|
VENTRICULAR SHUNT PROCEDURES WITH MCC
|
Facility
|
IP
|
$114,154.56
|
|
|
Service Code
|
MSDRG 031
|
| Min. Negotiated Rate |
$34,819.32 |
| Max. Negotiated Rate |
$114,154.56 |
| Rate for Payer: Aetna Managed Medicare |
$34,819.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$97,760.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$74,932.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$71,191.20
|
| Rate for Payer: Anthem Medicare Advantage |
$34,819.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$34,819.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$34,819.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$34,819.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79,028.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$34,819.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83,484.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$34,819.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$34,819.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$34,819.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$34,819.32
|
| Rate for Payer: NAPHCARE Commercial |
$52,228.99
|
| Rate for Payer: Quartz Medicare Advantage |
$34,819.32
|
| Rate for Payer: The Alliance Commercial |
$114,154.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34,819.32
|
| Rate for Payer: United Healthcare PPO |
$64,993.86
|
| Rate for Payer: Wellcare Medicare |
$34,819.32
|
|
|
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$45,205.68
|
|
|
Service Code
|
MSDRG 033
|
| Min. Negotiated Rate |
$13,241.59 |
| Max. Negotiated Rate |
$45,205.68 |
| Rate for Payer: Aetna Managed Medicare |
$13,241.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36,283.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27,810.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26,422.02
|
| Rate for Payer: Anthem Medicare Advantage |
$13,241.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13,241.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13,241.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13,241.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29,330.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13,241.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,912.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13,241.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13,241.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13,241.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13,241.59
|
| Rate for Payer: NAPHCARE Commercial |
$19,862.39
|
| Rate for Payer: Quartz Medicare Advantage |
$13,241.59
|
| Rate for Payer: The Alliance Commercial |
$45,205.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13,241.59
|
| Rate for Payer: United Healthcare PPO |
$25,622.73
|
| Rate for Payer: Wellcare Medicare |
$13,241.59
|
|
|
VENT TUBE COLLAR BUTTON 1.27MM FLUOROPLASTIC 145214-ENT
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
HCPCS L8613
|
| Hospital Charge Code |
4858870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
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 |
$58.24 |
| Max. Negotiated Rate |
$1,740.79 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Aetna Managed Medicare |
$58.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$135.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$99.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$135.20
|
| Rate for Payer: Quartz Medicare Advantage |
$124.80
|
| Rate for Payer: The Alliance Commercial |
$1,740.79
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
VENT TUBE COLLAR BUTTON 1.27MM SILICONE-ULTRASIL 70241314
|
Facility
|
OP
|
$254.00
|
|
| Hospital Charge Code |
2973366
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$73.96 |
| Max. Negotiated Rate |
$243.03 |
| Rate for Payer: Aetna Commercial |
$237.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.18
|
| Rate for Payer: Aetna Managed Medicare |
$73.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$171.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$132.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$126.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.00
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$243.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.83
|
| Rate for Payer: Health EOS Commercial |
$235.10
|
| Rate for Payer: HFN Commercial |
$243.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$198.12
|
| Rate for Payer: Multiplan Commercial |
$211.33
|
| Rate for Payer: NAPHCARE Commercial |
$158.50
|
| Rate for Payer: Preferred Network Access Commercial |
$243.03
|
| Rate for Payer: Quartz Beloit One Network |
$129.44
|
| Rate for Payer: Quartz Commercial |
$171.70
|
| Rate for Payer: Quartz Medicare Advantage |
$158.50
|
