|
TOGA HOOD FLYTE REGULAR 0408-801-400
|
Facility
|
IP
|
$445.00
|
|
| Hospital Charge Code |
5591280
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.77 |
| Max. Negotiated Rate |
$425.78 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.28
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$425.78
|
| Rate for Payer: Health EOS Commercial |
$411.89
|
| Rate for Payer: HFN Commercial |
$425.78
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: Preferred Network Access Commercial |
$425.78
|
| Rate for Payer: Quartz Beloit One Network |
$226.77
|
| Rate for Payer: Quartz Commercial |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$342.78
|
|
|
TOGA HOOD FLYTE REGULAR 0408-801-400
|
Facility
|
OP
|
$445.00
|
|
| Hospital Charge Code |
5591280
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$129.58 |
| Max. Negotiated Rate |
$425.78 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Aetna Managed Medicare |
$129.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$300.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$231.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$222.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.28
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$425.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.99
|
| Rate for Payer: Health EOS Commercial |
$411.89
|
| Rate for Payer: HFN Commercial |
$425.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.10
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: NAPHCARE Commercial |
$277.68
|
| Rate for Payer: Preferred Network Access Commercial |
$425.78
|
| Rate for Payer: Quartz Beloit One Network |
$226.77
|
| Rate for Payer: Quartz Commercial |
$300.82
|
| Rate for Payer: Quartz Medicare Advantage |
$277.68
|
| Rate for Payer: The Alliance Commercial |
$231.40
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$342.78
|
|
|
TOGA HOOD PEEL-AWAY FLYTE 0408-800-100
|
Facility
|
IP
|
$739.00
|
|
| Hospital Charge Code |
5591302
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$376.59 |
| Max. Negotiated Rate |
$707.08 |
| Rate for Payer: Aetna Commercial |
$691.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$660.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$407.34
|
| Rate for Payer: Cash Price |
$221.70
|
| Rate for Payer: Cigna Commercial |
$707.08
|
| Rate for Payer: Health EOS Commercial |
$684.02
|
| Rate for Payer: HFN Commercial |
$707.08
|
| Rate for Payer: Multiplan Commercial |
$614.85
|
| Rate for Payer: Preferred Network Access Commercial |
$707.08
|
| Rate for Payer: Quartz Beloit One Network |
$376.59
|
| Rate for Payer: Quartz Commercial |
$461.14
|
| Rate for Payer: WEA Trust Commercial |
$422.71
|
| Rate for Payer: WPS Commercial |
$569.25
|
|
|
TOGA HOOD PEEL-AWAY FLYTE 0408-800-100
|
Facility
|
OP
|
$739.00
|
|
| Hospital Charge Code |
5591302
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$215.20 |
| Max. Negotiated Rate |
$707.08 |
| Rate for Payer: Aetna Commercial |
$691.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$660.96
|
| Rate for Payer: Aetna Managed Medicare |
$215.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$499.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$384.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$368.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$407.34
|
| Rate for Payer: Cash Price |
$221.70
|
| Rate for Payer: Cigna Commercial |
$707.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$430.10
|
| Rate for Payer: Health EOS Commercial |
$684.02
|
| Rate for Payer: HFN Commercial |
$707.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$576.42
|
| Rate for Payer: Multiplan Commercial |
$614.85
|
| Rate for Payer: NAPHCARE Commercial |
$461.14
|
| Rate for Payer: Preferred Network Access Commercial |
$707.08
|
| Rate for Payer: Quartz Beloit One Network |
$376.59
|
| Rate for Payer: Quartz Commercial |
$499.56
|
| Rate for Payer: Quartz Medicare Advantage |
$461.14
|
| Rate for Payer: The Alliance Commercial |
$384.28
|
| Rate for Payer: WEA Trust Commercial |
$422.71
|
| Rate for Payer: WPS Commercial |
$569.25
|
|
|
TOGA HOOD T7 PLUS ANTI-REFLECTIVE LENS 0416-801-200
