|
VENT TUBE COLLAR BUTTON 1.27MM FLUOROPLASTIC 145214-ENT
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS L8613
|
| Hospital Charge Code |
4858870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.00
|
| Rate for Payer: Aetna Managed Medicare |
$56.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$130.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.92
|
| Rate for Payer: Health EOS Commercial |
$178.00
|
| Rate for Payer: HFN Commercial |
$184.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$150.00
|
| Rate for Payer: Multiplan Commercial |
$160.00
|
| Rate for Payer: NAPHCARE Commercial |
$120.00
|
| Rate for Payer: Preferred Network Access Commercial |
$184.00
|
| Rate for Payer: Quartz Beloit One Network |
$98.00
|
| Rate for Payer: Quartz Commercial |
$130.00
|
| Rate for Payer: Quartz Medicare Advantage |
$120.00
|
| Rate for Payer: The Alliance Commercial |
$800.00
|
| Rate for Payer: WEA Trust Commercial |
$110.00
|
| Rate for Payer: WPS Commercial |
$148.14
|
|
|
VENT TUBE COLLAR BUTTON 1.27MM SILICONE-ULTRASIL 70241314
|
Facility
|
OP
|
$254.00
|
|
| Hospital Charge Code |
2973366
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$71.12 |
| Max. Negotiated Rate |
$1,016.00 |
| Rate for Payer: Aetna Commercial |
$228.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.44
|
| Rate for Payer: Aetna Managed Medicare |
$71.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$165.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$127.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$121.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.62
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$233.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.14
|
| Rate for Payer: Health EOS Commercial |
$226.06
|
| Rate for Payer: HFN Commercial |
$233.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$190.50
|
| Rate for Payer: Multiplan Commercial |
$203.20
|
| Rate for Payer: NAPHCARE Commercial |
$152.40
|
| Rate for Payer: Preferred Network Access Commercial |
$233.68
|
| Rate for Payer: Quartz Beloit One Network |
$124.46
|
| Rate for Payer: Quartz Commercial |
$165.10
|
| Rate for Payer: Quartz Medicare Advantage |
$152.40
|
| Rate for Payer: The Alliance Commercial |
$1,016.00
|
| Rate for Payer: WEA Trust Commercial |
$139.70
|
| Rate for Payer: WPS Commercial |
$188.14
|
|
|
VENT TUBE COLLAR BUTTON 1.27MM SILICONE-ULTRASIL 70241314
|
Facility
|
IP
|
$254.00
|
|
| Hospital Charge Code |
2973366
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$124.46 |
| Max. Negotiated Rate |
$233.68 |
| Rate for Payer: Aetna Commercial |
$228.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.62
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$233.68
|
| Rate for Payer: Health EOS Commercial |
$226.06
|
| Rate for Payer: HFN Commercial |
$233.68
|
| Rate for Payer: Multiplan Commercial |
$203.20
|
| Rate for Payer: NAPHCARE Commercial |
$152.40
|
| Rate for Payer: Preferred Network Access Commercial |
$233.68
|
| Rate for Payer: Quartz Beloit One Network |
$124.46
|
| Rate for Payer: Quartz Commercial |
$152.40
|
| Rate for Payer: WEA Trust Commercial |
$139.70
|
| Rate for Payer: WPS Commercial |
$188.14
|
|
|
VENT TUBE EAR ARMSTRONG 1.14MM FLUOROPLASTIC 140242
|
Facility
|
OP
|
$378.00
|
|
| Hospital Charge Code |
2965126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.84 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: Aetna Commercial |
$340.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.08
|
| Rate for Payer: Aetna Managed Medicare |
$105.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$245.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$189.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$181.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$200.34
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$347.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$211.53
|
| Rate for Payer: Health EOS Commercial |
$336.42
|
| Rate for Payer: HFN Commercial |
$347.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$283.50
|
| Rate for Payer: Multiplan Commercial |
$302.40
|
| Rate for Payer: NAPHCARE Commercial |
$226.80
|
| Rate for Payer: Preferred Network Access Commercial |
$347.76
|
| Rate for Payer: Quartz Beloit One Network |
