|
Tube-Minidrip BCE
|
Facility
|
OP
|
$76.00
|
|
| Hospital Charge Code |
3101776
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.13 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Aetna Managed Medicare |
$22.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.23
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.28
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: NAPHCARE Commercial |
$47.42
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$51.38
|
| Rate for Payer: Quartz Medicare Advantage |
$47.42
|
| Rate for Payer: The Alliance Commercial |
$39.52
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$58.54
|
|
|
Tube-Minidrip BCE
|
Facility
|
IP
|
$76.00
|
|
| Hospital Charge Code |
3101776
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$47.42
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$58.54
|
|
|
TUBE NASAL RAE 6.0 CUFFED 96360
|
Facility
|
OP
|
$141.00
|
|
| Hospital Charge Code |
2974639
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.06 |
| Max. Negotiated Rate |
$134.91 |
| Rate for Payer: Aetna Commercial |
$131.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Aetna Managed Medicare |
$41.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.72
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$134.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.06
|
| Rate for Payer: Health EOS Commercial |
$130.51
|
| Rate for Payer: HFN Commercial |
$134.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.98
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: NAPHCARE Commercial |
$87.98
|
| Rate for Payer: Preferred Network Access Commercial |
$134.91
|
| Rate for Payer: Quartz Beloit One Network |
$71.85
|
| Rate for Payer: Quartz Commercial |
$95.32
|
| Rate for Payer: Quartz Medicare Advantage |
$87.98
|
| Rate for Payer: The Alliance Commercial |
$73.32
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: WPS Commercial |
$108.61
|
|
|
TUBE NASAL RAE 6.0 CUFFED 96360
|
Facility
|
IP
|
$141.00
|
|
| Hospital Charge Code |
2974639
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.85 |
| Max. Negotiated Rate |
$134.91 |
| Rate for Payer: Aetna Commercial |
$131.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.72
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$134.91
|
| Rate for Payer: Health EOS Commercial |
$130.51
|
| Rate for Payer: HFN Commercial |
$134.91
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: Preferred Network Access Commercial |
$134.91
|
| Rate for Payer: Quartz Beloit One Network |
$71.85
|
| Rate for Payer: Quartz Commercial |
$87.98
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: WPS Commercial |
$108.61
|
|
|
TUBE NASAL RAE 7.0 CUFFED 96370
|
Facility
|
IP
|
$141.00
|
|
| Hospital Charge Code |
2974640
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.85 |
| Max. Negotiated Rate |
$134.91 |
| Rate for Payer: Aetna Commercial |
$131.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.72
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$134.91
|
| Rate for Payer: Health EOS Commercial |
$130.51
|
| Rate for Payer: HFN Commercial |
$134.91
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: Preferred Network Access Commercial |
$134.91
|
| Rate for Payer: Quartz Beloit One Network |
$71.85
|
| Rate for Payer: Quartz Commercial |
$87.98
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: WPS Commercial |
$108.61
|
|
|
TUBE NASAL RAE 7.0 CUFFED 96370
|
Facility
|
OP
|
$141.00
|
|
| Hospital Charge Code |
2974640
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.06 |
| Max. Negotiated Rate |
$134.91 |
| Rate for Payer: Aetna Commercial |
$131.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Aetna Managed Medicare |
$41.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.72
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$134.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.06
|
| Rate for Payer: Health EOS Commercial |
$130.51
|
| Rate for Payer: HFN Commercial |
$134.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.98
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: NAPHCARE Commercial |
$87.98
|
| Rate for Payer: Preferred Network Access Commercial |
$134.91
|
| Rate for Payer: Quartz Beloit One Network |
$71.85
|
| Rate for Payer: Quartz Commercial |
$95.32
|
| Rate for Payer: Quartz Medicare Advantage |
$87.98
|
| Rate for Payer: The Alliance Commercial |
$73.32
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: WPS Commercial |