|
Facility
|
IP
|
$499.00
|
|
| Hospital Charge Code |
6181770
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$254.29 |
| Max. Negotiated Rate |
$477.44 |
| Rate for Payer: Aetna Commercial |
$467.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$446.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$275.05
|
| Rate for Payer: Cash Price |
$149.70
|
| Rate for Payer: Cigna Commercial |
$477.44
|
| Rate for Payer: Health EOS Commercial |
$461.87
|
| Rate for Payer: HFN Commercial |
$477.44
|
| Rate for Payer: Multiplan Commercial |
$415.17
|
| Rate for Payer: Preferred Network Access Commercial |
$477.44
|
| Rate for Payer: Quartz Beloit One Network |
$254.29
|
| Rate for Payer: Quartz Commercial |
$311.38
|
| Rate for Payer: WEA Trust Commercial |
$285.43
|
| Rate for Payer: WPS Commercial |
$384.38
|
|
|
TOGA HOOD T7 PLUS ANTI-REFLECTIVE LENS 0416-801-200
|
Facility
|
OP
|
$499.00
|
|
| Hospital Charge Code |
6181770
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$145.31 |
| Max. Negotiated Rate |
$477.44 |
| Rate for Payer: Aetna Commercial |
$467.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$446.31
|
| Rate for Payer: Aetna Managed Medicare |
$145.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$337.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$249.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$275.05
|
| Rate for Payer: Cash Price |
$149.70
|
| Rate for Payer: Cigna Commercial |
$477.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$290.42
|
| Rate for Payer: Health EOS Commercial |
$461.87
|
| Rate for Payer: HFN Commercial |
$477.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$389.22
|
| Rate for Payer: Multiplan Commercial |
$415.17
|
| Rate for Payer: NAPHCARE Commercial |
$311.38
|
| Rate for Payer: Preferred Network Access Commercial |
$477.44
|
| Rate for Payer: Quartz Beloit One Network |
$254.29
|
| Rate for Payer: Quartz Commercial |
$337.32
|
| Rate for Payer: Quartz Medicare Advantage |
$311.38
|
| Rate for Payer: The Alliance Commercial |
$259.48
|
| Rate for Payer: WEA Trust Commercial |
$285.43
|
| Rate for Payer: WPS Commercial |
$384.38
|
|
|
TOGA HOOD T7 PLUS PEEL-AWAY 0416-801-100
|
Facility
|
OP
|
$714.00
|
|
| Hospital Charge Code |
6181769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$207.92 |
| Max. Negotiated Rate |
$683.16 |
| Rate for Payer: Aetna Commercial |
$668.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$638.60
|
| Rate for Payer: Aetna Managed Medicare |
$207.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$482.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$371.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$356.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$393.56
|
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$683.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$415.55
|
| Rate for Payer: Health EOS Commercial |
$660.88
|
| Rate for Payer: HFN Commercial |
$683.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$556.92
|
| Rate for Payer: Multiplan Commercial |
$594.05
|
| Rate for Payer: NAPHCARE Commercial |
$445.54
|
| Rate for Payer: Preferred Network Access Commercial |
$683.16
|
| Rate for Payer: Quartz Beloit One Network |
$363.85
|
| Rate for Payer: Quartz Commercial |
$482.66
|
| Rate for Payer: Quartz Medicare Advantage |
$445.54
|
| Rate for Payer: The Alliance Commercial |
$371.28
|
| Rate for Payer: WEA Trust Commercial |
$408.41
|
| Rate for Payer: WPS Commercial |
$549.99
|
|
|
TOGA HOOD T7 PLUS PEEL-AWAY 0416-801-100
|
Facility
|
IP
|
$714.00
|
|
| Hospital Charge Code |
6181769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$363.85 |
| Max. Negotiated Rate |
$683.16 |
| Rate for Payer: Aetna Commercial |
$668.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$638.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$393.56
|
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$683.16
|
| Rate for Payer: Health EOS Commercial |
$660.88
|
| Rate for Payer: HFN Commercial |
$683.16
|
| Rate for Payer: Multiplan Commercial |
$594.05
|
| Rate for Payer: Preferred Network Access Commercial |
