|
IMPLANT DIGIFUSE 2.5MM 10 DEGREE DF2510
|
Facility
|
IP
|
$6,393.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5627642
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,257.87 |
| Max. Negotiated Rate |
$6,116.82 |
| Rate for Payer: Aetna Commercial |
$5,983.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,717.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,523.82
|
| Rate for Payer: Cash Price |
$1,917.90
|
| Rate for Payer: Cigna Commercial |
$6,116.82
|
| Rate for Payer: Health EOS Commercial |
$5,917.36
|
| Rate for Payer: HFN Commercial |
$6,116.82
|
| Rate for Payer: Multiplan Commercial |
$5,318.98
|
| Rate for Payer: Preferred Network Access Commercial |
$6,116.82
|
| Rate for Payer: Quartz Beloit One Network |
$3,257.87
|
| Rate for Payer: Quartz Commercial |
$3,989.23
|
| Rate for Payer: WEA Trust Commercial |
$3,656.80
|
| Rate for Payer: WPS Commercial |
$4,924.53
|
|
|
IMPLANT EAR KURZ ANGULAR PLESTER 2.25MM 1002 610
|
Facility
|
IP
|
$4,793.00
|
|
| Hospital Charge Code |
3713506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,442.51 |
| Max. Negotiated Rate |
$4,585.94 |
| Rate for Payer: Aetna Commercial |
$4,486.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,286.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,641.90
|
| Rate for Payer: Cash Price |
$1,437.90
|
| Rate for Payer: Cigna Commercial |
$4,585.94
|
| Rate for Payer: Health EOS Commercial |
$4,436.40
|
| Rate for Payer: HFN Commercial |
$4,585.94
|
| Rate for Payer: Multiplan Commercial |
$3,987.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,585.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,442.51
|
| Rate for Payer: Quartz Commercial |
$2,990.83
|
| Rate for Payer: WEA Trust Commercial |
$2,741.60
|
| Rate for Payer: WPS Commercial |
$3,692.05
|
|
|
IMPLANT EAR KURZ ANGULAR PLESTER 2.25MM 1002 610
|
Facility
|
OP
|
$4,793.00
|
|
| Hospital Charge Code |
3713506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,395.72 |
| Max. Negotiated Rate |
$4,585.94 |
| Rate for Payer: Aetna Commercial |
$4,486.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,286.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,395.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,240.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,492.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,392.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,641.90
|
| Rate for Payer: Cash Price |
$1,437.90
|
| Rate for Payer: Cigna Commercial |
$4,585.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,789.53
|
| Rate for Payer: Health EOS Commercial |
$4,436.40
|
| Rate for Payer: HFN Commercial |
$4,585.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,738.54
|
| Rate for Payer: Multiplan Commercial |
$3,987.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,990.83
|
| Rate for Payer: Preferred Network Access Commercial |
$4,585.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,442.51
|
| Rate for Payer: Quartz Commercial |
$3,240.07
|
| Rate for Payer: Quartz Medicare Advantage |
$2,990.83
|
| Rate for Payer: The Alliance Commercial |
$2,492.36
|
| Rate for Payer: WEA Trust Commercial |
$2,741.60
|
| Rate for Payer: WPS Commercial |
$3,692.05
|
|
|
IMPLANT EAR KURZ ANGULAR PLESTER 3.25MM 1002 612
|
Facility
|
OP
|
$4,793.00
|
|
| Hospital Charge Code |
3713507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,395.72 |
| Max. Negotiated Rate |
$4,585.94 |
| Rate for Payer: Aetna Commercial |
$4,486.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,286.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,395.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,240.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,492.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,392.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,641.90
