|
MASTECTOMY PROCEDURES
|
Facility
|
IP
|
$26,918.71
|
|
|
Service Code
|
APR-DRG 3624
|
| Min. Negotiated Rate |
$23,910.88 |
| Max. Negotiated Rate |
$26,918.71 |
| Rate for Payer: Anthem Medicaid |
$25,776.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$25,776.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25,776.15
|
| Rate for Payer: Dean Health Medicaid |
$25,776.15
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$23,910.88
|
| Rate for Payer: Managed Health Services Medicaid |
$26,918.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,776.15
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$25,776.15
|
| Rate for Payer: United Healthcare Medicaid |
$25,776.15
|
|
|
MASTECTOMY PROCEDURES
|
Facility
|
IP
|
$20,780.89
|
|
|
Service Code
|
APR-DRG 3622
|
| Min. Negotiated Rate |
$18,458.89 |
| Max. Negotiated Rate |
$20,780.89 |
| Rate for Payer: Anthem Medicaid |
$19,898.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$19,898.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19,898.85
|
| Rate for Payer: Dean Health Medicaid |
$19,898.85
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18,458.89
|
| Rate for Payer: Managed Health Services Medicaid |
$20,780.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,898.85
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19,898.85
|
| Rate for Payer: United Healthcare Medicaid |
$19,898.85
|
|
|
MASTECTOMY PROCEDURES
|
Facility
|
IP
|
$21,570.04
|
|
|
Service Code
|
APR-DRG 3623
|
| Min. Negotiated Rate |
$19,159.86 |
| Max. Negotiated Rate |
$21,570.04 |
| Rate for Payer: Anthem Medicaid |
$20,654.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$20,654.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20,654.50
|
| Rate for Payer: Dean Health Medicaid |
$20,654.50
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19,159.86
|
| Rate for Payer: Managed Health Services Medicaid |
$21,570.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$20,654.50
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$20,654.50
|
| Rate for Payer: United Healthcare Medicaid |
$20,654.50
|
|
|
MASTECTOMY PROCEDURES
|
Facility
|
IP
|
$13,853.93
|
|
|
Service Code
|
APR-DRG 3621
|
| Min. Negotiated Rate |
$12,305.92 |
| Max. Negotiated Rate |
$13,853.93 |
| Rate for Payer: Anthem Medicaid |
$13,265.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$13,265.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13,265.90
|
| Rate for Payer: Dean Health Medicaid |
$13,265.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12,305.92
|
| Rate for Payer: Managed Health Services Medicaid |
$13,853.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,265.90
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13,265.90
|
| Rate for Payer: United Healthcare Medicaid |
$13,265.90
|
|
|
MASTECTOMY, SIMPLE
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2950476
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
MASTECTOMY, SIMPLE
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2950476
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
MASTECTOMY, SIMPLE, COMPLETE
|
Facility
|
OP
|
$27,952.16
|
|
|
Service Code
|
CPT 19303
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,400.16 |
| Max. Negotiated Rate |
$27,952.16 |
| Rate for Payer: Aetna Managed Medicare |
$6,988.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,970.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,336.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,619.84
|
| Rate for Payer: Anthem Medicare Advantage |
$6,988.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,988.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,988.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,988.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,107.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,988.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,995.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,988.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,988.04
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,988.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,988.04
|
| Rate for Payer: NAPHCARE Commercial |
$10,482.06
|
| Rate for Payer: Quartz Medicare Advantage |
$6,988.04
|
| Rate for Payer: The Alliance Commercial |
$27,952.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,988.04
|
| Rate for Payer: United Healthcare PPO |
$6,400.16
|
| Rate for Payer: Wellcare Medicare |
$6,988.04
|
|
|
MA Stereotactic Localization Bilateral
|
Facility
|
OP
|
$6,094.00
|
|
|
Service Code
|
CPT 19081 LT
|
| Hospital Charge Code |
1268835
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$1,774.57 |
| Max. Negotiated Rate |
$5,830.74 |
| Rate for Payer: Aetna Commercial |
$5,703.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,774.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,119.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,168.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,042.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,359.01
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$5,830.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Health EOS Commercial |
$5,640.61
|
| Rate for Payer: HFN Commercial |
$5,830.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,753.32