$683.16
|
| Rate for Payer: Quartz Beloit One Network |
$363.85
|
| Rate for Payer: Quartz Commercial |
$445.54
|
| Rate for Payer: WEA Trust Commercial |
$408.41
|
| Rate for Payer: WPS Commercial |
$549.99
|
|
|
TOGA T7 PLUS ANTI-REFLECTIVE LENS 2X 0416-841-200
|
Facility
|
IP
|
$1,154.00
|
|
| Hospital Charge Code |
6181917
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$588.08 |
| Max. Negotiated Rate |
$1,104.15 |
| Rate for Payer: Aetna Commercial |
$1,080.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,032.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$636.08
|
| Rate for Payer: Cash Price |
$346.20
|
| Rate for Payer: Cigna Commercial |
$1,104.15
|
| Rate for Payer: Health EOS Commercial |
$1,068.14
|
| Rate for Payer: HFN Commercial |
$1,104.15
|
| Rate for Payer: Multiplan Commercial |
$960.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,104.15
|
| Rate for Payer: Quartz Beloit One Network |
$588.08
|
| Rate for Payer: Quartz Commercial |
$720.10
|
| Rate for Payer: WEA Trust Commercial |
$660.09
|
| Rate for Payer: WPS Commercial |
$888.93
|
|
|
TOGA T7 PLUS ANTI-REFLECTIVE LENS 2X 0416-841-200
|
Facility
|
OP
|
$1,154.00
|
|
| Hospital Charge Code |
6181917
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$336.04 |
| Max. Negotiated Rate |
$1,104.15 |
| Rate for Payer: Aetna Commercial |
$1,080.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,032.14
|
| Rate for Payer: Aetna Managed Medicare |
$336.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$780.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$600.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$576.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$636.08
|
| Rate for Payer: Cash Price |
$346.20
|
| Rate for Payer: Cigna Commercial |
$1,104.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$671.63
|
| Rate for Payer: Health EOS Commercial |
$1,068.14
|
| Rate for Payer: HFN Commercial |
$1,104.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.12
|
| Rate for Payer: Multiplan Commercial |
$960.13
|
| Rate for Payer: NAPHCARE Commercial |
$720.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,104.15
|
| Rate for Payer: Quartz Beloit One Network |
$588.08
|
| Rate for Payer: Quartz Commercial |
$780.10
|
| Rate for Payer: Quartz Medicare Advantage |
$720.10
|
| Rate for Payer: The Alliance Commercial |
$600.08
|
| Rate for Payer: WEA Trust Commercial |
$660.09
|
| Rate for Payer: WPS Commercial |
$888.93
|
|
|
TOGA T7 PLUS ANTI-REFLECTIVE LENS XL 0416-831-200
|
Facility
|
OP
|
$1,025.00
|
|
| Hospital Charge Code |
6181918
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$298.48 |
| Max. Negotiated Rate |
$980.72 |
| Rate for Payer: Aetna Commercial |
$959.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$916.76
|
| Rate for Payer: Aetna Managed Medicare |
$298.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$692.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$533.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$511.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$564.98
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: Cigna Commercial |
$980.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$596.55
|
| Rate for Payer: Health EOS Commercial |
$948.74
|
| Rate for Payer: HFN Commercial |
$980.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$799.50
|
| Rate for Payer: Multiplan Commercial |
$852.80
|
| Rate for Payer: NAPHCARE Commercial |
$639.60
|
| Rate for Payer: Preferred Network Access Commercial |
$980.72
|
| Rate for Payer: Quartz Beloit One Network |
$522.34
|
| Rate for Payer: Quartz Commercial |
$692.90
|
| Rate for Payer: Quartz Medicare Advantage |
$639.60
|
| Rate for Payer: The Alliance Commercial |
$533.00
|
| Rate for Payer: WEA Trust Commercial |
$586.30
|
| Rate for Payer: WPS Commercial |
$789.56
|
|
|
TOGA T7 PLUS ANTI-REFLECTIVE LENS XL 0416-831-200
|
Facility
|
IP
|
$1,025.00
|
|
| Hospital Charge Code |
6181918
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$522.34 |
| Max. Negotiated Rate |
$980.72 |
| Rate for Payer: Aetna Commercial |