| Rate for Payer: The Alliance Commercial |
$132.08
|
| Rate for Payer: WEA Trust Commercial |
$145.29
|
| Rate for Payer: WPS Commercial |
$195.66
|
|
|
VENT TUBE COLLAR BUTTON 1.27MM SILICONE-ULTRASIL 70241314
|
Facility
|
IP
|
$254.00
|
|
| Hospital Charge Code |
2973366
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$129.44 |
| Max. Negotiated Rate |
$243.03 |
| Rate for Payer: Aetna Commercial |
$237.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.00
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$243.03
|
| Rate for Payer: Health EOS Commercial |
$235.10
|
| Rate for Payer: HFN Commercial |
$243.03
|
| Rate for Payer: Multiplan Commercial |
$211.33
|
| Rate for Payer: Preferred Network Access Commercial |
$243.03
|
| Rate for Payer: Quartz Beloit One Network |
$129.44
|
| Rate for Payer: Quartz Commercial |
$158.50
|
| Rate for Payer: WEA Trust Commercial |
$145.29
|
| Rate for Payer: WPS Commercial |
$195.66
|
|
|
VENT TUBE EAR ARMSTRONG 1.14MM FLUOROPLASTIC 140242
|
Facility
|
OP
|
$378.00
|
|
| Hospital Charge Code |
2965126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$110.07 |
| Max. Negotiated Rate |
$361.67 |
| Rate for Payer: Aetna Commercial |
$353.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.08
|
| Rate for Payer: Aetna Managed Medicare |
$110.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$255.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$196.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$188.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.35
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$361.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$220.00
|
| Rate for Payer: Health EOS Commercial |
$349.88
|
| Rate for Payer: HFN Commercial |
$361.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$294.84
|
| Rate for Payer: Multiplan Commercial |
$314.50
|
| Rate for Payer: NAPHCARE Commercial |
$235.87
|
| Rate for Payer: Preferred Network Access Commercial |
$361.67
|
| Rate for Payer: Quartz Beloit One Network |
$192.63
|
| Rate for Payer: Quartz Commercial |
$255.53
|
| Rate for Payer: Quartz Medicare Advantage |
$235.87
|
| Rate for Payer: The Alliance Commercial |
$196.56
|
| Rate for Payer: WEA Trust Commercial |
$216.22
|
| Rate for Payer: WPS Commercial |
$291.17
|
|
|
VENT TUBE EAR ARMSTRONG 1.14MM FLUOROPLASTIC 140242
|
Facility
|
IP
|
$378.00
|
|
| Hospital Charge Code |
2965126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$192.63 |
| Max. Negotiated Rate |
$361.67 |
| Rate for Payer: Aetna Commercial |
$353.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.35
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$361.67
|
| Rate for Payer: Health EOS Commercial |
$349.88
|
| Rate for Payer: HFN Commercial |
$361.67
|
| Rate for Payer: Multiplan Commercial |
$314.50
|
| Rate for Payer: Preferred Network Access Commercial |
$361.67
|
| Rate for Payer: Quartz Beloit One Network |
$192.63
|
| Rate for Payer: Quartz Commercial |
$235.87
|
| Rate for Payer: WEA Trust Commercial |
$216.22
|
| Rate for Payer: WPS Commercial |
$291.17
|
|
|
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 |
$200.27 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$245.23
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
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 |
$114.44 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Aetna Managed Medicare |
$114.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$265.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$204.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$196.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$228.73
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$306.54
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: NAPHCARE Commercial |
$245.23
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$265.67
|
| Rate for Payer: Quartz Medicare Advantage |
$245.23
|
| Rate for Payer: The Alliance Commercial |
$204.36
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
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 |
$299.14 |
| Max. Negotiated Rate |
$561.64 |
| Rate for Payer: Aetna Commercial |
$549.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.55
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$561.64
|
| Rate for Payer: Health EOS Commercial |
$543.33
|
| Rate for Payer: HFN Commercial |
$561.64
|
| Rate for Payer: Multiplan Commercial |
$488.38
|
| Rate for Payer: Preferred Network Access Commercial |
$561.64
|
| Rate for Payer: Quartz Beloit One Network |
$299.14
|
| Rate for Payer: Quartz Commercial |
$366.29
|
| Rate for Payer: WEA Trust Commercial |
$335.76
|
| Rate for Payer: WPS Commercial |
$452.17
|
|
|
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 |
$170.93 |
| Max. Negotiated Rate |