$108.61
|
|
|
TUBE ORAL ENDOTRACHEAL #9799
|
Facility
|
IP
|
$194.00
|
|
| Hospital Charge Code |
2974736
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.86 |
| Max. Negotiated Rate |
$185.62 |
| Rate for Payer: Aetna Commercial |
$181.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.93
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Health EOS Commercial |
$179.57
|
| Rate for Payer: HFN Commercial |
$185.62
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: Preferred Network Access Commercial |
$185.62
|
| Rate for Payer: Quartz Beloit One Network |
$98.86
|
| Rate for Payer: Quartz Commercial |
$121.06
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$149.44
|
|
|
TUBE ORAL ENDOTRACHEAL #9799
|
Facility
|
OP
|
$194.00
|
|
| Hospital Charge Code |
2974736
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.49 |
| Max. Negotiated Rate |
$185.62 |
| Rate for Payer: Aetna Commercial |
$181.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Aetna Managed Medicare |
$56.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.93
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.91
|
| Rate for Payer: Health EOS Commercial |
$179.57
|
| Rate for Payer: HFN Commercial |
$185.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.32
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: NAPHCARE Commercial |
$121.06
|
| Rate for Payer: Preferred Network Access Commercial |
$185.62
|
| Rate for Payer: Quartz Beloit One Network |
$98.86
|
| Rate for Payer: Quartz Commercial |
$131.14
|
| Rate for Payer: Quartz Medicare Advantage |
$121.06
|
| Rate for Payer: The Alliance Commercial |
$100.88
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$149.44
|
|
|
TUBE ORAL/NASAL CO2 FOR ADULT #2013067-001
|
Facility
|
OP
|
$213.00
|
|
| Hospital Charge Code |
2972270
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.03 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Aetna Managed Medicare |
$62.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$143.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.97
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.14
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: NAPHCARE Commercial |
$132.91
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$143.99
|
| Rate for Payer: Quartz Medicare Advantage |
$132.91
|
| Rate for Payer: The Alliance Commercial |
$110.76
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
TUBE ORAL/NASAL CO2 FOR ADULT #2013067-001
|
Facility
|
IP
|
$213.00
|
|
| Hospital Charge Code |
2972270
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$108.54 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$132.91
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
TUBE ORAL/NASAL CO2 FOR PEDS #2013067-002
|
Facility
|
OP
|
$261.00
|
|
| Hospital Charge Code |
2969791
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.00 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Aetna Managed Medicare |
$76.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.90
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$203.58
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: NAPHCARE Commercial |
$162.86
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$176.44
|
| Rate for Payer: Quartz Medicare Advantage |
$162.86
|
| Rate for Payer: The Alliance Commercial |
$135.72
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
TUBE ORAL/NASAL CO2 FOR PEDS #2013067-002
|
Facility
|
IP
|
$261.00
|
|
| Hospital Charge Code |
2969791
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.01 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$162.86
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
TUBE REPLACEMENT, REVISION OR REMOVAL
|
Facility
|
OP
|
$256.82
|
|
|
Service Code
|
EAPG 00421
|
| Min. Negotiated Rate |
$246.94 |
| Max. Negotiated Rate |
$256.82 |
| Rate for Payer: Anthem Medicaid |
$246.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$246.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$246.94
|
| Rate for Payer: Dean Health Medicaid |
$246.94
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$246.94
|
| Rate for Payer: Managed Health Services Medicaid |
$256.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$246.94
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$246.94
|
| Rate for Payer: United Healthcare Medicaid |
$246.94
|
|
|
TUBE RUSCH DBL LMN LT 37FR #116100370
|
Facility
|
IP
|
$1,023.00
|
|
| Hospital Charge Code |
