|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$8,505.26
|
|
|
Service Code
|
APR-DRG 5323
|
| Min. Negotiated Rate |
$7,554.90 |
| Max. Negotiated Rate |
$8,505.26 |
| Rate for Payer: Anthem Medicaid |
$8,144.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,144.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,144.26
|
| Rate for Payer: Dean Health Medicaid |
$8,144.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,554.90
|
| Rate for Payer: Managed Health Services Medicaid |
$8,505.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,144.26
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,144.26
|
| Rate for Payer: United Healthcare Medicaid |
$8,144.26
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$4,559.52
|
|
|
Service Code
|
APR-DRG 5321
|
| Min. Negotiated Rate |
$4,050.05 |
| Max. Negotiated Rate |
$4,559.52 |
| Rate for Payer: Anthem Medicaid |
$4,365.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,365.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,365.99
|
| Rate for Payer: Dean Health Medicaid |
$4,365.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4,050.05
|
| Rate for Payer: Managed Health Services Medicaid |
$4,559.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,365.99
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,365.99
|
| Rate for Payer: United Healthcare Medicaid |
$4,365.99
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$13,766.25
|
|
|
Service Code
|
APR-DRG 5324
|
| Min. Negotiated Rate |
$12,228.04 |
| Max. Negotiated Rate |
$13,766.25 |
| Rate for Payer: Anthem Medicaid |
$13,181.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$13,181.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13,181.94
|
| Rate for Payer: Dean Health Medicaid |
$13,181.94
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12,228.04
|
| Rate for Payer: Managed Health Services Medicaid |
$13,766.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,181.94
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13,181.94
|
| Rate for Payer: United Healthcare Medicaid |
$13,181.94
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC
|
Facility
|
IP
|
$27,855.36
|
|
|
Service Code
|
MSDRG 760
|
| Min. Negotiated Rate |
$8,222.42 |
| Max. Negotiated Rate |
$27,855.36 |
| Rate for Payer: Aetna Managed Medicare |
$8,222.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,982.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,849.67
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,008.29
|
| Rate for Payer: Anthem Medicare Advantage |
$8,222.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,222.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,222.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,222.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,770.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,222.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,186.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,222.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,222.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,222.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,222.42
|
| Rate for Payer: NAPHCARE Commercial |
$12,333.63
|
| Rate for Payer: Quartz Medicare Advantage |
$8,222.42
|
| Rate for Payer: The Alliance Commercial |
$27,855.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,222.42
|
| Rate for Payer: United Healthcare PPO |
$15,715.62
|
| Rate for Payer: Wellcare Medicare |
$8,222.42
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$17,077.84
|
|
|
Service Code
|
MSDRG 761
|
| Min. Negotiated Rate |
$4,875.78 |
| Max. Negotiated Rate |
$17,077.84 |
| Rate for Payer: Aetna Managed Medicare |
$4,875.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,428.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,526.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,050.44
|
| Rate for Payer: Anthem Medicare Advantage |
$4,875.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4,875.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4,875.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4,875.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,046.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4,875.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,281.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4,875.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4,875.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4,875.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4,875.78
|
| Rate for Payer: NAPHCARE Commercial |
$7,313.67
|
| Rate for Payer: Quartz Medicare Advantage |
$4,875.78
|
| Rate for Payer: The Alliance Commercial |
$17,077.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,875.78
|
| Rate for Payer: United Healthcare PPO |
$9,561.35
|
| Rate for Payer: Wellcare Medicare |
$4,875.78
|
|
|
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE
|
Facility
|
IP
|
$12,889.42
|
|
|
Service Code
|
APR-DRG 7402
|
| Min. Negotiated Rate |