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: NAPHCARE Commercial |
$3,802.66
|
| Rate for Payer: Preferred Network Access Commercial |
$5,830.74
|
| Rate for Payer: Quartz Beloit One Network |
$3,105.50
|
| Rate for Payer: Quartz Commercial |
$4,119.54
|
| Rate for Payer: Quartz Medicare Advantage |
$3,802.66
|
| Rate for Payer: The Alliance Commercial |
$3,168.88
|
| Rate for Payer: United Healthcare PPO |
$4,753.32
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
MA Stereotactic Localization Bilateral
|
Facility
|
IP
|
$6,094.00
|
|
|
Service Code
|
CPT 19081 LT
|
| Hospital Charge Code |
1268835
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$3,105.50 |
| Max. Negotiated Rate |
$5,830.74 |
| Rate for Payer: Aetna Commercial |
$5,703.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,359.01
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$5,830.74
|
| Rate for Payer: Health EOS Commercial |
$5,640.61
|
| Rate for Payer: HFN Commercial |
$5,830.74
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: Preferred Network Access Commercial |
$5,830.74
|
| Rate for Payer: Quartz Beloit One Network |
$3,105.50
|
| Rate for Payer: Quartz Commercial |
$3,802.66
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
MA Stereotactic Localization Bilateral
|
Professional
|
Both
|
$6,094.00
|
|
|
Service Code
|
CPT 19081 LT
|
| Hospital Charge Code |
1268835
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$136.21 |
| Max. Negotiated Rate |
$6,020.87 |
| Rate for Payer: Aetna Commercial |
$6,020.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$6,020.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$136.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,802.66
|
| Rate for Payer: Health EOS Commercial |
$5,767.36
|
| Rate for Payer: HFN Commercial |
$6,020.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$577.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$577.19
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: Preferred Network Access Commercial |
$6,020.87
|
| Rate for Payer: Quartz Beloit One Network |
$2,788.61
|
| Rate for Payer: Quartz Commercial |
$3,612.52
|
| Rate for Payer: The Alliance Commercial |
$3,168.88
|
| Rate for Payer: United Healthcare Medicaid |
$136.21
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
MA Stereotactic Localization Left
|
Facility
|
OP
|
$6,094.00
|
|
|
Service Code
|
CPT 19081 LT
|
| Hospital Charge Code |
1268837
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$1,774.57 |
| Max. Negotiated Rate |
$5,830.74 |
| Rate for Payer: Aetna Commercial |
$5,703.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,774.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,119.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,168.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,042.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,359.01
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$5,830.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Health EOS Commercial |
$5,640.61
|
| Rate for Payer: HFN Commercial |
$5,830.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,753.32
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: NAPHCARE Commercial |
$3,802.66
|
| Rate for Payer: Preferred Network Access Commercial |
$5,830.74
|
| Rate for Payer: Quartz Beloit One Network |
$3,105.50
|
| Rate for Payer: Quartz Commercial |
$4,119.54
|
| Rate for Payer: Quartz Medicare Advantage |
$3,802.66
|
| Rate for Payer: The Alliance Commercial |
$3,168.88
|
| Rate for Payer: United Healthcare PPO |
$4,753.32
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
MA Stereotactic Localization Left
|
Facility
|
IP
|
$6,094.00
|
|
|
Service Code
|
CPT 19081 LT
|
| Hospital Charge Code |
1268837
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$3,105.50 |
| Max. Negotiated Rate |
$5,830.74 |
| Rate for Payer: Aetna Commercial |
$5,703.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,359.01
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$5,830.74
|
| Rate for Payer: Health EOS Commercial |
$5,640.61
|
| Rate for Payer: HFN Commercial |
$5,830.74
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: Preferred Network Access Commercial |
$5,830.74
|
| Rate for Payer: Quartz Beloit One Network |
$3,105.50
|
| Rate for Payer: Quartz Commercial |
$3,802.66
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
MA Stereotactic Localization Left
|
Professional
|
Both
|
$6,094.00
|
|
|
Service Code
|
CPT 19081 LT
|
| Hospital Charge Code |
1268837
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$136.21 |
| Max. Negotiated Rate |
$6,020.87 |
| Rate for Payer: Aetna Commercial |
$6,020.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$6,020.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$136.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,802.66
|
| Rate for Payer: Health EOS Commercial |
$5,767.36
|
| Rate for Payer: HFN Commercial |
$6,020.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$577.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$577.19
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: Preferred Network Access Commercial |
$6,020.87
|
| Rate for Payer: Quartz Beloit One Network |
$2,788.61
|
| Rate for Payer: Quartz Commercial |
$3,612.52
|
| Rate for Payer: The Alliance Commercial |
$3,168.88
|