2962805
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$521.32 |
| Max. Negotiated Rate |
$978.81 |
| Rate for Payer: Aetna Commercial |
$957.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$914.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$563.88
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cigna Commercial |
$978.81
|
| Rate for Payer: Health EOS Commercial |
$946.89
|
| Rate for Payer: HFN Commercial |
$978.81
|
| Rate for Payer: Multiplan Commercial |
$851.14
|
| Rate for Payer: Preferred Network Access Commercial |
$978.81
|
| Rate for Payer: Quartz Beloit One Network |
$521.32
|
| Rate for Payer: Quartz Commercial |
$638.35
|
| Rate for Payer: WEA Trust Commercial |
$585.16
|
| Rate for Payer: WPS Commercial |
$788.02
|
|
|
TUBE RUSCH DBL LMN LT 37FR #116100370
|
Facility
|
OP
|
$1,023.00
|
|
| Hospital Charge Code |
2962805
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$297.90 |
| Max. Negotiated Rate |
$978.81 |
| Rate for Payer: Aetna Commercial |
$957.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$914.97
|
| Rate for Payer: Aetna Managed Medicare |
$297.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$691.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$531.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$510.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$563.88
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cigna Commercial |
$978.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$595.39
|
| Rate for Payer: Health EOS Commercial |
$946.89
|
| Rate for Payer: HFN Commercial |
$978.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$797.94
|
| Rate for Payer: Multiplan Commercial |
$851.14
|
| Rate for Payer: NAPHCARE Commercial |
$638.35
|
| Rate for Payer: Preferred Network Access Commercial |
$978.81
|
| Rate for Payer: Quartz Beloit One Network |
$521.32
|
| Rate for Payer: Quartz Commercial |
$691.55
|
| Rate for Payer: Quartz Medicare Advantage |
$638.35
|
| Rate for Payer: The Alliance Commercial |
$531.96
|
| Rate for Payer: WEA Trust Commercial |
$585.16
|
| Rate for Payer: WPS Commercial |
$788.02
|
|
|
TUBE RUSCH DBL LMN LT 39FR #11610039
|
Facility
|
OP
|
$1,023.00
|
|
| Hospital Charge Code |
2974627
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$297.90 |
| Max. Negotiated Rate |
$978.81 |
| Rate for Payer: Aetna Commercial |
$957.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$914.97
|
| Rate for Payer: Aetna Managed Medicare |
$297.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$691.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$531.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$510.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$563.88
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cigna Commercial |
$978.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$595.39
|
| Rate for Payer: Health EOS Commercial |
$946.89
|
| Rate for Payer: HFN Commercial |
$978.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$797.94
|
| Rate for Payer: Multiplan Commercial |
$851.14
|
| Rate for Payer: NAPHCARE Commercial |
$638.35
|
| Rate for Payer: Preferred Network Access Commercial |
$978.81
|
| Rate for Payer: Quartz Beloit One Network |
$521.32
|
| Rate for Payer: Quartz Commercial |
$691.55
|
| Rate for Payer: Quartz Medicare Advantage |
$638.35
|
| Rate for Payer: The Alliance Commercial |
$531.96
|
| Rate for Payer: WEA Trust Commercial |
$585.16
|
| Rate for Payer: WPS Commercial |
$788.02
|
|
|
TUBE RUSCH DBL LMN LT 39FR #11610039
|
Facility
|
IP
|
$1,023.00
|
|
| Hospital Charge Code |
2974627
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$521.32 |
| Max. Negotiated Rate |
$978.81 |
| Rate for Payer: Aetna Commercial |
$957.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$914.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$563.88
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cigna Commercial |
$978.81
|
| Rate for Payer: Health EOS Commercial |
$946.89
|
| Rate for Payer: HFN Commercial |
$978.81
|
| Rate for Payer: Multiplan Commercial |
$851.14
|
| Rate for Payer: Preferred Network Access Commercial |
$978.81
|
| Rate for Payer: Quartz Beloit One Network |
$521.32
|
| Rate for Payer: Quartz Commercial |
$638.35
|
| Rate for Payer: WEA Trust Commercial |
$585.16
|
| Rate for Payer: WPS Commercial |
$788.02
|
|
|
TUBE RUSCH DBL LMN LT 41FR #116100041
|
Facility
|
IP
|
$1,063.00
|
|
| Hospital Charge Code |