$561.64 |
| Rate for Payer: Aetna Commercial |
$549.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.01
|
| Rate for Payer: Aetna Managed Medicare |
$170.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$396.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$305.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$293.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.55
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$561.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.63
|
| Rate for Payer: Health EOS Commercial |
$543.33
|
| Rate for Payer: HFN Commercial |
$561.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$457.86
|
| Rate for Payer: Multiplan Commercial |
$488.38
|
| Rate for Payer: NAPHCARE Commercial |
$366.29
|
| Rate for Payer: Preferred Network Access Commercial |
$561.64
|
| Rate for Payer: Quartz Beloit One Network |
$299.14
|
| Rate for Payer: Quartz Commercial |
$396.81
|
| Rate for Payer: Quartz Medicare Advantage |
$366.29
|
| Rate for Payer: The Alliance Commercial |
$305.24
|
| Rate for Payer: WEA Trust Commercial |
$335.76
|
| Rate for Payer: WPS Commercial |
$452.17
|
|
|
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 |
$119.39 |
| Max. Negotiated Rate |
$392.29 |
| Rate for Payer: Aetna Commercial |
$383.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$366.70
|
| Rate for Payer: Aetna Managed Medicare |
$119.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$277.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$213.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$204.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$225.99
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$392.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$238.62
|
| Rate for Payer: Health EOS Commercial |
$379.50
|
| Rate for Payer: HFN Commercial |
$392.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$319.80
|
| Rate for Payer: Multiplan Commercial |
$341.12
|
| Rate for Payer: NAPHCARE Commercial |
$255.84
|
| Rate for Payer: Preferred Network Access Commercial |
$392.29
|
| Rate for Payer: Quartz Beloit One Network |
$208.94
|
| Rate for Payer: Quartz Commercial |
$277.16
|
| Rate for Payer: Quartz Medicare Advantage |
$255.84
|
| Rate for Payer: The Alliance Commercial |
$213.20
|
| Rate for Payer: WEA Trust Commercial |
$234.52
|
| Rate for Payer: WPS Commercial |
$315.82
|
|
|
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 |
$208.94 |
| Max. Negotiated Rate |
$392.29 |
| Rate for Payer: Aetna Commercial |
$383.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$366.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$225.99
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$392.29
|
| Rate for Payer: Health EOS Commercial |
$379.50
|
| Rate for Payer: HFN Commercial |
$392.29
|
| Rate for Payer: Multiplan Commercial |
$341.12
|
| Rate for Payer: Preferred Network Access Commercial |
$392.29
|
| Rate for Payer: Quartz Beloit One Network |
$208.94
|
| Rate for Payer: Quartz Commercial |
$255.84
|
| Rate for Payer: WEA Trust Commercial |
$234.52
|
| Rate for Payer: WPS Commercial |
$315.82
|
|
|
VENT TUBE EAR TRIUNE SILICONE 510-121
|
Facility
|
IP
|
$543.00
|
|
| Hospital Charge Code |
4163062
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$276.71 |
| Max. Negotiated Rate |
$519.54 |
| Rate for Payer: Aetna Commercial |
$508.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$485.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$299.30
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cigna Commercial |
$519.54
|
| Rate for Payer: Health EOS Commercial |
$502.60
|
| Rate for Payer: HFN Commercial |
$519.54
|
| Rate for Payer: Multiplan Commercial |
$451.78
|
| Rate for Payer: Preferred Network Access Commercial |
$519.54
|
| Rate for Payer: Quartz Beloit One Network |
$276.71
|
| Rate for Payer: Quartz Commercial |
$338.83
|
| Rate for Payer: WEA Trust Commercial |
$310.60
|
| Rate for Payer: WPS Commercial |
$418.27
|
|
|
VENT TUBE EAR TRIUNE SILICONE 510-121
|
Facility
|
OP
|
$543.00
|
|
| Hospital Charge Code |
4163062
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$158.12 |
| Max. Negotiated Rate |
$519.54 |
| Rate for Payer: Aetna Commercial |
$508.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$485.66
|
| Rate for Payer: Aetna Managed Medicare |
$158.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$367.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$282.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$271.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$299.30
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cigna Commercial |
$519.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$316.03
|
| Rate for Payer: Health EOS Commercial |
$502.60
|
