|
MINOR PULMONARY TESTS AND SERVICES
|
Facility
|
OP
|
$52.41
|
|
|
Service Code
|
EAPG 00412
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$52.41 |
| Rate for Payer: Anthem Medicaid |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$50.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.40
|
| Rate for Payer: Dean Health Medicaid |
$50.40
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$50.40
|
| Rate for Payer: Managed Health Services Medicaid |
$52.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$50.40
|
| Rate for Payer: United Healthcare Medicaid |
$50.40
|
|
|
MINOR SKIN DISORDERS WITH MCC
|
Facility
|
IP
|
$44,179.20
|
|
|
Service Code
|
MSDRG 606
|
| Min. Negotiated Rate |
$12,459.27 |
| Max. Negotiated Rate |
$44,179.20 |
| Rate for Payer: Aetna Managed Medicare |
$12,459.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33,016.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,307.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,043.42
|
| Rate for Payer: Anthem Medicare Advantage |
$12,459.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,459.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,459.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,459.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26,690.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,459.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,160.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,459.27
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,459.27
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,459.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,459.27
|
| Rate for Payer: NAPHCARE Commercial |
$18,688.91
|
| Rate for Payer: Quartz Medicare Advantage |
$12,459.27
|
| Rate for Payer: The Alliance Commercial |
$44,179.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,459.27
|
| Rate for Payer: United Healthcare PPO |
$25,036.99
|
| Rate for Payer: Wellcare Medicare |
$12,459.27
|
|
|
MINOR SKIN DISORDERS WITHOUT MCC
|
Facility
|
IP
|
$25,038.00
|
|
|
Service Code
|
MSDRG 607
|
| Min. Negotiated Rate |
$7,448.17 |
| Max. Negotiated Rate |
$25,038.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,448.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,776.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,158.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,401.90
|
| Rate for Payer: Anthem Medicare Advantage |
$7,448.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,448.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,448.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,448.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,987.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,448.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,120.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,448.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,448.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,448.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,448.17
|
| Rate for Payer: NAPHCARE Commercial |
$11,172.25
|
| Rate for Payer: Quartz Medicare Advantage |
$7,448.17
|
| Rate for Payer: The Alliance Commercial |
$25,038.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,448.17
|
| Rate for Payer: United Healthcare PPO |
$14,106.79
|
| Rate for Payer: Wellcare Medicare |
$7,448.17
|
|
|
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC
|
Facility
|
IP
|
$42,930.16
|
|
|
Service Code
|
MSDRG 345
|
| Min. Negotiated Rate |
$12,030.09 |
| Max. Negotiated Rate |
$42,930.16 |
| Rate for Payer: Aetna Managed Medicare |
$12,030.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32,831.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,164.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23,908.36
|
| Rate for Payer: Anthem Medicare Advantage |
$12,030.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,030.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,030.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,030.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26,540.47
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,030.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,243.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,030.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,030.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,030.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,030.09
|
| Rate for Payer: NAPHCARE Commercial |
$18,045.13
|
| Rate for Payer: Quartz Medicare Advantage |
$12,030.09
|
| Rate for Payer: The Alliance Commercial |
$42,930.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,030.09
|
| Rate for Payer: United Healthcare PPO |
$24,323.36
|
| Rate for Payer: Wellcare Medicare |
$12,030.09
|
|
|
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC
|
Facility
|
IP
|
$76,104.08
|
|
|
Service Code
|
MSDRG 344
|
| Min. Negotiated Rate |
$20,286.36 |
| Max. Negotiated Rate |
