|
Fecal Fat, Total, Quantitative 24,48 Hour
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
CPT 82710
|
| Hospital Charge Code |
4494784
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.47 |
| Max. Negotiated Rate |
$76.88 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Aetna Managed Medicare |
$17.47
|
| Rate for Payer: Anthem Medicare Advantage |
$17.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.47
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$52.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.47
|
| Rate for Payer: Health EOS Commercial |
$50.16
|
| Rate for Payer: HFN Commercial |
$52.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$61.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.47
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: NAPHCARE Commercial |
$26.21
|
| Rate for Payer: Preferred Network Access Commercial |
$52.36
|
| Rate for Payer: Quartz Beloit One Network |
$24.25
|
| Rate for Payer: Quartz Commercial |
$31.42
|
| Rate for Payer: Quartz Medicare Advantage |
$17.47
|
| Rate for Payer: The Alliance Commercial |
$69.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.47
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$76.88
|
|
|
Fecal Fat, Total, Quantitative 24,48 Hour
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
CPT 82710
|
| Hospital Charge Code |
4494784
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.01 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$33.07
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$40.83
|
|
|
Fecal Fat, Total, Quantitative 24,48 Hour
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
CPT 82710
|
| Hospital Charge Code |
4494784
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.47 |
| Max. Negotiated Rate |
$69.89 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Aetna Managed Medicare |
$17.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.58
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.00
|
| Rate for Payer: Anthem Medicare Advantage |
$17.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.47
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.47
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.47
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.47
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.47
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: NAPHCARE Commercial |
$26.21
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$35.83
|
| Rate for Payer: Quartz Medicare Advantage |
$17.47
|
| Rate for Payer: The Alliance Commercial |
$69.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.47
|
| Rate for Payer: United Healthcare PPO |
$41.34
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: Wellcare Medicare |
$17.47
|
| Rate for Payer: WPS Commercial |
$40.83
|
|
|
Fecal Incontinence Mngt
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005550
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.74 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$64.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.79
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$173.94
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$139.15
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$150.75
|
| Rate for Payer: Quartz Medicare Advantage |
$139.15
|
| Rate for Payer: The Alliance Commercial |
$30.74
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
Fecal Incontinence Mngt
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005550
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$113.64 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$139.15
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
FEEDING PUMP
|
Facility
|
OP
|
$207.00
|
|
| Hospital Charge Code |
3075877
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$60.28 |
| Max. Negotiated Rate |
$198.06 |
| Rate for Payer: Aetna Commercial |
$193.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.14
|
| Rate for Payer: Aetna Managed Medicare |
$60.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$139.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$107.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$103.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$198.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$120.47
|
| Rate for Payer: Health EOS Commercial |
$191.60
|
| Rate for Payer: HFN Commercial |
$198.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$161.46
|
| Rate for Payer: Multiplan Commercial |
$172.22
|
| Rate for Payer: NAPHCARE Commercial |
$129.17
|
| Rate for Payer: Preferred Network Access Commercial |