$11,449.18 |
| Max. Negotiated Rate |
$12,889.42 |
| Rate for Payer: Anthem Medicaid |
$12,342.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12,342.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12,342.33
|
| Rate for Payer: Dean Health Medicaid |
$12,342.33
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11,449.18
|
| Rate for Payer: Managed Health Services Medicaid |
$12,889.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,342.33
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12,342.33
|
| Rate for Payer: United Healthcare Medicaid |
$12,342.33
|
|
|
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE
|
Facility
|
IP
|
$22,622.24
|
|
|
Service Code
|
APR-DRG 7403
|
| Min. Negotiated Rate |
$20,094.48 |
| Max. Negotiated Rate |
$22,622.24 |
| Rate for Payer: Anthem Medicaid |
$21,662.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$21,662.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21,662.04
|
| Rate for Payer: Dean Health Medicaid |
$21,662.04
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$20,094.48
|
| Rate for Payer: Managed Health Services Medicaid |
$22,622.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$21,662.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$21,662.04
|
| Rate for Payer: United Healthcare Medicaid |
$21,662.04
|
|
|
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE
|
Facility
|
IP
|
$49,102.54
|
|
|
Service Code
|
APR-DRG 7404
|
| Min. Negotiated Rate |
$43,615.94 |
| Max. Negotiated Rate |
$49,102.54 |
| Rate for Payer: Anthem Medicaid |
$47,018.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$47,018.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47,018.38
|
| Rate for Payer: Dean Health Medicaid |
$47,018.38
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$43,615.94
|
| Rate for Payer: Managed Health Services Medicaid |
$49,102.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$47,018.38
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$47,018.38
|
| Rate for Payer: United Healthcare Medicaid |
$47,018.38
|
|
|
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE
|
Facility
|
IP
|
$7,716.11
|
|
|
Service Code
|
APR-DRG 7401
|
| Min. Negotiated Rate |
$6,853.93 |
| Max. Negotiated Rate |
$7,716.11 |
| Rate for Payer: Anthem Medicaid |
$7,388.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$7,388.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,388.60
|
| Rate for Payer: Dean Health Medicaid |
$7,388.60
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6,853.93
|
| Rate for Payer: Managed Health Services Medicaid |
$7,716.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,388.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7,388.60
|
| Rate for Payer: United Healthcare Medicaid |
$7,388.60
|
|
|
Menveo Vaccine 90734
|
Facility
|
IP
|
$406.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5577560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$206.90 |
| Max. Negotiated Rate |
$388.46 |
| Rate for Payer: Aetna Commercial |
$380.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.79
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$388.46
|
| Rate for Payer: Health EOS Commercial |
$375.79
|
| Rate for Payer: HFN Commercial |
$388.46
|
| Rate for Payer: Multiplan Commercial |
$337.79
|
| Rate for Payer: Preferred Network Access Commercial |
$388.46
|
| Rate for Payer: Quartz Beloit One Network |
$206.90
|
| Rate for Payer: Quartz Commercial |
$253.34
|
| Rate for Payer: WEA Trust Commercial |
$232.23
|
| Rate for Payer: WPS Commercial |
$312.74
|
|
|
Menveo Vaccine 90734
|
Facility
|
OP
|
$406.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5577560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.23 |
| Max. Negotiated Rate |
$388.46 |
| Rate for Payer: Aetna Commercial |
$380.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.13
|
| Rate for Payer: Aetna Managed Medicare |
$118.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$274.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$211.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$202.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.79
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$388.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.29
|
| Rate for Payer: Health EOS Commercial |
$375.79
|
| Rate for Payer: HFN Commercial |
$388.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$316.68
|
| Rate for Payer: Multiplan Commercial |
$337.79
|
| Rate for Payer: NAPHCARE Commercial |
$253.34
|
| Rate for Payer: Preferred Network Access Commercial |
$388.46
|
| Rate for Payer: Quartz Beloit One Network |
$206.90
|
| Rate for Payer: Quartz Commercial |
$274.46
|
| Rate for Payer: Quartz Medicare Advantage |
$253.34
|
| Rate for Payer: The Alliance Commercial |
$211.12
|
| Rate for Payer: WEA Trust Commercial |
$232.23
|
| Rate for Payer: WPS Commercial |
$312.74
|
|
|
Menveo Vaccine 90734
|
Professional
|
Both
|