$76,104.08 |
| Rate for Payer: Aetna Managed Medicare |
$20,286.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56,354.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43,195.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41,038.42
|
| Rate for Payer: Anthem Medicare Advantage |
$20,286.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20,286.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20,286.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20,286.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45,556.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20,286.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55,575.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20,286.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20,286.36
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20,286.36
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20,286.36
|
| Rate for Payer: NAPHCARE Commercial |
$30,429.55
|
| Rate for Payer: Quartz Medicare Advantage |
$20,286.36
|
| Rate for Payer: The Alliance Commercial |
$76,104.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20,286.36
|
| Rate for Payer: United Healthcare PPO |
$43,266.09
|
| Rate for Payer: Wellcare Medicare |
$20,286.36
|
|
|
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$35,940.32
|
|
|
Service Code
|
MSDRG 346
|
| Min. Negotiated Rate |
$9,590.93 |
| Max. Negotiated Rate |
$35,940.32 |
| Rate for Payer: Aetna Managed Medicare |
$9,590.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,881.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,838.29
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,847.67
|
| Rate for Payer: Anthem Medicare Advantage |
$9,590.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,590.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,590.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,590.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,922.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,590.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,116.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,590.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,590.93
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,590.93
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,590.93
|
| Rate for Payer: NAPHCARE Commercial |
$14,386.40
|
| Rate for Payer: Quartz Medicare Advantage |
$9,590.93
|
| Rate for Payer: The Alliance Commercial |
$35,940.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,590.93
|
| Rate for Payer: United Healthcare PPO |
$20,332.09
|
| Rate for Payer: Wellcare Medicare |
$9,590.93
|
|
|
MINOR SPECIMEN COLLECTION SERVICES
|
Facility
|
OP
|
$28.83
|
|
|
Service Code
|
EAPG 00304
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$28.83 |
| Rate for Payer: Anthem Medicaid |
$27.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$27.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.72
|
| Rate for Payer: Dean Health Medicaid |
$27.72
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$27.72
|
| Rate for Payer: Managed Health Services Medicaid |
$28.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$27.72
|
| Rate for Payer: United Healthcare Medicaid |
$27.72
|
|
|
MINOR SPLINT AND STRAPPING APPLICATION
|
Facility
|
OP
|
$151.99
|
|
|
Service Code
|
EAPG 00040
|
| Min. Negotiated Rate |
$146.15 |
| Max. Negotiated Rate |
$151.99 |
| Rate for Payer: Anthem Medicaid |
$146.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$146.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$146.15
|
| Rate for Payer: Dean Health Medicaid |
$146.15
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$146.15
|
| Rate for Payer: Managed Health Services Medicaid |
$151.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$146.15
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$146.15
|
| Rate for Payer: United Healthcare Medicaid |
$146.15
|
|
|
MINOR UROLOGY SERVICES
|
Facility
|
OP
|
$280.40
|
|
|
Service Code
|
EAPG 00159
|
| Min. Negotiated Rate |
$269.62 |
| Max. Negotiated Rate |
$280.40 |
| Rate for Payer: Anthem Medicaid |
$269.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$269.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$269.62
|
| Rate for Payer: Dean Health Medicaid |
$269.62
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$269.62
|
| Rate for Payer: Managed Health Services Medicaid |
$280.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$269.62
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$269.62
|
| Rate for Payer: United Healthcare Medicaid |
$269.62
|
|
|
MIRCO SHEATH 5F ACCESS KIT MAK501N-E
|
Facility
|
IP
|
$317.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
6207078
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$161.54 |
| Max. Negotiated Rate |
$303.31 |
| Rate for Payer: Aetna Commercial |
$296.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.73