$198.06
|
| Rate for Payer: Quartz Beloit One Network |
$105.49
|
| Rate for Payer: Quartz Commercial |
$139.93
|
| Rate for Payer: Quartz Medicare Advantage |
$129.17
|
| Rate for Payer: The Alliance Commercial |
$107.64
|
| Rate for Payer: WEA Trust Commercial |
$118.40
|
| Rate for Payer: WPS Commercial |
$159.45
|
|
|
FEEDING PUMP
|
Facility
|
IP
|
$207.00
|
|
| Hospital Charge Code |
3075877
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$105.49 |
| Max. Negotiated Rate |
$198.06 |
| Rate for Payer: Aetna Commercial |
$193.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$198.06
|
| Rate for Payer: Health EOS Commercial |
$191.60
|
| Rate for Payer: HFN Commercial |
$198.06
|
| Rate for Payer: Multiplan Commercial |
$172.22
|
| Rate for Payer: Preferred Network Access Commercial |
$198.06
|
| Rate for Payer: Quartz Beloit One Network |
$105.49
|
| Rate for Payer: Quartz Commercial |
$129.17
|
| Rate for Payer: WEA Trust Commercial |
$118.40
|
| Rate for Payer: WPS Commercial |
$159.45
|
|
|
FEEDING TUBE JEJUNAL BENT TIP 12F X 68CM M00566340
|
Facility
|
IP
|
$2,059.00
|
|
| Hospital Charge Code |
4154498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,049.27 |
| Max. Negotiated Rate |
$1,970.05 |
| Rate for Payer: Aetna Commercial |
$1,927.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,841.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,134.92
|
| Rate for Payer: Cash Price |
$617.70
|
| Rate for Payer: Cigna Commercial |
$1,970.05
|
| Rate for Payer: Health EOS Commercial |
$1,905.81
|
| Rate for Payer: HFN Commercial |
$1,970.05
|
| Rate for Payer: Multiplan Commercial |
$1,713.09
|
| Rate for Payer: Preferred Network Access Commercial |
$1,970.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,049.27
|
| Rate for Payer: Quartz Commercial |
$1,284.82
|
| Rate for Payer: WEA Trust Commercial |
$1,177.75
|
| Rate for Payer: WPS Commercial |
$1,586.05
|
|
|
FEEDING TUBE JEJUNAL BENT TIP 12F X 68CM M00566340
|
Facility
|
OP
|
$2,059.00
|
|
| Hospital Charge Code |
4154498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.58 |
| Max. Negotiated Rate |
$1,970.05 |
| Rate for Payer: Aetna Commercial |
$1,927.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,841.57
|
| Rate for Payer: Aetna Managed Medicare |
$599.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,391.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,070.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,027.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,134.92
|
| Rate for Payer: Cash Price |
$617.70
|
| Rate for Payer: Cigna Commercial |
$1,970.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,198.34
|
| Rate for Payer: Health EOS Commercial |
$1,905.81
|
| Rate for Payer: HFN Commercial |
$1,970.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,606.02
|
| Rate for Payer: Multiplan Commercial |
$1,713.09
|
| Rate for Payer: NAPHCARE Commercial |
$1,284.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,970.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,049.27
|
| Rate for Payer: Quartz Commercial |
$1,391.88
|
| Rate for Payer: Quartz Medicare Advantage |
$1,284.82
|
| Rate for Payer: The Alliance Commercial |
$1,070.68
|
| Rate for Payer: WEA Trust Commercial |
$1,177.75
|
| Rate for Payer: WPS Commercial |
$1,586.05
|
|
|
FEEDING TUBE JEJUNAL PIGTAIL TIP 12F X 68CM M00566350
|
Facility
|
IP
|
$2,059.00
|
|
| Hospital Charge Code |
4154499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,049.27 |
| Max. Negotiated Rate |
$1,970.05 |
| Rate for Payer: Aetna Commercial |
$1,927.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,841.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,134.92
|
| Rate for Payer: Cash Price |
$617.70
|
| Rate for Payer: Cigna Commercial |
$1,970.05
|
| Rate for Payer: Health EOS Commercial |
$1,905.81
|
| Rate for Payer: HFN Commercial |
$1,970.05
|
| Rate for Payer: Multiplan Commercial |
$1,713.09
|
| Rate for Payer: Preferred Network Access Commercial |
$1,970.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,049.27
|
| Rate for Payer: Quartz Commercial |
$1,284.82
|
| Rate for Payer: WEA Trust Commercial |
$1,177.75
|
| Rate for Payer: WPS Commercial |
$1,586.05
|
|
|
FEEDING TUBE JEJUNAL PIGTAIL TIP 12F X 68CM M00566350
|
Facility
|
OP
|
$2,059.00
|
|
| Hospital Charge Code |
4154499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.58 |
| Max. Negotiated Rate |
$1,970.05 |
| Rate for Payer: Aetna Commercial |
$1,927.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,841.57
|