$185.22
|
| Rate for Payer: Quartz Commercial |
$245.70
|
| Rate for Payer: Quartz Medicare Advantage |
$226.80
|
| Rate for Payer: The Alliance Commercial |
$1,512.00
|
| Rate for Payer: WEA Trust Commercial |
$207.90
|
| Rate for Payer: WPS Commercial |
$279.98
|
|
|
VENT TUBE EAR ARMSTRONG 1.14MM FLUOROPLASTIC 140242
|
Facility
|
IP
|
$378.00
|
|
| Hospital Charge Code |
2965126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$185.22 |
| Max. Negotiated Rate |
$347.76 |
| Rate for Payer: Aetna Commercial |
$340.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$200.34
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$347.76
|
| Rate for Payer: Health EOS Commercial |
$336.42
|
| Rate for Payer: HFN Commercial |
$347.76
|
| Rate for Payer: Multiplan Commercial |
$302.40
|
| Rate for Payer: NAPHCARE Commercial |
$226.80
|
| Rate for Payer: Preferred Network Access Commercial |
$347.76
|
| Rate for Payer: Quartz Beloit One Network |
$185.22
|
| Rate for Payer: Quartz Commercial |
$226.80
|
| Rate for Payer: WEA Trust Commercial |
$207.90
|
| Rate for Payer: WPS Commercial |
$279.98
|
|
|
VENT TUBE EAR POPE BEVELED GROMMET 1.14MM POLYETHYLENE 145250
|
Facility
|
OP
|
$393.00
|
|
| Hospital Charge Code |
2965127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$110.04 |
| Max. Negotiated Rate |
$1,572.00 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Aetna Managed Medicare |
$110.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$255.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$196.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$188.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$219.92
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$294.75
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$255.45
|
| Rate for Payer: Quartz Medicare Advantage |
$235.80
|
| Rate for Payer: The Alliance Commercial |
$1,572.00
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
VENT TUBE EAR POPE BEVELED GROMMET 1.14MM POLYETHYLENE 145250
|
Facility
|
IP
|
$393.00
|
|
| Hospital Charge Code |
2965127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$192.57 |
| Max. Negotiated Rate |
$361.56 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$235.80
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
VENT TUBE EAR REUTER BOBBIN WITH FLANGE HOLES 1.00MM TITANIUM 145215
|
Facility
|
OP
|
$587.00
|
|
| Hospital Charge Code |
3939328
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$164.36 |
| Max. Negotiated Rate |
$2,348.00 |
| Rate for Payer: Aetna Commercial |
$528.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$504.82
|
| Rate for Payer: Aetna Managed Medicare |
$164.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$381.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$293.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$281.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.11
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$540.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$328.49
|
| Rate for Payer: Health EOS Commercial |
$522.43
|
| Rate for Payer: HFN Commercial |
$540.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$440.25
|
| Rate for Payer: Multiplan Commercial |
$469.60
|
| Rate for Payer: NAPHCARE Commercial |
$352.20
|
| Rate for Payer: Preferred Network Access Commercial |
$540.04
|
| Rate for Payer: Quartz Beloit One Network |
$287.63
|
| Rate for Payer: Quartz Commercial |
$381.55
|
| Rate for Payer: Quartz Medicare Advantage |
$352.20
|
| Rate for Payer: The Alliance Commercial |
$2,348.00
|
| Rate for Payer: WEA Trust Commercial |
$322.85
|
| Rate for Payer: WPS Commercial |
$434.79
|
|
|
VENT TUBE EAR REUTER BOBBIN WITH FLANGE HOLES 1.00MM TITANIUM 145215
|
Facility
|
IP
|
$587.00
|
|
| Hospital Charge Code |
3939328
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$287.63 |
| Max. Negotiated Rate |
$540.04 |
| Rate for Payer: Aetna Commercial |
$528.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$504.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.11
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$540.04
|
| Rate for Payer: Health EOS Commercial |
$522.43
|
| Rate for Payer: HFN Commercial |
$540.04
|
| Rate for Payer: Multiplan Commercial |
$469.60
|
| Rate for Payer: NAPHCARE Commercial |