| Rate for Payer: United Healthcare Medicaid |
$136.21
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
MA Stereotactic Localization Right
|
Facility
|
OP
|
$6,094.00
|
|
|
Service Code
|
CPT 19081 RT
|
| Hospital Charge Code |
1268839
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$1,774.57 |
| Max. Negotiated Rate |
$5,830.74 |
| Rate for Payer: Aetna Commercial |
$5,703.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,774.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,119.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,168.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,042.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,359.01
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$5,830.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Health EOS Commercial |
$5,640.61
|
| Rate for Payer: HFN Commercial |
$5,830.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,753.32
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: NAPHCARE Commercial |
$3,802.66
|
| Rate for Payer: Preferred Network Access Commercial |
$5,830.74
|
| Rate for Payer: Quartz Beloit One Network |
$3,105.50
|
| Rate for Payer: Quartz Commercial |
$4,119.54
|
| Rate for Payer: Quartz Medicare Advantage |
$3,802.66
|
| Rate for Payer: The Alliance Commercial |
$3,168.88
|
| Rate for Payer: United Healthcare PPO |
$4,753.32
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
MA Stereotactic Localization Right
|
Professional
|
Both
|
$6,094.00
|
|
|
Service Code
|
CPT 19081 RT
|
| Hospital Charge Code |
1268839
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$136.21 |
| Max. Negotiated Rate |
$6,020.87 |
| Rate for Payer: Aetna Commercial |
$6,020.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$6,020.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$136.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,802.66
|
| Rate for Payer: Health EOS Commercial |
$5,767.36
|
| Rate for Payer: HFN Commercial |
$6,020.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$577.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$577.19
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: Preferred Network Access Commercial |
$6,020.87
|
| Rate for Payer: Quartz Beloit One Network |
$2,788.61
|
| Rate for Payer: Quartz Commercial |
$3,612.52
|
| Rate for Payer: The Alliance Commercial |
$3,168.88
|
| Rate for Payer: United Healthcare Medicaid |
$136.21
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
MA Stereotactic Localization Right
|
Facility
|
IP
|
$6,094.00
|
|
|
Service Code
|
CPT 19081 RT
|
| Hospital Charge Code |
1268839
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$3,105.50 |
| Max. Negotiated Rate |
$5,830.74 |
| Rate for Payer: Aetna Commercial |
$5,703.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,359.01
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$5,830.74
|
| Rate for Payer: Health EOS Commercial |
$5,640.61
|
| Rate for Payer: HFN Commercial |
$5,830.74
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: Preferred Network Access Commercial |
$5,830.74
|
| Rate for Payer: Quartz Beloit One Network |
$3,105.50
|
| Rate for Payer: Quartz Commercial |
$3,802.66
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
MA Stereotactic Localization Right
|
Facility
|
IP
|
$6,094.00
|
|
|
Service Code
|
CPT 19082 RT
|
| Hospital Charge Code |
6166213
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$3,105.50 |
| Max. Negotiated Rate |
$5,830.74 |
| Rate for Payer: Aetna Commercial |
$5,703.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,359.01
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$5,830.74
|
| Rate for Payer: Health EOS Commercial |
$5,640.61
|
| Rate for Payer: HFN Commercial |
$5,830.74
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: Preferred Network Access Commercial |
$5,830.74
|
| Rate for Payer: Quartz Beloit One Network |
$3,105.50
|
| Rate for Payer: Quartz Commercial |
$3,802.66
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
MA Stereotactic Localization Right
|
Facility
|
OP
|
$6,094.00
|
|
|
Service Code
|
CPT 19082 RT
|
| Hospital Charge Code |
6166213
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$1,774.57 |
| Max. Negotiated Rate |
$5,830.74 |
| Rate for Payer: Aetna Commercial |
$5,703.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,774.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,119.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,168.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,042.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,359.01
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$5,830.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Health EOS Commercial |
$5,640.61
|
| Rate for Payer: HFN Commercial |
$5,830.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,753.32
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: NAPHCARE Commercial |
$3,802.66
|
| Rate for Payer: Preferred Network Access Commercial |
$5,830.74
|
| Rate for Payer: Quartz Beloit One Network |
$3,105.50
|
| Rate for Payer: Quartz Commercial |
$4,119.54
|
| Rate for Payer: Quartz Medicare Advantage |
$3,802.66
|
| Rate for Payer: The Alliance Commercial |
$3,168.88
|
| Rate for Payer: United Healthcare PPO |
$4,753.32
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
MA Stereotactic Localization Right