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$303.31
|
| Rate for Payer: Health EOS Commercial |
$293.42
|
| Rate for Payer: HFN Commercial |
$303.31
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: Preferred Network Access Commercial |
$303.31
|
| Rate for Payer: Quartz Beloit One Network |
$161.54
|
| Rate for Payer: Quartz Commercial |
$197.81
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$244.19
|
|
|
MIRCO SHEATH 5F ACCESS KIT MAK501N-E
|
Facility
|
OP
|
$317.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
6207078
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$92.31 |
| Max. Negotiated Rate |
$303.31 |
| Rate for Payer: Aetna Commercial |
$296.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Aetna Managed Medicare |
$92.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$214.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$164.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$158.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.73
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$303.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$184.49
|
| Rate for Payer: Health EOS Commercial |
$293.42
|
| Rate for Payer: HFN Commercial |
$303.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$247.26
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: NAPHCARE Commercial |
$197.81
|
| Rate for Payer: Preferred Network Access Commercial |
$303.31
|
| Rate for Payer: Quartz Beloit One Network |
$161.54
|
| Rate for Payer: Quartz Commercial |
$214.29
|
| Rate for Payer: Quartz Medicare Advantage |
$197.81
|
| Rate for Payer: The Alliance Commercial |
$164.84
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$244.19
|
|
|
MIRCO SHEATH 5F WITH NITNOL WIRE MR190521
|
Facility
|
OP
|
$284.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
6207054
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$82.70 |
| Max. Negotiated Rate |
$271.73 |
| Rate for Payer: Aetna Commercial |
$265.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.01
|
| Rate for Payer: Aetna Managed Medicare |
$82.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$191.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$147.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$141.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$156.54
|
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Cigna Commercial |
$271.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.29
|
| Rate for Payer: Health EOS Commercial |
$262.87
|
| Rate for Payer: HFN Commercial |
$271.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$221.52
|
| Rate for Payer: Multiplan Commercial |
$236.29
|
| Rate for Payer: NAPHCARE Commercial |
$177.22
|
| Rate for Payer: Preferred Network Access Commercial |
$271.73
|
| Rate for Payer: Quartz Beloit One Network |
$144.73
|
| Rate for Payer: Quartz Commercial |
$191.98
|
| Rate for Payer: Quartz Medicare Advantage |
$177.22
|
| Rate for Payer: The Alliance Commercial |
$147.68
|
| Rate for Payer: WEA Trust Commercial |
$162.45
|
| Rate for Payer: WPS Commercial |
$218.77
|
|
|
MIRCO SHEATH 5F WITH NITNOL WIRE MR190521
|
Facility
|
IP
|
$284.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
6207054
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$144.73 |
| Max. Negotiated Rate |
$271.73 |
| Rate for Payer: Aetna Commercial |
$265.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$156.54
|
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Cigna Commercial |
$271.73
|
| Rate for Payer: Health EOS Commercial |
$262.87
|
| Rate for Payer: HFN Commercial |
$271.73
|
| Rate for Payer: Multiplan Commercial |
$236.29
|
| Rate for Payer: Preferred Network Access Commercial |
$271.73
|
| Rate for Payer: Quartz Beloit One Network |
$144.73
|
| Rate for Payer: Quartz Commercial |
$177.22
|
| Rate for Payer: WEA Trust Commercial |
$162.45
|
| Rate for Payer: WPS Commercial |
$218.77
|
|
|
Mirena 1 unit Charge
|
Professional
|
Both
|
$2,362.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
2958942
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,039.25 |
| Max. Negotiated Rate |
$2,333.66 |
| Rate for Payer: Aetna Commercial |
$2,333.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,112.57
|
| Rate for Payer: Anthem Commercial |
$1,039.25
|
| Rate for Payer: Cash Price |
$708.60
|
| Rate for Payer: Cash Price |
$708.60
|
| Rate for Payer: Cigna Commercial |
$2,333.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,263.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,473.89
|
| Rate for Payer: Health EOS Commercial |
$2,235.40
|
| Rate for Payer: HFN Commercial |
$2,333.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,555.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,555.24
|
| Rate for Payer: Multiplan Commercial |
$1,965.18
|
| Rate for Payer: Preferred Network Access Commercial |
$2,333.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,080.85
|