$352.20
|
| Rate for Payer: Preferred Network Access Commercial |
$540.04
|
| Rate for Payer: Quartz Beloit One Network |
$287.63
|
| Rate for Payer: Quartz Commercial |
$352.20
|
| Rate for Payer: WEA Trust Commercial |
$322.85
|
| Rate for Payer: WPS Commercial |
$434.79
|
|
|
VENT TUBE EAR RICHARDS T-TUBE 1.14X12X9.8MM SILICONE 240071
|
Facility
|
IP
|
$410.00
|
|
| Hospital Charge Code |
5459827
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$200.90 |
| Max. Negotiated Rate |
$377.20 |
| Rate for Payer: Aetna Commercial |
$369.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.30
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$377.20
|
| Rate for Payer: Health EOS Commercial |
$364.90
|
| Rate for Payer: HFN Commercial |
$377.20
|
| Rate for Payer: Multiplan Commercial |
$328.00
|
| Rate for Payer: NAPHCARE Commercial |
$246.00
|
| Rate for Payer: Preferred Network Access Commercial |
$377.20
|
| Rate for Payer: Quartz Beloit One Network |
$200.90
|
| Rate for Payer: Quartz Commercial |
$246.00
|
| Rate for Payer: WEA Trust Commercial |
$225.50
|
| Rate for Payer: WPS Commercial |
$303.69
|
|
|
VENT TUBE EAR RICHARDS T-TUBE 1.14X12X9.8MM SILICONE 240071
|
Facility
|
OP
|
$410.00
|
|
| Hospital Charge Code |
5459827
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$114.80 |
| Max. Negotiated Rate |
$1,640.00 |
| Rate for Payer: Aetna Commercial |
$369.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.60
|
| Rate for Payer: Aetna Managed Medicare |
$114.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$266.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$205.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$196.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.30
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$377.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$229.44
|
| Rate for Payer: Health EOS Commercial |
$364.90
|
| Rate for Payer: HFN Commercial |
$377.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$307.50
|
| Rate for Payer: Multiplan Commercial |
$328.00
|
| Rate for Payer: NAPHCARE Commercial |
$246.00
|
| Rate for Payer: Preferred Network Access Commercial |
$377.20
|
| Rate for Payer: Quartz Beloit One Network |
$200.90
|
| Rate for Payer: Quartz Commercial |
$266.50
|
| Rate for Payer: Quartz Medicare Advantage |
$246.00
|
| Rate for Payer: The Alliance Commercial |
$1,640.00
|
| Rate for Payer: WEA Trust Commercial |
$225.50
|
| Rate for Payer: WPS Commercial |
$303.69
|
|
|
VENT TUBE EAR TRIUNE SILICONE 510-121
|
Facility
|
OP
|
$543.00
|
|
| Hospital Charge Code |
4163062
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$152.04 |
| Max. Negotiated Rate |
$2,172.00 |
| Rate for Payer: Aetna Commercial |
$488.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$466.98
|
| Rate for Payer: Aetna Managed Medicare |
$152.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$352.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$271.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$260.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$287.79
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cigna Commercial |
$499.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$303.86
|
| Rate for Payer: Health EOS Commercial |
$483.27
|
| Rate for Payer: HFN Commercial |
$499.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$407.25
|
| Rate for Payer: Multiplan Commercial |
$434.40
|
| Rate for Payer: NAPHCARE Commercial |
$325.80
|
| Rate for Payer: Preferred Network Access Commercial |
$499.56
|
| Rate for Payer: Quartz Beloit One Network |
$266.07
|
| Rate for Payer: Quartz Commercial |
$352.95
|
| Rate for Payer: Quartz Medicare Advantage |
$325.80
|
| Rate for Payer: The Alliance Commercial |
$2,172.00
|
| Rate for Payer: WEA Trust Commercial |
$298.65
|
| Rate for Payer: WPS Commercial |
$402.20
|
|
|
VENT TUBE EAR TRIUNE SILICONE 510-121
|
Facility
|
IP
|
$543.00
|
|
| Hospital Charge Code |
4163062
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.07 |
| Max. Negotiated Rate |
$499.56 |
| Rate for Payer: Aetna Commercial |
$488.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$466.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$287.79
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cigna Commercial |