| Rate for Payer: HFN Commercial |
$519.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.54
|
| Rate for Payer: Multiplan Commercial |
$451.78
|
| Rate for Payer: NAPHCARE Commercial |
$338.83
|
| Rate for Payer: Preferred Network Access Commercial |
$519.54
|
| Rate for Payer: Quartz Beloit One Network |
$276.71
|
| Rate for Payer: Quartz Commercial |
$367.07
|
| Rate for Payer: Quartz Medicare Advantage |
$338.83
|
| Rate for Payer: The Alliance Commercial |
$282.36
|
| Rate for Payer: WEA Trust Commercial |
$310.60
|
| Rate for Payer: WPS Commercial |
$418.27
|
|
|
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 |
$239.51 |
| Max. Negotiated Rate |
$449.70 |
| Rate for Payer: Aetna Commercial |
$439.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$259.06
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$449.70
|
| Rate for Payer: Health EOS Commercial |
$435.03
|
| Rate for Payer: HFN Commercial |
$449.70
|
| Rate for Payer: Multiplan Commercial |
$391.04
|
| Rate for Payer: Preferred Network Access Commercial |
$449.70
|
| Rate for Payer: Quartz Beloit One Network |
$239.51
|
| Rate for Payer: Quartz Commercial |
$293.28
|
| Rate for Payer: WEA Trust Commercial |
$268.84
|
| Rate for Payer: WPS Commercial |
$362.04
|
|
|
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 |
$136.86 |
| Max. Negotiated Rate |
$1,740.79 |
| Rate for Payer: Aetna Commercial |
$439.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.37
|
| Rate for Payer: Aetna Managed Medicare |
$136.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$317.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$244.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$234.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$259.06
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$449.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$273.54
|
| Rate for Payer: Health EOS Commercial |
$435.03
|
| Rate for Payer: HFN Commercial |
$449.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$366.60
|
| Rate for Payer: Multiplan Commercial |
$391.04
|
| Rate for Payer: NAPHCARE Commercial |
$293.28
|
| Rate for Payer: Preferred Network Access Commercial |
$449.70
|
| Rate for Payer: Quartz Beloit One Network |
$239.51
|
| Rate for Payer: Quartz Commercial |
$317.72
|
| Rate for Payer: Quartz Medicare Advantage |
$293.28
|
| Rate for Payer: The Alliance Commercial |
$1,740.79
|
| Rate for Payer: WEA Trust Commercial |
$268.84
|
| Rate for Payer: WPS Commercial |
$362.04
|
|
|
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 |
$223.20 |
| Max. Negotiated Rate |
$419.08 |
| Rate for Payer: Aetna Commercial |
$409.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$391.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.43
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$419.08
|
| Rate for Payer: Health EOS Commercial |
$405.41
|
| Rate for Payer: HFN Commercial |
$419.08
|
| Rate for Payer: Multiplan Commercial |
$364.42
|
| Rate for Payer: Preferred Network Access Commercial |
$419.08
|
| Rate for Payer: Quartz Beloit One Network |
$223.20
|
| Rate for Payer: Quartz Commercial |
$273.31
|
| Rate for Payer: WEA Trust Commercial |
$250.54
|
| Rate for Payer: WPS Commercial |
$337.39
|
|
|
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 |
$127.55 |
| Max. Negotiated Rate |
$419.08 |
| Rate for Payer: Aetna Commercial |
$409.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$391.75
|
| Rate for Payer: Aetna Managed Medicare |
$127.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$296.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$227.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$218.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.43
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$419.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$254.92
|
| Rate for Payer: Health EOS Commercial |
$405.41
|
| Rate for Payer: HFN Commercial |
$419.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$341.64
|
| Rate for Payer: Multiplan Commercial |
$364.42
|
| Rate for Payer: NAPHCARE Commercial |
$273.31
|
| Rate for Payer: Preferred Network Access Commercial |
$419.08
|
| Rate for Payer: Quartz Beloit One Network |
$223.20
|
| Rate for Payer: Quartz Commercial |
$296.09
|
| Rate for Payer: Quartz Medicare Advantage |
$273.31
|
| Rate for Payer: The Alliance Commercial |
$227.76
|
| Rate for Payer: WEA Trust Commercial |
$250.54
|
| Rate for Payer: WPS Commercial |
$337.39
|
|
|
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 |
$152.30 |
| Max. Negotiated Rate |
$500.41 |
| Rate for Payer: Aetna Commercial |
$489.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$467.77
|
| Rate for Payer: Aetna Managed Medicare |