|
| Rate for Payer: Cash Price |
$1,437.90
|
| Rate for Payer: Cigna Commercial |
$4,585.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,789.53
|
| Rate for Payer: Health EOS Commercial |
$4,436.40
|
| Rate for Payer: HFN Commercial |
$4,585.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,738.54
|
| Rate for Payer: Multiplan Commercial |
$3,987.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,990.83
|
| Rate for Payer: Preferred Network Access Commercial |
$4,585.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,442.51
|
| Rate for Payer: Quartz Commercial |
$3,240.07
|
| Rate for Payer: Quartz Medicare Advantage |
$2,990.83
|
| Rate for Payer: The Alliance Commercial |
$2,492.36
|
| Rate for Payer: WEA Trust Commercial |
$2,741.60
|
| Rate for Payer: WPS Commercial |
$3,692.05
|
|
|
IMPLANT EAR KURZ ANGULAR PLESTER 3.25MM 1002 612
|
Facility
|
IP
|
$4,793.00
|
|
| Hospital Charge Code |
3713507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,442.51 |
| Max. Negotiated Rate |
$4,585.94 |
| Rate for Payer: Aetna Commercial |
$4,486.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,286.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,641.90
|
| Rate for Payer: Cash Price |
$1,437.90
|
| Rate for Payer: Cigna Commercial |
$4,585.94
|
| Rate for Payer: Health EOS Commercial |
$4,436.40
|
| Rate for Payer: HFN Commercial |
$4,585.94
|
| Rate for Payer: Multiplan Commercial |
$3,987.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,585.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,442.51
|
| Rate for Payer: Quartz Commercial |
$2,990.83
|
| Rate for Payer: WEA Trust Commercial |
$2,741.60
|
| Rate for Payer: WPS Commercial |
$3,692.05
|
|
|
IMPLANT EAR KURZ TTP VARIAC PARTIAL (1.75 - 4.5MM) 1002 020
|
Facility
|
OP
|
$4,856.00
|
|
| Hospital Charge Code |
3583499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,414.07 |
| Max. Negotiated Rate |
$4,646.22 |
| Rate for Payer: Aetna Commercial |
$4,545.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,343.21
|
| Rate for Payer: Aetna Managed Medicare |
$1,414.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,282.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,525.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,424.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,676.63
|
| Rate for Payer: Cash Price |
$1,456.80
|
| Rate for Payer: Cigna Commercial |
$4,646.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,826.19
|
| Rate for Payer: Health EOS Commercial |
$4,494.71
|
| Rate for Payer: HFN Commercial |
$4,646.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,787.68
|
| Rate for Payer: Multiplan Commercial |
$4,040.19
|
| Rate for Payer: NAPHCARE Commercial |
$3,030.14
|
| Rate for Payer: Preferred Network Access Commercial |
$4,646.22
|
| Rate for Payer: Quartz Beloit One Network |
$2,474.62
|
| Rate for Payer: Quartz Commercial |
$3,282.66
|
| Rate for Payer: Quartz Medicare Advantage |
$3,030.14
|
| Rate for Payer: The Alliance Commercial |
$2,525.12
|
| Rate for Payer: WEA Trust Commercial |
$2,777.63
|
| Rate for Payer: WPS Commercial |
$3,740.58
|
|
|
IMPLANT EAR KURZ TTP VARIAC PARTIAL (1.75 - 4.5MM) 1002 020
|
Facility
|
IP
|
$4,856.00
|
|
| Hospital Charge Code |
3583499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,474.62 |
| Max. Negotiated Rate |
$4,646.22 |
| Rate for Payer: Aetna Commercial |
$4,545.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,343.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,676.63
|
| Rate for Payer: Cash Price |
$1,456.80
|
| Rate for Payer: Cigna Commercial |
$4,646.22
|
| Rate for Payer: Health EOS Commercial |
$4,494.71
|
| Rate for Payer: HFN Commercial |
$4,646.22
|
| Rate for Payer: Multiplan Commercial |