$499.56
|
| Rate for Payer: Health EOS Commercial |
$483.27
|
| Rate for Payer: HFN Commercial |
$499.56
|
| Rate for Payer: Multiplan Commercial |
$434.40
|
| Rate for Payer: NAPHCARE Commercial |
$325.80
|
| Rate for Payer: Preferred Network Access Commercial |
$499.56
|
| Rate for Payer: Quartz Beloit One Network |
$266.07
|
| Rate for Payer: Quartz Commercial |
$325.80
|
| Rate for Payer: WEA Trust Commercial |
$298.65
|
| Rate for Payer: WPS Commercial |
$402.20
|
|
|
VENT TUBE EAR T-TUBE GOODE SILICONE BLUE 1087701
|
Facility
|
OP
|
$470.00
|
|
|
Service Code
|
HCPCS L8613
|
| Hospital Charge Code |
5563241
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$131.60 |
| Max. Negotiated Rate |
$1,880.00 |
| Rate for Payer: Aetna Commercial |
$423.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.20
|
| Rate for Payer: Aetna Managed Medicare |
$131.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$305.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$235.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$225.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.10
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$432.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$263.01
|
| Rate for Payer: Health EOS Commercial |
$418.30
|
| Rate for Payer: HFN Commercial |
$432.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$352.50
|
| Rate for Payer: Multiplan Commercial |
$376.00
|
| Rate for Payer: NAPHCARE Commercial |
$282.00
|
| Rate for Payer: Preferred Network Access Commercial |
$432.40
|
| Rate for Payer: Quartz Beloit One Network |
$230.30
|
| Rate for Payer: Quartz Commercial |
$305.50
|
| Rate for Payer: Quartz Medicare Advantage |
$282.00
|
| Rate for Payer: The Alliance Commercial |
$1,880.00
|
| Rate for Payer: WEA Trust Commercial |
$258.50
|
| Rate for Payer: WPS Commercial |
$348.13
|
|
|
VENT TUBE EAR T-TUBE GOODE SILICONE BLUE 1087701
|
Facility
|
IP
|
$470.00
|
|
|
Service Code
|
HCPCS L8613
|
| Hospital Charge Code |
5563241
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.30 |
| Max. Negotiated Rate |
$432.40 |
| Rate for Payer: Aetna Commercial |
$423.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.10
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$432.40
|
| Rate for Payer: Health EOS Commercial |
$418.30
|
| Rate for Payer: HFN Commercial |
$432.40
|
| Rate for Payer: Multiplan Commercial |
$376.00
|
| Rate for Payer: NAPHCARE Commercial |
$282.00
|
| Rate for Payer: Preferred Network Access Commercial |
$432.40
|
| Rate for Payer: Quartz Beloit One Network |
$230.30
|
| Rate for Payer: Quartz Commercial |
$282.00
|
| Rate for Payer: WEA Trust Commercial |
$258.50
|
| Rate for Payer: WPS Commercial |
$348.13
|
|
|
VENT TUBE EAR T-TUBE GROMMET ET-GTGST-50 VT-0403-01
|
Facility
|
IP
|
$438.00
|
|
| Hospital Charge Code |
5107219
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$214.62 |
| Max. Negotiated Rate |
$402.96 |
| Rate for Payer: Aetna Commercial |
$394.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$376.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$232.14
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$402.96
|
| Rate for Payer: Health EOS Commercial |
$389.82
|
| Rate for Payer: HFN Commercial |
$402.96
|
| Rate for Payer: Multiplan Commercial |
$350.40
|
| Rate for Payer: NAPHCARE Commercial |
$262.80
|
| Rate for Payer: Preferred Network Access Commercial |
$402.96
|
| Rate for Payer: Quartz Beloit One Network |
$214.62
|
| Rate for Payer: Quartz Commercial |
$262.80
|
| Rate for Payer: WEA Trust Commercial |
$240.90
|
| Rate for Payer: WPS Commercial |
$324.43
|
|
|
VENT TUBE EAR T-TUBE GROMMET ET-GTGST-50 VT-0403-01
|
Facility
|
OP
|
$438.00
|
|
| Hospital Charge Code |
5107219
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$122.64 |
| Max. Negotiated Rate |
$1,752.00 |
| Rate for Payer: Aetna Commercial |
$394.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$376.68
|
| Rate for Payer: Aetna Managed Medicare |
$122.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$284.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$219.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$210.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$232.14
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$402.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$245.10