| Rate for Payer: Quartz Commercial |
$1,400.19
|
| Rate for Payer: The Alliance Commercial |
$1,228.24
|
| Rate for Payer: United Healthcare Medicaid |
$1,263.22
|
| Rate for Payer: WEA Trust Commercial |
$1,351.06
|
| Rate for Payer: WPS Commercial |
$1,819.45
|
|
|
Mirena 1 unit Charge
|
Facility
|
IP
|
$2,362.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
2958942
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,203.68 |
| Max. Negotiated Rate |
$2,259.96 |
| Rate for Payer: Aetna Commercial |
$2,210.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,112.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,301.93
|
| Rate for Payer: Cash Price |
$708.60
|
| Rate for Payer: Cigna Commercial |
$2,259.96
|
| Rate for Payer: Health EOS Commercial |
$2,186.27
|
| Rate for Payer: HFN Commercial |
$2,259.96
|
| Rate for Payer: Multiplan Commercial |
$1,965.18
|
| Rate for Payer: Preferred Network Access Commercial |
$2,259.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,203.68
|
| Rate for Payer: Quartz Commercial |
$1,473.89
|
| Rate for Payer: WEA Trust Commercial |
$1,351.06
|
| Rate for Payer: WPS Commercial |
$1,819.45
|
|
|
Mirena 1 unit Charge
|
Facility
|
OP
|
$2,362.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
2958942
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$687.81 |
| Max. Negotiated Rate |
$2,259.96 |
| Rate for Payer: Aetna Commercial |
$2,210.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,112.57
|
| Rate for Payer: Aetna Managed Medicare |
$687.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,596.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,228.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,179.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,301.93
|
| Rate for Payer: Cash Price |
$708.60
|
| Rate for Payer: Cigna Commercial |
$2,259.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,374.68
|
| Rate for Payer: Health EOS Commercial |
$2,186.27
|
| Rate for Payer: HFN Commercial |
$2,259.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,842.36
|
| Rate for Payer: Multiplan Commercial |
$1,965.18
|
| Rate for Payer: NAPHCARE Commercial |
$1,473.89
|
| Rate for Payer: Preferred Network Access Commercial |
$2,259.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,203.68
|
| Rate for Payer: Quartz Commercial |
$1,596.71
|
| Rate for Payer: Quartz Medicare Advantage |
$1,473.89
|
| Rate for Payer: The Alliance Commercial |
$1,228.24
|
| Rate for Payer: WEA Trust Commercial |
$1,351.06
|
| Rate for Payer: WPS Commercial |
$1,819.45
|
|
|
Mirtazapine (Remeron)
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
983326
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.24 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Aetna Managed Medicare |
$58.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$135.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$99.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$135.20
|
| Rate for Payer: Quartz Medicare Advantage |
$124.80
|
| Rate for Payer: The Alliance Commercial |
$104.00
|
| Rate for Payer: United Healthcare PPO |
$156.00
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
Mirtazapine (Remeron)
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
983326
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$197.60 |
| Rate for Payer: Aetna Commercial |
$197.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$197.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.80
|
| Rate for Payer: Health EOS Commercial |
$189.28
|
| Rate for Payer: HFN Commercial |
$197.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: Preferred Network Access Commercial |
$197.60
|
| Rate for Payer: Quartz Beloit One Network |
$91.52
|
| Rate for Payer: Quartz Commercial |
$118.56
|
| Rate for Payer: The Alliance Commercial |
$104.00
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
Mirtazapine (Remeron)
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
983326
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC
|
Facility
|
IP
|
$36,697.44
|
|
|
Service Code
|
MSDRG 640
|
| Min. Negotiated Rate |
$10,735.07 |
| Max. Negotiated Rate |
$36,697.44 |
| Rate for Payer: Aetna Managed Medicare |
$10,735.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,141.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,336.89
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,221.51
|
| Rate for Payer: Anthem Medicare Advantage |
$10,735.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,735.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,735.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,735.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,557.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,735.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,672.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,735.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,735.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,735.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,735.07