$406.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5577560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.42 |
| Max. Negotiated Rate |
$401.13 |
| Rate for Payer: Aetna Commercial |
$401.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.13
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$401.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$173.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$253.34
|
| Rate for Payer: Health EOS Commercial |
$384.24
|
| Rate for Payer: HFN Commercial |
$401.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$233.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$233.06
|
| Rate for Payer: Multiplan Commercial |
$337.79
|
| Rate for Payer: Preferred Network Access Commercial |
$401.13
|
| Rate for Payer: Quartz Beloit One Network |
$185.79
|
| Rate for Payer: Quartz Commercial |
$240.68
|
| Rate for Payer: The Alliance Commercial |
$211.12
|
| Rate for Payer: United Healthcare Medicaid |
$173.42
|
| Rate for Payer: WEA Trust Commercial |
$232.23
|
| Rate for Payer: WPS Commercial |
$312.74
|
|
|
Menveo Vaccine 90734VFC
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5577614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$233.06 |
| Rate for Payer: Aetna Commercial |
$20.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$20.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$173.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.00
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$233.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$233.06
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$20.58
|
| Rate for Payer: Quartz Beloit One Network |
$9.53
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: United Healthcare Medicaid |
$173.42
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
Menveo Vaccine 90734VFC
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5577614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.12
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$13.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$14.08
|
| Rate for Payer: Quartz Medicare Advantage |
$13.00
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
Menveo Vaccine 90734VFC
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5577614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.61 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
meperidine 50 mg/mL Syr [Med]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
2983115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$33.90 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.49
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$33.90
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$17.94
|
|
|
meperidine 50 mg/mL Syr [Med]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
2983115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Meperidine hydrochl/100 mg J2175 man
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
3373625
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$8.48
|
| Rate for Payer: Anthem Medicare Advantage |
$8.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.48
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.18
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.48
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$12.71
|
| Rate for Payer: Preferred Network Access Commercial |
$6.92
|
| Rate for Payer: Quartz Beloit One Network |
$3.20
|
| Rate for Payer: Quartz Commercial |
$4.15
|
| Rate for Payer: Quartz Medicare Advantage |
$8.48
|
| Rate for Payer: The Alliance Commercial |
$23.31
|
| Rate for Payer: United Healthcare Medicaid |
$8.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.48
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$17.94
|
|
|
Meperidine hydrochl/100 mg J2175 man
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
3373625
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Meperidine hydrochl/100 mg J2175 man
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
3373625
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$33.90 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.49
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$33.90
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$17.94
|
|
|
MEPILEX 4X10 BORDER AG DRESSING 498450"
|
Facility
|
IP
|
$887.00
|
|
| Hospital Charge Code |
2963577
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$452.02 |
| Max. Negotiated Rate |
$848.68 |
| Rate for Payer: Aetna Commercial |
$830.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$793.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$488.91
|
| Rate for Payer: Cash Price |
$266.10
|
| Rate for Payer: Cigna Commercial |
$848.68
|
| Rate for Payer: Health EOS Commercial |
$821.01
|
| Rate for Payer: HFN Commercial |
$848.68
|
| Rate for Payer: Multiplan Commercial |
$737.98
|
| Rate for Payer: Preferred Network Access Commercial |
$848.68
|
| Rate for Payer: Quartz Beloit One Network |
$452.02
|
| Rate for Payer: Quartz Commercial |
$553.49
|
| Rate for Payer: WEA Trust Commercial |