|
| Rate for Payer: Health EOS Commercial |
$389.82
|
| Rate for Payer: HFN Commercial |
$402.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$328.50
|
| Rate for Payer: Multiplan Commercial |
$350.40
|
| Rate for Payer: NAPHCARE Commercial |
$262.80
|
| Rate for Payer: Preferred Network Access Commercial |
$402.96
|
| Rate for Payer: Quartz Beloit One Network |
$214.62
|
| Rate for Payer: Quartz Commercial |
$284.70
|
| Rate for Payer: Quartz Medicare Advantage |
$262.80
|
| Rate for Payer: The Alliance Commercial |
$1,752.00
|
| Rate for Payer: WEA Trust Commercial |
$240.90
|
| Rate for Payer: WPS Commercial |
$324.43
|
|
|
VENT TUBE EAR T-TUBE MODIFIED 1.32X4.80MM SILICONE BLUE 240072
|
Facility
|
OP
|
$523.00
|
|
| Hospital Charge Code |
2965128
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$146.44 |
| Max. Negotiated Rate |
$2,092.00 |
| Rate for Payer: Aetna Commercial |
$470.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$449.78
|
| Rate for Payer: Aetna Managed Medicare |
$146.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$339.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$261.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$251.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$277.19
|
| Rate for Payer: Cash Price |
$156.90
|
| Rate for Payer: Cigna Commercial |
$481.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$292.67
|
| Rate for Payer: Health EOS Commercial |
$465.47
|
| Rate for Payer: HFN Commercial |
$481.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$392.25
|
| Rate for Payer: Multiplan Commercial |
$418.40
|
| Rate for Payer: NAPHCARE Commercial |
$313.80
|
| Rate for Payer: Preferred Network Access Commercial |
$481.16
|
| Rate for Payer: Quartz Beloit One Network |
$256.27
|
| Rate for Payer: Quartz Commercial |
$339.95
|
| Rate for Payer: Quartz Medicare Advantage |
$313.80
|
| Rate for Payer: The Alliance Commercial |
$2,092.00
|
| Rate for Payer: WEA Trust Commercial |
$287.65
|
| Rate for Payer: WPS Commercial |
$387.39
|
|
|
VENT TUBE EAR T-TUBE MODIFIED 1.32X4.80MM SILICONE BLUE 240072
|
Facility
|
IP
|
$523.00
|
|
| Hospital Charge Code |
2965128
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$256.27 |
| Max. Negotiated Rate |
$481.16 |
| Rate for Payer: Aetna Commercial |
$470.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$449.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$277.19
|
| Rate for Payer: Cash Price |
$156.90
|
| Rate for Payer: Cigna Commercial |
$481.16
|
| Rate for Payer: Health EOS Commercial |
$465.47
|
| Rate for Payer: HFN Commercial |
$481.16
|
| Rate for Payer: Multiplan Commercial |
$418.40
|
| Rate for Payer: NAPHCARE Commercial |
$313.80
|
| Rate for Payer: Preferred Network Access Commercial |
$481.16
|
| Rate for Payer: Quartz Beloit One Network |
$256.27
|
| Rate for Payer: Quartz Commercial |
$313.80
|
| Rate for Payer: WEA Trust Commercial |
$287.65
|
| Rate for Payer: WPS Commercial |
$387.39
|
|
|
VENT TUBE EAR TUEBINGER 2-EYELET GOLD PLATINUM LONG TERM 1015065
|
Facility
|
IP
|
$831.00
|
|
| Hospital Charge Code |
4366022
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$407.19 |
| Max. Negotiated Rate |
$764.52 |
| Rate for Payer: Aetna Commercial |
$747.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$714.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$440.43
|
| Rate for Payer: Cash Price |
$249.30
|
| Rate for Payer: Cigna Commercial |
$764.52
|
| Rate for Payer: Health EOS Commercial |
$739.59
|
| Rate for Payer: HFN Commercial |
$764.52
|
| Rate for Payer: Multiplan Commercial |
$664.80
|
| Rate for Payer: NAPHCARE Commercial |
$498.60
|
| Rate for Payer: Preferred Network Access Commercial |
$764.52
|
| Rate for Payer: Quartz Beloit One Network |
$407.19
|
| Rate for Payer: Quartz Commercial |
$498.60
|
| Rate for Payer: WEA Trust Commercial |
$457.05
|
| Rate for Payer: WPS Commercial |
$615.52
|
|
|
VENT TUBE EAR TUEBINGER 2-EYELET GOLD PLATINUM LONG TERM 1015065
|
Facility
|
OP
|
$831.00
|
|
| Hospital Charge Code |
4366022
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$232.68 |
| Max. Negotiated Rate |
$3,324.00 |
| Rate for Payer: Aetna Commercial |
$747.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$714.66