2974628
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$541.70 |
| Max. Negotiated Rate |
$1,017.08 |
| Rate for Payer: Aetna Commercial |
$994.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$950.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$585.93
|
| Rate for Payer: Cash Price |
$318.90
|
| Rate for Payer: Cigna Commercial |
$1,017.08
|
| Rate for Payer: Health EOS Commercial |
$983.91
|
| Rate for Payer: HFN Commercial |
$1,017.08
|
| Rate for Payer: Multiplan Commercial |
$884.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,017.08
|
| Rate for Payer: Quartz Beloit One Network |
$541.70
|
| Rate for Payer: Quartz Commercial |
$663.31
|
| Rate for Payer: WEA Trust Commercial |
$608.04
|
| Rate for Payer: WPS Commercial |
$818.83
|
|
|
TUBE RUSCH DBL LMN LT 41FR #116100041
|
Facility
|
OP
|
$1,063.00
|
|
| Hospital Charge Code |
2974628
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$309.55 |
| Max. Negotiated Rate |
$1,017.08 |
| Rate for Payer: Aetna Commercial |
$994.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$950.75
|
| Rate for Payer: Aetna Managed Medicare |
$309.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$718.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$552.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$530.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$585.93
|
| Rate for Payer: Cash Price |
$318.90
|
| Rate for Payer: Cigna Commercial |
$1,017.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$618.67
|
| Rate for Payer: Health EOS Commercial |
$983.91
|
| Rate for Payer: HFN Commercial |
$1,017.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$829.14
|
| Rate for Payer: Multiplan Commercial |
$884.42
|
| Rate for Payer: NAPHCARE Commercial |
$663.31
|
| Rate for Payer: Preferred Network Access Commercial |
$1,017.08
|
| Rate for Payer: Quartz Beloit One Network |
$541.70
|
| Rate for Payer: Quartz Commercial |
$718.59
|
| Rate for Payer: Quartz Medicare Advantage |
$663.31
|
| Rate for Payer: The Alliance Commercial |
$552.76
|
| Rate for Payer: WEA Trust Commercial |
$608.04
|
| Rate for Payer: WPS Commercial |
$818.83
|
|
|
TUBE RUSCH DBL LMN RT 35FR #116200035
|
Facility
|
IP
|
$1,319.00
|
|
| Hospital Charge Code |
2974714
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$672.16 |
| Max. Negotiated Rate |
$1,262.02 |
| Rate for Payer: Aetna Commercial |
$1,234.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,179.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$727.03
|
| Rate for Payer: Cash Price |
$395.70
|
| Rate for Payer: Cigna Commercial |
$1,262.02
|
| Rate for Payer: Health EOS Commercial |
$1,220.87
|
| Rate for Payer: HFN Commercial |
$1,262.02
|
| Rate for Payer: Multiplan Commercial |
$1,097.41
|
| Rate for Payer: Preferred Network Access Commercial |
$1,262.02
|
| Rate for Payer: Quartz Beloit One Network |
$672.16
|
| Rate for Payer: Quartz Commercial |
$823.06
|
| Rate for Payer: WEA Trust Commercial |
$754.47
|
| Rate for Payer: WPS Commercial |
$1,016.03
|
|
|
TUBE RUSCH DBL LMN RT 35FR #116200035
|
Facility
|
OP
|
$1,319.00
|
|
| Hospital Charge Code |
2974714
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$384.09 |
| Max. Negotiated Rate |
$1,262.02 |
| Rate for Payer: Aetna Commercial |
$1,234.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,179.71
|
| Rate for Payer: Aetna Managed Medicare |
$384.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$891.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$685.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$658.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$727.03
|
| Rate for Payer: Cash Price |
$395.70
|
| Rate for Payer: Cigna Commercial |
$1,262.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$767.66
|
| Rate for Payer: Health EOS Commercial |
$1,220.87
|
| Rate for Payer: HFN Commercial |
$1,262.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,028.82
|
| Rate for Payer: Multiplan Commercial |
$1,097.41
|
| Rate for Payer: NAPHCARE Commercial |
$823.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,262.02
|
| Rate for Payer: Quartz Beloit One Network |
$672.16
|
| Rate for Payer: Quartz Commercial |
$891.64
|
| Rate for Payer: Quartz Medicare Advantage |
$823.06
|
| Rate for Payer: The Alliance Commercial |
$685.88
|
| Rate for Payer: WEA Trust Commercial |
$754.47
|
| Rate for Payer: WPS Commercial |
$1,016.03
|
|
|
TUBE RUSCH DBL LMN RT 37fr. #116200037