|
Professional
|
Both
|
$6,094.00
|
|
|
Service Code
|
CPT 19082 RT
|
| Hospital Charge Code |
6166213
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$66.13 |
| Max. Negotiated Rate |
$6,020.87 |
| Rate for Payer: Aetna Commercial |
$6,020.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,450.47
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cash Price |
$1,828.20
|
| Rate for Payer: Cigna Commercial |
$6,020.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$66.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,802.66
|
| Rate for Payer: Health EOS Commercial |
$5,767.36
|
| Rate for Payer: HFN Commercial |
$6,020.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$289.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$289.84
|
| Rate for Payer: Multiplan Commercial |
$5,070.21
|
| Rate for Payer: Preferred Network Access Commercial |
$6,020.87
|
| Rate for Payer: Quartz Beloit One Network |
$2,788.61
|
| Rate for Payer: Quartz Commercial |
$3,612.52
|
| Rate for Payer: The Alliance Commercial |
$3,168.88
|
| Rate for Payer: United Healthcare Medicaid |
$66.13
|
| Rate for Payer: WEA Trust Commercial |
$3,485.77
|
| Rate for Payer: WPS Commercial |
$4,694.21
|
|
|
Mastisol UD [Med]
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
2974960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
Mastisol UD [Med]
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
2974960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.55
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.60
|
| Rate for Payer: The Alliance Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
MASTOIDECTOMY
|
Facility
|
IP
|
$7,513.00
|
|
| Hospital Charge Code |
2960224
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,828.62 |
| Max. Negotiated Rate |
$7,188.44 |
| Rate for Payer: Aetna Commercial |
$7,032.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,719.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,141.17
|
| Rate for Payer: Cash Price |
$2,253.90
|
| Rate for Payer: Cigna Commercial |
$7,188.44
|
| Rate for Payer: Health EOS Commercial |
$6,954.03
|
| Rate for Payer: HFN Commercial |
$7,188.44
|
| Rate for Payer: Multiplan Commercial |
$6,250.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,188.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,828.62
|
| Rate for Payer: Quartz Commercial |
$4,688.11
|
| Rate for Payer: WEA Trust Commercial |
$4,297.44
|
| Rate for Payer: WPS Commercial |
$5,787.26
|
|
|
MASTOIDECTOMY
|
Facility
|
OP
|
$7,513.00
|
|
| Hospital Charge Code |
2960224
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,187.79 |
| Max. Negotiated Rate |
$7,188.44 |
| Rate for Payer: Aetna Commercial |
$7,032.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,719.63
|
| Rate for Payer: Aetna Managed Medicare |
$2,187.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,078.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,906.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,750.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,141.17
|
| Rate for Payer: Cash Price |
$2,253.90
|
| Rate for Payer: Cigna Commercial |
$7,188.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,372.57
|
| Rate for Payer: Health EOS Commercial |
$6,954.03
|
| Rate for Payer: HFN Commercial |
$7,188.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,860.14
|
| Rate for Payer: Multiplan Commercial |
$6,250.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,688.11
|
| Rate for Payer: Preferred Network Access Commercial |
$7,188.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,828.62
|
| Rate for Payer: Quartz Commercial |
$5,078.79
|
| Rate for Payer: Quartz Medicare Advantage |
$4,688.11
|
| Rate for Payer: The Alliance Commercial |
$3,906.76
|
| Rate for Payer: WEA Trust Commercial |
$4,297.44
|
| Rate for Payer: WPS Commercial |
$5,787.26
|
|
|
MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP
|
Facility
|
OP
|
$6,952.48
|
|
|
Service Code
|
CPT 19020
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,738.12 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Aetna Managed Medicare |
$1,738.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$1,738.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,738.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,738.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,738.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,738.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,465.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,738.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,738.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,738.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,738.12
|
| Rate for Payer: NAPHCARE Commercial |
$2,607.18
|
| Rate for Payer: Quartz Medicare Advantage |
$1,738.12
|
| Rate for Payer: The Alliance Commercial |
$6,952.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,738.12
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$1,738.12
|
|
|
Matrix Metalloproteinase-9 (MMP-9)
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5242625
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$126.38 |
| Max. Negotiated Rate |
$237.29 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$154.75
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