$4,040.19
|
| Rate for Payer: Preferred Network Access Commercial |
$4,646.22
|
| Rate for Payer: Quartz Beloit One Network |
$2,474.62
|
| Rate for Payer: Quartz Commercial |
$3,030.14
|
| Rate for Payer: WEA Trust Commercial |
$2,777.63
|
| Rate for Payer: WPS Commercial |
$3,740.58
|
|
|
IMPLANT EAR KURZ TTP VARIAC TOTAL (3.0 - 7.0MM) 1004 020
|
Facility
|
IP
|
$4,856.00
|
|
| Hospital Charge Code |
3591496
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,474.62 |
| Max. Negotiated Rate |
$4,646.22 |
| Rate for Payer: Aetna Commercial |
$4,545.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,343.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,676.63
|
| Rate for Payer: Cash Price |
$1,456.80
|
| Rate for Payer: Cigna Commercial |
$4,646.22
|
| Rate for Payer: Health EOS Commercial |
$4,494.71
|
| Rate for Payer: HFN Commercial |
$4,646.22
|
| Rate for Payer: Multiplan Commercial |
$4,040.19
|
| Rate for Payer: Preferred Network Access Commercial |
$4,646.22
|
| Rate for Payer: Quartz Beloit One Network |
$2,474.62
|
| Rate for Payer: Quartz Commercial |
$3,030.14
|
| Rate for Payer: WEA Trust Commercial |
$2,777.63
|
| Rate for Payer: WPS Commercial |
$3,740.58
|
|
|
IMPLANT EAR KURZ TTP VARIAC TOTAL (3.0 - 7.0MM) 1004 020
|
Facility
|
OP
|
$4,856.00
|
|
| Hospital Charge Code |
3591496
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,414.07 |
| Max. Negotiated Rate |
$4,646.22 |
| Rate for Payer: Aetna Commercial |
$4,545.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,343.21
|
| Rate for Payer: Aetna Managed Medicare |
$1,414.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,282.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,525.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,424.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,676.63
|
| Rate for Payer: Cash Price |
$1,456.80
|
| Rate for Payer: Cigna Commercial |
$4,646.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,826.19
|
| Rate for Payer: Health EOS Commercial |
$4,494.71
|
| Rate for Payer: HFN Commercial |
$4,646.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,787.68
|
| Rate for Payer: Multiplan Commercial |
$4,040.19
|
| Rate for Payer: NAPHCARE Commercial |
$3,030.14
|
| Rate for Payer: Preferred Network Access Commercial |
$4,646.22
|
| Rate for Payer: Quartz Beloit One Network |
$2,474.62
|
| Rate for Payer: Quartz Commercial |
$3,282.66
|
| Rate for Payer: Quartz Medicare Advantage |
$3,030.14
|
| Rate for Payer: The Alliance Commercial |
$2,525.12
|
| Rate for Payer: WEA Trust Commercial |
$2,777.63
|
| Rate for Payer: WPS Commercial |
$3,740.58
|
|
|
IMPLANT EAR MEDPOR EAR BASE EXTENDED LT 30MM X 59MM 8331
|
Facility
|
OP
|
$7,197.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6200990
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,095.77 |
| Max. Negotiated Rate |
$6,886.09 |
| Rate for Payer: Aetna Commercial |
$6,736.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,437.00
|
| Rate for Payer: Aetna Managed Medicare |
$2,095.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,865.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,742.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,592.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,966.99
|
| Rate for Payer: Cash Price |
$2,159.10
|
| Rate for Payer: Cigna Commercial |
$6,886.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,188.65
|
| Rate for Payer: Health EOS Commercial |
$6,661.54
|
| Rate for Payer: HFN Commercial |
$6,886.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,613.66
|
| Rate for Payer: Multiplan Commercial |
$5,987.90
|
| Rate for Payer: NAPHCARE Commercial |
$4,490.93
|
| Rate for Payer: Preferred Network Access Commercial |
$6,886.09
|
| Rate for Payer: Quartz Beloit One Network |
$3,667.59
|