$959.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$916.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$564.98
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: Cigna Commercial |
$980.72
|
| Rate for Payer: Health EOS Commercial |
$948.74
|
| Rate for Payer: HFN Commercial |
$980.72
|
| Rate for Payer: Multiplan Commercial |
$852.80
|
| Rate for Payer: Preferred Network Access Commercial |
$980.72
|
| Rate for Payer: Quartz Beloit One Network |
$522.34
|
| Rate for Payer: Quartz Commercial |
$639.60
|
| Rate for Payer: WEA Trust Commercial |
$586.30
|
| Rate for Payer: WPS Commercial |
$789.56
|
|
|
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 |
$694.58 |
| Max. Negotiated Rate |
$1,304.12 |
| Rate for Payer: Aetna Commercial |
$1,275.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,219.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$751.29
|
| Rate for Payer: Cash Price |
$408.90
|
| Rate for Payer: Cigna Commercial |
$1,304.12
|
| Rate for Payer: Health EOS Commercial |
$1,261.59
|
| Rate for Payer: HFN Commercial |
$1,304.12
|
| Rate for Payer: Multiplan Commercial |
$1,134.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,304.12
|
| Rate for Payer: Quartz Beloit One Network |
$694.58
|
| Rate for Payer: Quartz Commercial |
$850.51
|
| Rate for Payer: WEA Trust Commercial |
$779.64
|
| Rate for Payer: WPS Commercial |
$1,049.92
|
|
|
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 |
$396.91 |
| Max. Negotiated Rate |
$1,304.12 |
| Rate for Payer: Aetna Commercial |
$1,275.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,219.07
|
| Rate for Payer: Aetna Managed Medicare |
$396.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$921.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$708.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$680.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$751.29
|
| Rate for Payer: Cash Price |
$408.90
|
| Rate for Payer: Cigna Commercial |
$1,304.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$793.27
|
| Rate for Payer: Health EOS Commercial |
$1,261.59
|
| Rate for Payer: HFN Commercial |
$1,304.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,063.14
|
| Rate for Payer: Multiplan Commercial |
$1,134.02
|
| Rate for Payer: NAPHCARE Commercial |
$850.51
|
| Rate for Payer: Preferred Network Access Commercial |
$1,304.12
|
| Rate for Payer: Quartz Beloit One Network |
$694.58
|
| Rate for Payer: Quartz Commercial |
$921.39
|
| Rate for Payer: Quartz Medicare Advantage |
$850.51
|
| Rate for Payer: The Alliance Commercial |
$708.76
|
| Rate for Payer: WEA Trust Commercial |
$779.64
|
| Rate for Payer: WPS Commercial |
$1,049.92
|
|
|
TOGA ZIPPERED REGULAR T5 0400-830-000
|
Facility
|
IP
|
$1,075.00
|
|
| Hospital Charge Code |
2966092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$547.82 |
| Max. Negotiated Rate |
$1,028.56 |
| Rate for Payer: Aetna Commercial |
$1,006.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$961.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$592.54
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cigna Commercial |
$1,028.56
|
| Rate for Payer: Health EOS Commercial |
$995.02
|
| Rate for Payer: HFN Commercial |
$1,028.56
|
| Rate for Payer: Multiplan Commercial |
$894.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,028.56
|
| Rate for Payer: Quartz Beloit One Network |
$547.82
|
| Rate for Payer: Quartz Commercial |
$670.80
|
| Rate for Payer: WEA Trust Commercial |
$614.90
|
| Rate for Payer: WPS Commercial |
$828.07
|
|
|
TOGA ZIPPERED REGULAR T5 0400-830-000
|
Facility
|
OP
|
$1,075.00
|
|
| Hospital Charge Code |
2966092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$1,028.56 |
| Rate for Payer: Aetna Commercial |
$1,006.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$961.48
|
| Rate for Payer: Aetna Managed Medicare |
$313.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$726.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$559.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$536.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$592.54
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cigna Commercial |