$507.36
|
| Rate for Payer: WPS Commercial |
$683.26
|
|
|
MEPILEX 4X10 BORDER AG DRESSING 498450"
|
Facility
|
OP
|
$887.00
|
|
| Hospital Charge Code |
2963577
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$258.29 |
| Max. Negotiated Rate |
$848.68 |
| Rate for Payer: Aetna Commercial |
$830.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$793.33
|
| Rate for Payer: Aetna Managed Medicare |
$258.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$599.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$461.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$442.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$488.91
|
| Rate for Payer: Cash Price |
$266.10
|
| Rate for Payer: Cigna Commercial |
$848.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$516.23
|
| Rate for Payer: Health EOS Commercial |
$821.01
|
| Rate for Payer: HFN Commercial |
$848.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$691.86
|
| Rate for Payer: Multiplan Commercial |
$737.98
|
| Rate for Payer: NAPHCARE Commercial |
$553.49
|
| Rate for Payer: Preferred Network Access Commercial |
$848.68
|
| Rate for Payer: Quartz Beloit One Network |
$452.02
|
| Rate for Payer: Quartz Commercial |
$599.61
|
| Rate for Payer: Quartz Medicare Advantage |
$553.49
|
| Rate for Payer: The Alliance Commercial |
$461.24
|
| Rate for Payer: WEA Trust Commercial |
$507.36
|
| Rate for Payer: WPS Commercial |
$683.26
|
|
|
MEPILEX 4X14 BORDER AG DRESSING 498650"
|
Facility
|
OP
|
$988.00
|
|
| Hospital Charge Code |
2963552
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$287.71 |
| Max. Negotiated Rate |
$945.32 |
| Rate for Payer: Aetna Commercial |
$924.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$883.67
|
| Rate for Payer: Aetna Managed Medicare |
$287.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$667.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$513.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$493.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$544.59
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$945.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$575.02
|
| Rate for Payer: Health EOS Commercial |
$914.49
|
| Rate for Payer: HFN Commercial |
$945.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$770.64
|
| Rate for Payer: Multiplan Commercial |
$822.02
|
| Rate for Payer: NAPHCARE Commercial |
$616.51
|
| Rate for Payer: Preferred Network Access Commercial |
$945.32
|
| Rate for Payer: Quartz Beloit One Network |
$503.48
|
| Rate for Payer: Quartz Commercial |
$667.89
|
| Rate for Payer: Quartz Medicare Advantage |
$616.51
|
| Rate for Payer: The Alliance Commercial |
$513.76
|
| Rate for Payer: WEA Trust Commercial |
$565.14
|
| Rate for Payer: WPS Commercial |
$761.06
|
|
|
MEPILEX 4X14 BORDER AG DRESSING 498650"
|
Facility
|
IP
|
$988.00
|
|
| Hospital Charge Code |
2963552
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$503.48 |
| Max. Negotiated Rate |
$945.32 |
| Rate for Payer: Aetna Commercial |
$924.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$883.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$544.59
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$945.32
|
| Rate for Payer: Health EOS Commercial |
$914.49
|
| Rate for Payer: HFN Commercial |
$945.32
|
| Rate for Payer: Multiplan Commercial |
$822.02
|
| Rate for Payer: Preferred Network Access Commercial |
$945.32
|
| Rate for Payer: Quartz Beloit One Network |
$503.48
|
| Rate for Payer: Quartz Commercial |
$616.51
|
| Rate for Payer: WEA Trust Commercial |
$565.14
|
| Rate for Payer: WPS Commercial |
$761.06
|
|
|
MEPILEX 4X6 BORDER AG DRESSING 498300"
|
Facility
|
OP
|
$709.00
|
|
| Hospital Charge Code |
2963646
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$206.46 |
| Max. Negotiated Rate |
$678.37 |
| Rate for Payer: Aetna Commercial |
$663.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$634.13
|
| Rate for Payer: Aetna Managed Medicare |
$206.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$479.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$368.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$353.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$390.80
|
| Rate for Payer: Cash Price |
$212.70
|
| Rate for Payer: Cigna Commercial |
$678.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$412.64
|
| Rate for Payer: Health EOS Commercial |
$656.25
|
| Rate for Payer: HFN Commercial |
$678.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$553.02
|
| Rate for Payer: Multiplan Commercial |
$589.89
|
| Rate for Payer: NAPHCARE Commercial |
$442.42
|
| Rate for Payer: Preferred Network Access Commercial |
$678.37
|
| Rate for Payer: Quartz Beloit One Network |
$361.31
|
| Rate for Payer: Quartz Commercial |
$479.28
|
| Rate for Payer: Quartz Medicare Advantage |
$442.42
|
| Rate for Payer: The Alliance Commercial |
$368.68
|
| Rate for Payer: WEA Trust Commercial |
$405.55
|
| Rate for Payer: WPS Commercial |
$546.14
|
|