| Rate for Payer: Quartz Commercial |
$4,865.17
|
| Rate for Payer: Quartz Medicare Advantage |
$4,490.93
|
| Rate for Payer: The Alliance Commercial |
$3,742.44
|
| Rate for Payer: WEA Trust Commercial |
$4,116.68
|
| Rate for Payer: WPS Commercial |
$5,543.85
|
|
|
IMPLANT EAR MEDPOR EAR BASE EXTENDED LT 30MM X 59MM 8331
|
Facility
|
IP
|
$7,197.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6200990
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,667.59 |
| Max. Negotiated Rate |
$6,886.09 |
| Rate for Payer: Aetna Commercial |
$6,736.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,437.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,966.99
|
| Rate for Payer: Cash Price |
$2,159.10
|
| Rate for Payer: Cigna Commercial |
$6,886.09
|
| Rate for Payer: Health EOS Commercial |
$6,661.54
|
| Rate for Payer: HFN Commercial |
$6,886.09
|
| Rate for Payer: Multiplan Commercial |
$5,987.90
|
| Rate for Payer: Preferred Network Access Commercial |
$6,886.09
|
| Rate for Payer: Quartz Beloit One Network |
$3,667.59
|
| Rate for Payer: Quartz Commercial |
$4,490.93
|
| Rate for Payer: WEA Trust Commercial |
$4,116.68
|
| Rate for Payer: WPS Commercial |
$5,543.85
|
|
|
IMPLANT EAR MEDPOR EAR BASE EXTENDED RT 30MM X 59MM 8330
|
Facility
|
IP
|
$7,197.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6200986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,667.59 |
| Max. Negotiated Rate |
$6,886.09 |
| Rate for Payer: Aetna Commercial |
$6,736.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,437.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,966.99
|
| Rate for Payer: Cash Price |
$2,159.10
|
| Rate for Payer: Cigna Commercial |
$6,886.09
|
| Rate for Payer: Health EOS Commercial |
$6,661.54
|
| Rate for Payer: HFN Commercial |
$6,886.09
|
| Rate for Payer: Multiplan Commercial |
$5,987.90
|
| Rate for Payer: Preferred Network Access Commercial |
$6,886.09
|
| Rate for Payer: Quartz Beloit One Network |
$3,667.59
|
| Rate for Payer: Quartz Commercial |
$4,490.93
|
| Rate for Payer: WEA Trust Commercial |
$4,116.68
|
| Rate for Payer: WPS Commercial |
$5,543.85
|
|
|
IMPLANT EAR MEDPOR EAR BASE EXTENDED RT 30MM X 59MM 8330
|
Facility
|
OP
|
$7,197.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6200986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,095.77 |
| Max. Negotiated Rate |
$6,886.09 |
| Rate for Payer: Aetna Commercial |
$6,736.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,437.00
|
| Rate for Payer: Aetna Managed Medicare |
$2,095.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,865.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,742.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,592.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,966.99
|
| Rate for Payer: Cash Price |
$2,159.10
|
| Rate for Payer: Cigna Commercial |
$6,886.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,188.65
|
| Rate for Payer: Health EOS Commercial |
$6,661.54
|
| Rate for Payer: HFN Commercial |
$6,886.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,613.66
|
| Rate for Payer: Multiplan Commercial |
$5,987.90
|
| Rate for Payer: NAPHCARE Commercial |
$4,490.93
|
| Rate for Payer: Preferred Network Access Commercial |
$6,886.09
|
| Rate for Payer: Quartz Beloit One Network |
$3,667.59
|
| Rate for Payer: Quartz Commercial |
$4,865.17
|
| Rate for Payer: Quartz Medicare Advantage |
$4,490.93
|
| Rate for Payer: The Alliance Commercial |
$3,742.44
|
| Rate for Payer: WEA Trust Commercial |
$4,116.68
|
| Rate for Payer: WPS Commercial |
$5,543.85
|
|
|
IMPLANT EAR MEDPOR HELICAL RIM LT 37MM X 62MM 8329
|
Facility
|
OP
|
$5,894.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6200984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,716.33 |
| Max. Negotiated Rate |
