |
$312.80
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: NAPHCARE Commercial |
$204.00
|
| Rate for Payer: Preferred Network Access Commercial |
$312.80
|
| Rate for Payer: Quartz Beloit One Network |
$166.60
|
| Rate for Payer: Quartz Commercial |
$204.00
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: WPS Commercial |
$251.84
|
|
|
Topiramate Level
|
Facility
OP
|
$340.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
978080
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.92 |
| Max. Negotiated Rate |
$1,360.00 |
| Rate for Payer: Aetna Commercial |
$306.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.40
|
| Rate for Payer: Aetna Managed Medicare |
$11.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.86
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.79
|
| Rate for Payer: Anthem Medicaid |
$12.32
|
| Rate for Payer: Anthem Medicare Advantage |
$11.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.92
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$312.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.32
|
| Rate for Payer: Dean Health Medicaid |
$12.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.92
|
| Rate for Payer: Health EOS Commercial |
$302.60
|
| Rate for Payer: HFN Commercial |
$312.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.92
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.92
|
| Rate for Payer: Managed Health Services Medicaid |
$12.81
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.92
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.92
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: NAPHCARE Commercial |
$17.88
|
| Rate for Payer: Preferred Network Access Commercial |
$312.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.32
|
| Rate for Payer: Quartz Beloit One Network |
$166.60
|
| Rate for Payer: Quartz Commercial |
$221.00
|
| Rate for Payer: Quartz Medicare Advantage |
$11.92
|
| Rate for Payer: The Alliance Commercial |
$1,360.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.92
|
| Rate for Payer: United Healthcare PPO |
$255.00
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: Wellcare Medicare |
$11.92
|
| Rate for Payer: WMAP Medicaid |
$12.32
|
| Rate for Payer: WPS Commercial |
$251.84
|
|
|
Topiramate Level
|
Professional
|
$340.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
978080
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.92 |
| Max. Negotiated Rate |
$323.00 |
| Rate for Payer: Aetna Commercial |
$323.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.40
|
| Rate for Payer: Aetna Managed Medicare |
$11.92
|
| Rate for Payer: Anthem Medicare Advantage |
$11.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.92
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$170.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.92
|
| Rate for Payer: Health EOS Commercial |
$309.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.92
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: Preferred Network Access Commercial |
$323.00
|
| Rate for Payer: Quartz Beloit One Network |
$149.60
|
| Rate for Payer: Quartz Commercial |
$193.80
|
| Rate for Payer: Quartz Medicare Advantage |
$11.92
|
| Rate for Payer: The Alliance Commercial |
$47.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.92
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: WPS Commercial |
$52.45
|
|
|
Toposar 10 mg Charge
|
Facility
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
2958962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$1,571.88 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.38
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.60
|
| Rate for Payer: The Alliance Commercial |
$1,571.88
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$2.62
|
|
|
Toposar 10 mg Charge
|
Facility
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
2958962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
Toposar 10 mg Charge
|
Professional
|
$26.00
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
2958962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$0.70
|
| Rate for Payer: Anthem Medicare Advantage |
$0.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.70
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.05
|
| Rate for Payer: Health EOS Commercial |
$23.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$24.70
|
| Rate for Payer: Quartz Beloit One Network |
$11.44
|
| Rate for Payer: Quartz Commercial |
$14.82
|
| Rate for Payer: Quartz Medicare Advantage |
$0.70
|
| Rate for Payer: The Alliance Commercial |
$1.94
|
| Rate for Payer: United Healthcare Medicaid |
$0.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.70
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$2.62
|
|
|
Toradol 15 mg Charge
|
Facility
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
2958957
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$17,002.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.93
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$17,002.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$1.76
|
|