$1,028.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$625.65
|
| Rate for Payer: Health EOS Commercial |
$995.02
|
| Rate for Payer: HFN Commercial |
$1,028.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$838.50
|
| Rate for Payer: Multiplan Commercial |
$894.40
|
| Rate for Payer: NAPHCARE Commercial |
$670.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,028.56
|
| Rate for Payer: Quartz Beloit One Network |
$547.82
|
| Rate for Payer: Quartz Commercial |
$726.70
|
| Rate for Payer: Quartz Medicare Advantage |
$670.80
|
| Rate for Payer: The Alliance Commercial |
$559.00
|
| Rate for Payer: WEA Trust Commercial |
$614.90
|
| Rate for Payer: WPS Commercial |
$828.07
|
|
|
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 |
$569.22 |
| Max. Negotiated Rate |
$1,068.75 |
| Rate for Payer: Aetna Commercial |
$1,045.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$999.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$615.69
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cigna Commercial |
$1,068.75
|
| Rate for Payer: Health EOS Commercial |
$1,033.90
|
| Rate for Payer: HFN Commercial |
$1,068.75
|
| Rate for Payer: Multiplan Commercial |
$929.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,068.75
|
| Rate for Payer: Quartz Beloit One Network |
$569.22
|
| Rate for Payer: Quartz Commercial |
$697.01
|
| Rate for Payer: WEA Trust Commercial |
$638.92
|
| Rate for Payer: WPS Commercial |
$860.43
|
|
|
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 |
$325.27 |
| Max. Negotiated Rate |
$1,068.75 |
| Rate for Payer: Aetna Commercial |
$1,045.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$999.04
|
| Rate for Payer: Aetna Managed Medicare |
$325.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$755.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$580.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$557.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$615.69
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cigna Commercial |
$1,068.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$650.09
|
| Rate for Payer: Health EOS Commercial |
$1,033.90
|
| Rate for Payer: HFN Commercial |
$1,068.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$871.26
|
| Rate for Payer: Multiplan Commercial |
$929.34
|
| Rate for Payer: NAPHCARE Commercial |
$697.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,068.75
|
| Rate for Payer: Quartz Beloit One Network |
$569.22
|
| Rate for Payer: Quartz Commercial |
$755.09
|
| Rate for Payer: Quartz Medicare Advantage |
$697.01
|
| Rate for Payer: The Alliance Commercial |
$580.84
|
| Rate for Payer: WEA Trust Commercial |
$638.92
|
| Rate for Payer: WPS Commercial |
$860.43
|
|
|
TONGUE PADDED #ACM-9187
|
Facility
|
IP
|
$402.00
|
|
| Hospital Charge Code |
2971080
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$204.86 |
| Max. Negotiated Rate |
$384.63 |
| Rate for Payer: Aetna Commercial |
$376.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.58
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$384.63
|
| Rate for Payer: Health EOS Commercial |
$372.09
|
| Rate for Payer: HFN Commercial |
$384.63
|
| Rate for Payer: Multiplan Commercial |
$334.46
|
| Rate for Payer: Preferred Network Access Commercial |
$384.63
|
| Rate for Payer: Quartz Beloit One Network |
$204.86
|
| Rate for Payer: Quartz Commercial |
$250.85
|
| Rate for Payer: WEA Trust Commercial |
$229.94
|
| Rate for Payer: WPS Commercial |
$309.66
|
|
|
TONGUE PADDED #ACM-9187
|
Facility
|
OP
|
$402.00
|
|
| Hospital Charge Code |
2971080
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$117.06 |
| Max. Negotiated Rate |
$384.63 |
| Rate for Payer: Aetna Commercial |
$376.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.55
|
| Rate for Payer: Aetna Managed Medicare |
$117.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$271.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$209.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$200.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.58
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$384.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.96
|