$5,639.38 |
| Rate for Payer: Aetna Commercial |
$5,516.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,271.59
|
| Rate for Payer: Aetna Managed Medicare |
$1,716.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,984.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,064.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,942.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,248.77
|
| Rate for Payer: Cash Price |
$1,768.20
|
| Rate for Payer: Cigna Commercial |
$5,639.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,430.31
|
| Rate for Payer: Health EOS Commercial |
$5,455.49
|
| Rate for Payer: HFN Commercial |
$5,639.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,597.32
|
| Rate for Payer: Multiplan Commercial |
$4,903.81
|
| Rate for Payer: NAPHCARE Commercial |
$3,677.86
|
| Rate for Payer: Preferred Network Access Commercial |
$5,639.38
|
| Rate for Payer: Quartz Beloit One Network |
$3,003.58
|
| Rate for Payer: Quartz Commercial |
$3,984.34
|
| Rate for Payer: Quartz Medicare Advantage |
$3,677.86
|
| Rate for Payer: The Alliance Commercial |
$3,064.88
|
| Rate for Payer: WEA Trust Commercial |
$3,371.37
|
| Rate for Payer: WPS Commercial |
$4,540.15
|
|
|
IMPLANT EAR MEDPOR HELICAL RIM LT 37MM X 62MM 8329
|
Facility
|
IP
|
$5,894.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6200984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,003.58 |
| Max. Negotiated Rate |
$5,639.38 |
| Rate for Payer: Aetna Commercial |
$5,516.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,271.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,248.77
|
| Rate for Payer: Cash Price |
$1,768.20
|
| Rate for Payer: Cigna Commercial |
$5,639.38
|
| Rate for Payer: Health EOS Commercial |
$5,455.49
|
| Rate for Payer: HFN Commercial |
$5,639.38
|
| Rate for Payer: Multiplan Commercial |
$4,903.81
|
| Rate for Payer: Preferred Network Access Commercial |
$5,639.38
|
| Rate for Payer: Quartz Beloit One Network |
$3,003.58
|
| Rate for Payer: Quartz Commercial |
$3,677.86
|
| Rate for Payer: WEA Trust Commercial |
$3,371.37
|
| Rate for Payer: WPS Commercial |
$4,540.15
|
|
|
IMPLANT EAR MEDPOR HELICAL RIM RT 37MM X 62MM 8328
|
Facility
|
OP
|
$5,894.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6200982
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,716.33 |
| Max. Negotiated Rate |
$5,639.38 |
| Rate for Payer: Aetna Commercial |
$5,516.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,271.59
|
| Rate for Payer: Aetna Managed Medicare |
$1,716.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,984.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,064.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,942.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,248.77
|
| Rate for Payer: Cash Price |
$1,768.20
|
| Rate for Payer: Cigna Commercial |
$5,639.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,430.31
|
| Rate for Payer: Health EOS Commercial |
$5,455.49
|
| Rate for Payer: HFN Commercial |
$5,639.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,597.32
|
| Rate for Payer: Multiplan Commercial |
$4,903.81
|
| Rate for Payer: NAPHCARE Commercial |
$3,677.86
|
| Rate for Payer: Preferred Network Access Commercial |
$5,639.38
|
| Rate for Payer: Quartz Beloit One Network |
$3,003.58
|
| Rate for Payer: Quartz Commercial |
$3,984.34
|
| Rate for Payer: Quartz Medicare Advantage |
$3,677.86
|
| Rate for Payer: The Alliance Commercial |
$3,064.88
|
| Rate for Payer: WEA Trust Commercial |
$3,371.37
|
| Rate for Payer: WPS Commercial |
$4,540.15
|
|
|
IMPLANT EAR MEDPOR HELICAL RIM RT 37MM X 62MM 8328
|
Facility
|
IP
|
$5,894.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6200982
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,003.58 |
| Max. Negotiated Rate |