|
Facility
|
OP
|
$1,319.00
|
|
| Hospital Charge Code |
2974713
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$384.09 |
| Max. Negotiated Rate |
$1,262.02 |
| Rate for Payer: Aetna Commercial |
$1,234.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,179.71
|
| Rate for Payer: Aetna Managed Medicare |
$384.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$891.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$685.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$658.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$727.03
|
| Rate for Payer: Cash Price |
$395.70
|
| Rate for Payer: Cigna Commercial |
$1,262.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$767.66
|
| Rate for Payer: Health EOS Commercial |
$1,220.87
|
| Rate for Payer: HFN Commercial |
$1,262.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,028.82
|
| Rate for Payer: Multiplan Commercial |
$1,097.41
|
| Rate for Payer: NAPHCARE Commercial |
$823.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,262.02
|
| Rate for Payer: Quartz Beloit One Network |
$672.16
|
| Rate for Payer: Quartz Commercial |
$891.64
|
| Rate for Payer: Quartz Medicare Advantage |
$823.06
|
| Rate for Payer: The Alliance Commercial |
$685.88
|
| Rate for Payer: WEA Trust Commercial |
$754.47
|
| Rate for Payer: WPS Commercial |
$1,016.03
|
|
|
TUBE RUSCH DBL LMN RT 37fr. #116200037
|
Facility
|
IP
|
$1,319.00
|
|
| Hospital Charge Code |
2974713
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$672.16 |
| Max. Negotiated Rate |
$1,262.02 |
| Rate for Payer: Aetna Commercial |
$1,234.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,179.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$727.03
|
| Rate for Payer: Cash Price |
$395.70
|
| Rate for Payer: Cigna Commercial |
$1,262.02
|
| Rate for Payer: Health EOS Commercial |
$1,220.87
|
| Rate for Payer: HFN Commercial |
$1,262.02
|
| Rate for Payer: Multiplan Commercial |
$1,097.41
|
| Rate for Payer: Preferred Network Access Commercial |
$1,262.02
|
| Rate for Payer: Quartz Beloit One Network |
$672.16
|
| Rate for Payer: Quartz Commercial |
$823.06
|
| Rate for Payer: WEA Trust Commercial |
$754.47
|
| Rate for Payer: WPS Commercial |
$1,016.03
|
|
|
TUBE RUSCH DBL LMN RT 39FR #116200039
|
Facility
|
OP
|
$1,308.00
|
|
| Hospital Charge Code |
2974712
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$380.89 |
| Max. Negotiated Rate |
$1,251.49 |
| Rate for Payer: Aetna Commercial |
$1,224.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,169.88
|
| Rate for Payer: Aetna Managed Medicare |
$380.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$884.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$680.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$652.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$720.97
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$1,251.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$761.26
|
| Rate for Payer: Health EOS Commercial |
$1,210.68
|
| Rate for Payer: HFN Commercial |
$1,251.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,020.24
|
| Rate for Payer: Multiplan Commercial |
$1,088.26
|
| Rate for Payer: NAPHCARE Commercial |
$816.19
|
| Rate for Payer: Preferred Network Access Commercial |
$1,251.49
|
| Rate for Payer: Quartz Beloit One Network |
$666.56
|
| Rate for Payer: Quartz Commercial |
$884.21
|
| Rate for Payer: Quartz Medicare Advantage |
$816.19
|
| Rate for Payer: The Alliance Commercial |
$680.16
|
| Rate for Payer: WEA Trust Commercial |
$748.18
|
| Rate for Payer: WPS Commercial |
$1,007.55
|
|
|
TUBE RUSCH DBL LMN RT 39FR #116200039
|
Facility
|
IP
|
$1,308.00
|
|
| Hospital Charge Code |
2974712
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$666.56 |
| Max. Negotiated Rate |
$1,251.49 |
| Rate for Payer: Aetna Commercial |
$1,224.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,169.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$720.97
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$1,251.49
|
| Rate for Payer: Health EOS Commercial |
$1,210.68
|
| Rate for Payer: HFN Commercial |
$1,251.49
|
| Rate for Payer: Multiplan Commercial |
$1,088.26
|
| Rate for Payer: Preferred Network Access Commercial |
$1,251.49
|
| Rate for Payer: Quartz Beloit One Network |
$666.56
|
| Rate for Payer: Quartz Commercial |
$816.19
|
| Rate for Payer: WEA Trust Commercial |
$748.18
|
| Rate for Payer: WPS Commercial |
$1,007.55
|
|