| Rate for Payer: Health EOS Commercial |
$372.09
|
| Rate for Payer: HFN Commercial |
$384.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$313.56
|
| Rate for Payer: Multiplan Commercial |
$334.46
|
| Rate for Payer: NAPHCARE Commercial |
$250.85
|
| Rate for Payer: Preferred Network Access Commercial |
$384.63
|
| Rate for Payer: Quartz Beloit One Network |
$204.86
|
| Rate for Payer: Quartz Commercial |
$271.75
|
| Rate for Payer: Quartz Medicare Advantage |
$250.85
|
| Rate for Payer: The Alliance Commercial |
$209.04
|
| Rate for Payer: WEA Trust Commercial |
$229.94
|
| Rate for Payer: WPS Commercial |
$309.66
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
|
IP
|
$5,787.08
|
|
|
Service Code
|
APR-DRG 0971
|
| Min. Negotiated Rate |
$5,140.45 |
| Max. Negotiated Rate |
$5,787.08 |
| Rate for Payer: Anthem Medicaid |
$5,541.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,541.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,541.45
|
| Rate for Payer: Dean Health Medicaid |
$5,541.45
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,140.45
|
| Rate for Payer: Managed Health Services Medicaid |
$5,787.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,541.45
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,541.45
|
| Rate for Payer: United Healthcare Medicaid |
$5,541.45
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
|
IP
|
$9,031.36
|
|
|
Service Code
|
APR-DRG 0972
|
| Min. Negotiated Rate |
$8,022.22 |
| Max. Negotiated Rate |
$9,031.36 |
| Rate for Payer: Anthem Medicaid |
$8,648.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,648.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,648.02
|
| Rate for Payer: Dean Health Medicaid |
$8,648.02
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,022.22
|
| Rate for Payer: Managed Health Services Medicaid |
$9,031.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,648.02
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,648.02
|
| Rate for Payer: United Healthcare Medicaid |
$8,648.02
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
|
OP
|
$1,031.21
|
|
|
Service Code
|
EAPG 00256
|
| Min. Negotiated Rate |
$991.54 |
| Max. Negotiated Rate |
$1,031.21 |
| Rate for Payer: Anthem Medicaid |
$991.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$991.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$991.54
|
| Rate for Payer: Dean Health Medicaid |
$991.54
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$991.54
|
| Rate for Payer: Managed Health Services Medicaid |
$1,031.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$991.54
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$991.54
|
| Rate for Payer: United Healthcare Medicaid |
$991.54
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
|
IP
|
$23,148.34
|
|
|
Service Code
|
APR-DRG 0974
|
| Min. Negotiated Rate |
$20,561.80 |
| Max. Negotiated Rate |
$23,148.34 |
| Rate for Payer: Anthem Medicaid |
$22,165.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$22,165.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22,165.81
|
| Rate for Payer: Dean Health Medicaid |
$22,165.81
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$20,561.80
|
| Rate for Payer: Managed Health Services Medicaid |
$23,148.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$22,165.81
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$22,165.81
|
| Rate for Payer: United Healthcare Medicaid |
$22,165.81
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
|
IP
|
$14,292.35
|
|
|
Service Code
|
APR-DRG 0973
|
| Min. Negotiated Rate |
$12,695.35 |
| Max. Negotiated Rate |
$14,292.35 |
| Rate for Payer: Anthem Medicaid |
$13,685.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$13,685.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13,685.71
|
| Rate for Payer: Dean Health Medicaid |
$13,685.71
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12,695.35
|
| Rate for Payer: Managed Health Services Medicaid |
$14,292.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,685.71
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13,685.71
|
| Rate for Payer: United Healthcare Medicaid |
$13,685.71
|
|