$5,639.38 |
| Rate for Payer: Aetna Commercial |
$5,516.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,271.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,248.77
|
| Rate for Payer: Cash Price |
$1,768.20
|
| Rate for Payer: Cigna Commercial |
$5,639.38
|
| Rate for Payer: Health EOS Commercial |
$5,455.49
|
| Rate for Payer: HFN Commercial |
$5,639.38
|
| Rate for Payer: Multiplan Commercial |
$4,903.81
|
| Rate for Payer: Preferred Network Access Commercial |
$5,639.38
|
| Rate for Payer: Quartz Beloit One Network |
$3,003.58
|
| Rate for Payer: Quartz Commercial |
$3,677.86
|
| Rate for Payer: WEA Trust Commercial |
$3,371.37
|
| Rate for Payer: WPS Commercial |
$4,540.15
|
|
|
Implanted port - accessed - Central IV Activity:
|
Facility
|
IP
|
$597.00
|
|
| Hospital Charge Code |
3025898
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$304.23 |
| Max. Negotiated Rate |
$571.21 |
| Rate for Payer: Aetna Commercial |
$558.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$533.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$329.07
|
| Rate for Payer: Cash Price |
$179.10
|
| Rate for Payer: Cigna Commercial |
$571.21
|
| Rate for Payer: Health EOS Commercial |
$552.58
|
| Rate for Payer: HFN Commercial |
$571.21
|
| Rate for Payer: Multiplan Commercial |
$496.70
|
| Rate for Payer: Preferred Network Access Commercial |
$571.21
|
| Rate for Payer: Quartz Beloit One Network |
$304.23
|
| Rate for Payer: Quartz Commercial |
$372.53
|
| Rate for Payer: WEA Trust Commercial |
$341.48
|
| Rate for Payer: WPS Commercial |
$459.87
|
|
|
Implanted port - accessed - Central IV Activity:
|
Facility
|
OP
|
$597.00
|
|
| Hospital Charge Code |
3025898
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$173.85 |
| Max. Negotiated Rate |
$571.21 |
| Rate for Payer: Aetna Commercial |
$558.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$533.96
|
| Rate for Payer: Aetna Managed Medicare |
$173.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$403.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$310.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$298.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$329.07
|
| Rate for Payer: Cash Price |
$179.10
|
| Rate for Payer: Cigna Commercial |
$571.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$347.45
|
| Rate for Payer: Health EOS Commercial |
$552.58
|
| Rate for Payer: HFN Commercial |
$571.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$465.66
|
| Rate for Payer: Multiplan Commercial |
$496.70
|
| Rate for Payer: NAPHCARE Commercial |
$372.53
|
| Rate for Payer: Preferred Network Access Commercial |
$571.21
|
| Rate for Payer: Quartz Beloit One Network |
$304.23
|
| Rate for Payer: Quartz Commercial |
$403.57
|
| Rate for Payer: Quartz Medicare Advantage |
$372.53
|
| Rate for Payer: The Alliance Commercial |
$310.44
|
| Rate for Payer: WEA Trust Commercial |
$341.48
|
| Rate for Payer: WPS Commercial |
$459.87
|
|
|
Implanted port - blood drawn - Central IV Activity:
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
CPT 36591
|
| Hospital Charge Code |
3025899
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$88.86 |
| Max. Negotiated Rate |
$560.06 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$120.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.86
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$120.33
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
Implanted port - blood drawn - Central IV Activity:
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
CPT 36591
|
| Hospital Charge Code |
3025899
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$90.71 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$111.07
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
IMPLANTED TISSUE OF ANY TYPE
|
Facility