| Rate for Payer: Aetna Managed Medicare |
$599.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,391.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,070.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,027.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,134.92
|
| Rate for Payer: Cash Price |
$617.70
|
| Rate for Payer: Cigna Commercial |
$1,970.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,198.34
|
| Rate for Payer: Health EOS Commercial |
$1,905.81
|
| Rate for Payer: HFN Commercial |
$1,970.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,606.02
|
| Rate for Payer: Multiplan Commercial |
$1,713.09
|
| Rate for Payer: NAPHCARE Commercial |
$1,284.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,970.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,049.27
|
| Rate for Payer: Quartz Commercial |
$1,391.88
|
| Rate for Payer: Quartz Medicare Advantage |
$1,284.82
|
| Rate for Payer: The Alliance Commercial |
$1,070.68
|
| Rate for Payer: WEA Trust Commercial |
$1,177.75
|
| Rate for Payer: WPS Commercial |
$1,586.05
|
|
|
FEEDING TUBE MIC BOLUS G-TUBE 18FR 0110-18
|
Facility
|
OP
|
$788.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5286775
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$229.47 |
| Max. Negotiated Rate |
$753.96 |
| Rate for Payer: Aetna Commercial |
$737.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$704.79
|
| Rate for Payer: Aetna Managed Medicare |
$229.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$532.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$409.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$393.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$434.35
|
| Rate for Payer: Cash Price |
$236.40
|
| Rate for Payer: Cigna Commercial |
$753.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$458.62
|
| Rate for Payer: Health EOS Commercial |
$729.37
|
| Rate for Payer: HFN Commercial |
$753.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$614.64
|
| Rate for Payer: Multiplan Commercial |
$655.62
|
| Rate for Payer: NAPHCARE Commercial |
$491.71
|
| Rate for Payer: Preferred Network Access Commercial |
$753.96
|
| Rate for Payer: Quartz Beloit One Network |
$401.56
|
| Rate for Payer: Quartz Commercial |
$532.69
|
| Rate for Payer: Quartz Medicare Advantage |
$491.71
|
| Rate for Payer: The Alliance Commercial |
$409.76
|
| Rate for Payer: WEA Trust Commercial |
$450.74
|
| Rate for Payer: WPS Commercial |
$607.00
|
|
|
FEEDING TUBE MIC BOLUS G-TUBE 18FR 0110-18
|
Facility
|
IP
|
$788.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5286775
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$401.56 |
| Max. Negotiated Rate |
$753.96 |
| Rate for Payer: Aetna Commercial |
$737.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$704.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$434.35
|
| Rate for Payer: Cash Price |
$236.40
|
| Rate for Payer: Cigna Commercial |
$753.96
|
| Rate for Payer: Health EOS Commercial |
$729.37
|
| Rate for Payer: HFN Commercial |
$753.96
|
| Rate for Payer: Multiplan Commercial |
$655.62
|
| Rate for Payer: Preferred Network Access Commercial |
$753.96
|
| Rate for Payer: Quartz Beloit One Network |
$401.56
|
| Rate for Payer: Quartz Commercial |
$491.71
|
| Rate for Payer: WEA Trust Commercial |
$450.74
|
| Rate for Payer: WPS Commercial |
$607.00
|
|
|
FEEDING TUBE MIC BOLUS G-TUBE 18FR ENFIT CONNECT 8110-18
|
Facility
|
OP
|
$687.00
|
|
| Hospital Charge Code |
5563636
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$200.05 |
| Max. Negotiated Rate |
$657.32 |
| Rate for Payer: Aetna Commercial |
$643.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$614.45
|
| Rate for Payer: Aetna Managed Medicare |
$200.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$464.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$357.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$342.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$378.67
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cigna Commercial |
$657.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$399.83
|
| Rate for Payer: Health EOS Commercial |
$635.89
|
| Rate for Payer: HFN Commercial |
$657.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$535.86
|
| Rate for Payer: Multiplan Commercial |
$571.58
|
| Rate for Payer: NAPHCARE Commercial |
$428.69
|
| Rate for Payer: Preferred Network Access Commercial |
$657.32
|
| Rate for Payer: Quartz Beloit One Network |
$350.10
|
| Rate for Payer: Quartz Commercial |
$464.41
|
| Rate for Payer: Quartz Medicare Advantage |
$428.69
|