$152.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$353.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$271.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$261.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$288.28
|
| Rate for Payer: Cash Price |
$156.90
|
| Rate for Payer: Cigna Commercial |
$500.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$304.39
|
| Rate for Payer: Health EOS Commercial |
$484.09
|
| Rate for Payer: HFN Commercial |
$500.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$407.94
|
| Rate for Payer: Multiplan Commercial |
$435.14
|
| Rate for Payer: NAPHCARE Commercial |
$326.35
|
| Rate for Payer: Preferred Network Access Commercial |
$500.41
|
| Rate for Payer: Quartz Beloit One Network |
$266.52
|
| Rate for Payer: Quartz Commercial |
$353.55
|
| Rate for Payer: Quartz Medicare Advantage |
$326.35
|
| Rate for Payer: The Alliance Commercial |
$271.96
|
| Rate for Payer: WEA Trust Commercial |
$299.16
|
| Rate for Payer: WPS Commercial |
$402.87
|
|
|
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 |
$266.52 |
| Max. Negotiated Rate |
$500.41 |
| Rate for Payer: Aetna Commercial |
$489.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$467.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$288.28
|
| Rate for Payer: Cash Price |
$156.90
|
| Rate for Payer: Cigna Commercial |
$500.41
|
| Rate for Payer: Health EOS Commercial |
$484.09
|
| Rate for Payer: HFN Commercial |
$500.41
|
| Rate for Payer: Multiplan Commercial |
$435.14
|
| Rate for Payer: Preferred Network Access Commercial |
$500.41
|
| Rate for Payer: Quartz Beloit One Network |
$266.52
|
| Rate for Payer: Quartz Commercial |
$326.35
|
| Rate for Payer: WEA Trust Commercial |
$299.16
|
| Rate for Payer: WPS Commercial |
$402.87
|
|
|
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 |
$423.48 |
| Max. Negotiated Rate |
$795.10 |
| Rate for Payer: Aetna Commercial |
$777.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$743.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$458.05
|
| Rate for Payer: Cash Price |
$249.30
|
| Rate for Payer: Cigna Commercial |
$795.10
|
| Rate for Payer: Health EOS Commercial |
$769.17
|
| Rate for Payer: HFN Commercial |
$795.10
|
| Rate for Payer: Multiplan Commercial |
$691.39
|
| Rate for Payer: Preferred Network Access Commercial |
$795.10
|
| Rate for Payer: Quartz Beloit One Network |
$423.48
|
| Rate for Payer: Quartz Commercial |
$518.54
|
| Rate for Payer: WEA Trust Commercial |
$475.33
|
| Rate for Payer: WPS Commercial |
$640.12
|
|
|
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 |
$241.99 |
| Max. Negotiated Rate |
$795.10 |
| Rate for Payer: Aetna Commercial |
$777.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$743.25
|
| Rate for Payer: Aetna Managed Medicare |
$241.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$561.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$432.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$414.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$458.05
|
| Rate for Payer: Cash Price |
$249.30
|
| Rate for Payer: Cigna Commercial |
$795.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$483.64
|
| Rate for Payer: Health EOS Commercial |
$769.17
|
| Rate for Payer: HFN Commercial |
$795.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$648.18
|
| Rate for Payer: Multiplan Commercial |
$691.39
|
| Rate for Payer: NAPHCARE Commercial |
$518.54
|
| Rate for Payer: Preferred Network Access Commercial |
$795.10
|
| Rate for Payer: Quartz Beloit One Network |
$423.48
|
| Rate for Payer: Quartz Commercial |
$561.76
|
| Rate for Payer: Quartz Medicare Advantage |
$518.54
|
| Rate for Payer: The Alliance Commercial |
$432.12
|
| Rate for Payer: WEA Trust Commercial |
$475.33
|
| Rate for Payer: WPS Commercial |
$640.12
|
|
|
Verapamil Level
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5364649
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$108.12 |
| Rate for Payer: Aetna Commercial |
$105.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.07
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.18
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cigna Commercial |
$108.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$104.59
|
| Rate for Payer: HFN Commercial |
$108.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$94.02
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$108.12
|
| Rate for Payer: Quartz Beloit One Network |
$57.58
|
| Rate for Payer: Quartz Commercial |
$76.39
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$77.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: United Healthcare PPO |
$88.14
|
| Rate for Payer: WEA Trust Commercial |
$64.64
|
| Rate for Payer: Wellcare Medicare |
$19.39
|
| Rate for Payer: WPS Commercial |
$87.04
|
|