|
OP
|
$846.45
|
|
|
Service Code
|
EAPG 00455
|
| Min. Negotiated Rate |
$813.90 |
| Max. Negotiated Rate |
$846.45 |
| Rate for Payer: Anthem Medicaid |
$813.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$813.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$813.90
|
| Rate for Payer: Dean Health Medicaid |
$813.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$813.90
|
| Rate for Payer: Managed Health Services Medicaid |
$846.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$813.90
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$813.90
|
| Rate for Payer: United Healthcare Medicaid |
$813.90
|
|
|
IMPLANT ENCOMPASS 19MM
|
Facility
|
IP
|
$12,509.00
|
|
| Hospital Charge Code |
2965450
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,374.59 |
| Max. Negotiated Rate |
$11,968.61 |
| Rate for Payer: Aetna Commercial |
$11,708.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,188.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,894.96
|
| Rate for Payer: Cash Price |
$3,752.70
|
| Rate for Payer: Cigna Commercial |
$11,968.61
|
| Rate for Payer: Health EOS Commercial |
$11,578.33
|
| Rate for Payer: HFN Commercial |
$11,968.61
|
| Rate for Payer: Multiplan Commercial |
$10,407.49
|
| Rate for Payer: Preferred Network Access Commercial |
$11,968.61
|
| Rate for Payer: Quartz Beloit One Network |
$6,374.59
|
| Rate for Payer: Quartz Commercial |
$7,805.62
|
| Rate for Payer: WEA Trust Commercial |
$7,155.15
|
| Rate for Payer: WPS Commercial |
$9,635.68
|
|
|
IMPLANT ENCOMPASS 19MM
|
Facility
|
OP
|
$12,509.00
|
|
| Hospital Charge Code |
2965450
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,642.62 |
| Max. Negotiated Rate |
$11,968.61 |
| Rate for Payer: Aetna Commercial |
$11,708.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,188.05
|
| Rate for Payer: Aetna Managed Medicare |
$3,642.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,456.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,504.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,244.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,894.96
|
| Rate for Payer: Cash Price |
$3,752.70
|
| Rate for Payer: Cigna Commercial |
$11,968.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,280.24
|
| Rate for Payer: Health EOS Commercial |
$11,578.33
|
| Rate for Payer: HFN Commercial |
$11,968.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,757.02
|
| Rate for Payer: Multiplan Commercial |
$10,407.49
|
| Rate for Payer: NAPHCARE Commercial |
$7,805.62
|
| Rate for Payer: Preferred Network Access Commercial |
$11,968.61
|
| Rate for Payer: Quartz Beloit One Network |
$6,374.59
|
| Rate for Payer: Quartz Commercial |
$8,456.08
|
| Rate for Payer: Quartz Medicare Advantage |
$7,805.62
|
| Rate for Payer: The Alliance Commercial |
$6,504.68
|
| Rate for Payer: WEA Trust Commercial |
$7,155.15
|
| Rate for Payer: WPS Commercial |
$9,635.68
|
|
|
IMPLANT ENDOTINE 3.5 FOREHEAD CFD-22102
|
Facility
|
IP
|
$4,793.00
|
|
| Hospital Charge Code |
5106850
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,442.51 |
| Max. Negotiated Rate |
$4,585.94 |
| Rate for Payer: Aetna Commercial |
$4,486.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,286.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,641.90
|
| Rate for Payer: Cash Price |
$1,437.90
|
| Rate for Payer: Cigna Commercial |
$4,585.94
|
| Rate for Payer: Health EOS Commercial |
$4,436.40
|
| Rate for Payer: HFN Commercial |
$4,585.94
|
| Rate for Payer: Multiplan Commercial |
$3,987.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,585.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,442.51
|
| Rate for Payer: Quartz Commercial |
$2,990.83
|
| Rate for Payer: WEA Trust Commercial |
$2,741.60
|
| Rate for Payer: WPS Commercial |
$3,692.05
|
|