| Rate for Payer: The Alliance Commercial |
$357.24
|
| Rate for Payer: WEA Trust Commercial |
$392.96
|
| Rate for Payer: WPS Commercial |
$529.20
|
|
|
FEEDING TUBE MIC BOLUS G-TUBE 18FR ENFIT CONNECT 8110-18
|
Facility
|
IP
|
$687.00
|
|
| Hospital Charge Code |
5563636
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$350.10 |
| Max. Negotiated Rate |
$657.32 |
| Rate for Payer: Aetna Commercial |
$643.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$614.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$378.67
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cigna Commercial |
$657.32
|
| Rate for Payer: Health EOS Commercial |
$635.89
|
| Rate for Payer: HFN Commercial |
$657.32
|
| Rate for Payer: Multiplan Commercial |
$571.58
|
| Rate for Payer: Preferred Network Access Commercial |
$657.32
|
| Rate for Payer: Quartz Beloit One Network |
$350.10
|
| Rate for Payer: Quartz Commercial |
$428.69
|
| Rate for Payer: WEA Trust Commercial |
$392.96
|
| Rate for Payer: WPS Commercial |
$529.20
|
|
|
FEEDING TUBE MIC BOLUS G-TUBE 20FR 0110-20
|
Facility
|
IP
|
$788.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5286776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$401.56 |
| Max. Negotiated Rate |
$753.96 |
| Rate for Payer: Aetna Commercial |
$737.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$704.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$434.35
|
| Rate for Payer: Cash Price |
$236.40
|
| Rate for Payer: Cigna Commercial |
$753.96
|
| Rate for Payer: Health EOS Commercial |
$729.37
|
| Rate for Payer: HFN Commercial |
$753.96
|
| Rate for Payer: Multiplan Commercial |
$655.62
|
| Rate for Payer: Preferred Network Access Commercial |
$753.96
|
| Rate for Payer: Quartz Beloit One Network |
$401.56
|
| Rate for Payer: Quartz Commercial |
$491.71
|
| Rate for Payer: WEA Trust Commercial |
$450.74
|
| Rate for Payer: WPS Commercial |
$607.00
|
|
|
FEEDING TUBE MIC BOLUS G-TUBE 20FR 0110-20
|
Facility
|
OP
|
$788.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5286776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$229.47 |
| Max. Negotiated Rate |
$753.96 |
| Rate for Payer: Aetna Commercial |
$737.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$704.79
|
| Rate for Payer: Aetna Managed Medicare |
$229.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$532.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$409.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$393.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$434.35
|
| Rate for Payer: Cash Price |
$236.40
|
| Rate for Payer: Cigna Commercial |
$753.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$458.62
|
| Rate for Payer: Health EOS Commercial |
$729.37
|
| Rate for Payer: HFN Commercial |
$753.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$614.64
|
| Rate for Payer: Multiplan Commercial |
$655.62
|
| Rate for Payer: NAPHCARE Commercial |
$491.71
|
| Rate for Payer: Preferred Network Access Commercial |
$753.96
|
| Rate for Payer: Quartz Beloit One Network |
$401.56
|
| Rate for Payer: Quartz Commercial |
$532.69
|
| Rate for Payer: Quartz Medicare Advantage |
$491.71
|
| Rate for Payer: The Alliance Commercial |
$409.76
|
| Rate for Payer: WEA Trust Commercial |
$450.74
|
| Rate for Payer: WPS Commercial |
$607.00
|
|
|
FEEDING TUBE MIC BOLUS G-TUBE 20FR ENFIT CONNECT 8110-20
|
Facility
|
IP
|
$687.00
|
|
| Hospital Charge Code |
5563637
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$350.10 |
| Max. Negotiated Rate |
$657.32 |
| Rate for Payer: Aetna Commercial |
$643.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$614.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$378.67
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cigna Commercial |
$657.32
|
| Rate for Payer: Health EOS Commercial |
$635.89
|
| Rate for Payer: HFN Commercial |
$657.32
|
| Rate for Payer: Multiplan Commercial |
$571.58
|
| Rate for Payer: Preferred Network Access Commercial |
$657.32
|
| Rate for Payer: Quartz Beloit One Network |
$350.10
|
| Rate for Payer: Quartz Commercial |
$428.69
|
| Rate for Payer: WEA Trust Commercial |
$392.96
|
| Rate for Payer: WPS Commercial |
$529.20
|
|
|
FEEDING TUBE MIC BOLUS G-TUBE 20FR ENFIT CONNECT 8110-20
|
Facility
|
OP
|
$687.00
|
|
| Hospital Charge Code |
5563637
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$200.05 |
| Max. Negotiated Rate |
$657.32 |
| Rate for Payer: Aetna Commercial |
$643.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$614.45
|
| Rate for Payer: Aetna Managed Medicare |