|
| Rate for Payer: Aetna Managed Medicare |
$232.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$540.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$415.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$398.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$440.43
|
| Rate for Payer: Cash Price |
$249.30
|
| Rate for Payer: Cigna Commercial |
$764.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$465.03
|
| Rate for Payer: Health EOS Commercial |
$739.59
|
| Rate for Payer: HFN Commercial |
$764.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$623.25
|
| Rate for Payer: Multiplan Commercial |
$664.80
|
| Rate for Payer: NAPHCARE Commercial |
$498.60
|
| Rate for Payer: Preferred Network Access Commercial |
$764.52
|
| Rate for Payer: Quartz Beloit One Network |
$407.19
|
| Rate for Payer: Quartz Commercial |
$540.15
|
| Rate for Payer: Quartz Medicare Advantage |
$498.60
|
| Rate for Payer: The Alliance Commercial |
$3,324.00
|
| Rate for Payer: WEA Trust Commercial |
$457.05
|
| Rate for Payer: WPS Commercial |
$615.52
|
|
|
Verapamil Level
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5364649
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$55.37 |
| Max. Negotiated Rate |
$103.96 |
| Rate for Payer: Aetna Commercial |
$101.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.89
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cigna Commercial |
$103.96
|
| Rate for Payer: Health EOS Commercial |
$100.57
|
| Rate for Payer: HFN Commercial |
$103.96
|
| Rate for Payer: Multiplan Commercial |
$90.40
|
| Rate for Payer: NAPHCARE Commercial |
$67.80
|
| Rate for Payer: Preferred Network Access Commercial |
$103.96
|
| Rate for Payer: Quartz Beloit One Network |
$55.37
|
| Rate for Payer: Quartz Commercial |
$67.80
|
| Rate for Payer: WEA Trust Commercial |
$62.15
|
| Rate for Payer: WPS Commercial |
$83.70
|
|
|
Verapamil Level
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5364649
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$103.96 |
| Rate for Payer: Aetna Commercial |
$101.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97.18
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cigna Commercial |
$103.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.23
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$100.57
|
| Rate for Payer: HFN Commercial |
$103.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$90.40
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$103.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$55.37
|
| Rate for Payer: Quartz Commercial |
$73.45
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$74.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$84.75
|
| Rate for Payer: WEA Trust Commercial |
$62.15
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$83.70
|
|
|
Verapamil Level
|
Professional
|
Both
|
$113.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5364649
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.72 |
| Max. Negotiated Rate |
$107.35 |
| Rate for Payer: Aetna Commercial |
$107.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97.18
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cigna Commercial |
$107.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.80
|
| Rate for Payer: Health EOS Commercial |
$102.83
|
| Rate for Payer: HFN Commercial |
$107.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Multiplan Commercial |
$90.40
|
| Rate for Payer: Preferred Network Access Commercial |
$107.35
|
| Rate for Payer: Quartz Beloit One Network |
$49.72
|
| Rate for Payer: Quartz Commercial |
$64.41
|
| Rate for Payer: The Alliance Commercial |
$56.50
|
| Rate for Payer: WEA Trust Commercial |
$62.15
|
| Rate for Payer: WPS Commercial |
$83.70
|
|
|
Verbalizes understanding
|
Facility
|
OP
|
$53.00
|
|
| Hospital Charge Code |
2990174
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$212.00 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Aetna Managed Medicare |
$14.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.75
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$34.45
|
| Rate for Payer: Quartz Medicare Advantage |
$31.80
|
| Rate for Payer: The Alliance Commercial |
$212.00
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