$200.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$464.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$357.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$342.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$378.67
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cigna Commercial |
$657.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$399.83
|
| Rate for Payer: Health EOS Commercial |
$635.89
|
| Rate for Payer: HFN Commercial |
$657.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$535.86
|
| Rate for Payer: Multiplan Commercial |
$571.58
|
| Rate for Payer: NAPHCARE Commercial |
$428.69
|
| Rate for Payer: Preferred Network Access Commercial |
$657.32
|
| Rate for Payer: Quartz Beloit One Network |
$350.10
|
| Rate for Payer: Quartz Commercial |
$464.41
|
| Rate for Payer: Quartz Medicare Advantage |
$428.69
|
| Rate for Payer: The Alliance Commercial |
$357.24
|
| Rate for Payer: WEA Trust Commercial |
$392.96
|
| Rate for Payer: WPS Commercial |
$529.20
|
|
|
FEEDING TUBE MIC J-TUBE 12FR 0200-12LV
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5286774
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
FEEDING TUBE MIC J-TUBE 12FR 0200-12LV
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5286774
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
FEEDING TUBE MIC J-TUBE 12FR ENFIT CONNECT 8200-12LV
|
Facility
|
IP
|
$1,796.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5563635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$915.24 |
| Max. Negotiated Rate |
$1,718.41 |
| Rate for Payer: Aetna Commercial |
$1,681.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,606.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$989.96
|
| Rate for Payer: Cash Price |
$538.80
|
| Rate for Payer: Cigna Commercial |
$1,718.41
|
| Rate for Payer: Health EOS Commercial |
$1,662.38
|
| Rate for Payer: HFN Commercial |
$1,718.41
|
| Rate for Payer: Multiplan Commercial |
$1,494.27
|
| Rate for Payer: Preferred Network Access Commercial |
$1,718.41
|
| Rate for Payer: Quartz Beloit One Network |
$915.24
|
| Rate for Payer: Quartz Commercial |
$1,120.70
|
| Rate for Payer: WEA Trust Commercial |
$1,027.31
|
| Rate for Payer: WPS Commercial |
$1,383.46
|
|
|
FEEDING TUBE MIC J-TUBE 12FR ENFIT CONNECT 8200-12LV
|
Facility
|
OP
|
$1,796.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5563635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$523.00 |
| Max. Negotiated Rate |
$1,718.41 |
| Rate for Payer: Aetna Commercial |
$1,681.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,606.34
|
| Rate for Payer: Aetna Managed Medicare |
$523.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,214.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$933.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$896.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$989.96
|
| Rate for Payer: Cash Price |
$538.80
|
| Rate for Payer: Cigna Commercial |
$1,718.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,045.27
|
| Rate for Payer: Health EOS Commercial |
$1,662.38
|
| Rate for Payer: HFN Commercial |
$1,718.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,400.88
|
| Rate for Payer: Multiplan Commercial |
$1,494.27
|
| Rate for Payer: NAPHCARE Commercial |
$1,120.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,718.41
|
| Rate for Payer: Quartz Beloit One Network |
$915.24
|
| Rate for Payer: Quartz Commercial |
$1,214.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,120.70
|
| Rate for Payer: The Alliance Commercial |
$933.92
|
| Rate for Payer: WEA Trust Commercial |
$1,027.31
|
| Rate for Payer: WPS Commercial |
$1,383.46
|
|
|
Felbamate Level
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
977949
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| 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 |
$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 |
$106.93
|
| 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 |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$179.57
|
| Rate for Payer: HFN Commercial |
$185.62
|
| 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 |
$161.41
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| 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 |
$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 |
$151.32
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: Wellcare Medicare |
$19.39
|
| Rate for Payer: WPS Commercial |
$149.44
|
|
|
Felbamate Level
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
977949
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