|
| Rate for Payer: NAPHCARE Commercial |
$16,102.60
|
| Rate for Payer: Quartz Medicare Advantage |
$10,735.07
|
| Rate for Payer: The Alliance Commercial |
$36,697.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,735.07
|
| Rate for Payer: United Healthcare PPO |
$20,764.69
|
| Rate for Payer: Wellcare Medicare |
$10,735.07
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC
|
Facility
|
IP
|
$21,938.80
|
|
|
Service Code
|
MSDRG 641
|
| Min. Negotiated Rate |
$6,466.39 |
| Max. Negotiated Rate |
$21,938.80 |
| Rate for Payer: Aetna Managed Medicare |
$6,466.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,979.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,014.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,364.91
|
| Rate for Payer: Anthem Medicare Advantage |
$6,466.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,466.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,466.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,466.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,726.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,466.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,846.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,466.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,466.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,466.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,466.39
|
| Rate for Payer: NAPHCARE Commercial |
$9,699.58
|
| Rate for Payer: Quartz Medicare Advantage |
$6,466.39
|
| Rate for Payer: The Alliance Commercial |
$21,938.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,466.39
|
| Rate for Payer: United Healthcare PPO |
$12,336.93
|
| Rate for Payer: Wellcare Medicare |
$6,466.39
|
|
|
Miscellaneous Staple Supply
|
Facility
|
IP
|
$60.00
|
|
| Hospital Charge Code |
3004326
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$57.41 |
| Rate for Payer: Aetna Commercial |
$56.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.41
|
| Rate for Payer: Health EOS Commercial |
$55.54
|
| Rate for Payer: HFN Commercial |
$57.41
|
| Rate for Payer: Multiplan Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$57.41
|
| Rate for Payer: Quartz Beloit One Network |
$30.58
|
| Rate for Payer: Quartz Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$34.32
|
| Rate for Payer: WPS Commercial |
$46.22
|
|
|
Miscellaneous Staple Supply
|
Facility
|
OP
|
$60.00
|
|
| Hospital Charge Code |
3004326
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.47 |
| Max. Negotiated Rate |
$57.41 |
| Rate for Payer: Aetna Commercial |
$56.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.66
|
| Rate for Payer: Aetna Managed Medicare |
$17.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.92
|
| Rate for Payer: Health EOS Commercial |
$55.54
|
| Rate for Payer: HFN Commercial |
$57.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.80
|
| Rate for Payer: Multiplan Commercial |
$49.92
|
| Rate for Payer: NAPHCARE Commercial |
$37.44
|
| Rate for Payer: Preferred Network Access Commercial |
$57.41
|
| Rate for Payer: Quartz Beloit One Network |
$30.58
|
| Rate for Payer: Quartz Commercial |
$40.56
|
| Rate for Payer: Quartz Medicare Advantage |
$37.44
|
| Rate for Payer: The Alliance Commercial |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$34.32
|
| Rate for Payer: WPS Commercial |
$46.22
|
|
|
Miscellaneous Suture Supply
|
Facility
|
OP
|
$131.00
|
|
| Hospital Charge Code |
3004336
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.15 |
| Max. Negotiated Rate |
$125.34 |
| Rate for Payer: Aetna Commercial |
$122.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.17
|
| Rate for Payer: Aetna Managed Medicare |
$38.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$88.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$68.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$65.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.21
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$125.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.24
|
| Rate for Payer: Health EOS Commercial |
$121.25
|
| Rate for Payer: HFN Commercial |
$125.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.18
|
| Rate for Payer: Multiplan Commercial |
$108.99
|
| Rate for Payer: NAPHCARE Commercial |
$81.74
|
| Rate for Payer: Preferred Network Access Commercial |
$125.34
|
| Rate for Payer: Quartz Beloit One Network |
$66.76
|
| Rate for Payer: Quartz Commercial |
$88.56
|
| Rate for Payer: Quartz Medicare Advantage |
$81.74
|
| Rate for Payer: The Alliance Commercial |
$68.12
|
| Rate for Payer: WEA Trust Commercial |
$74.93
|
| Rate for Payer: WPS Commercial |
$100.91
|
|
|
Miscellaneous Suture Supply
|
Facility
|
IP
|
$131.00
|
|
| Hospital Charge Code |
3004336
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.76 |
| Max. Negotiated Rate |
$125.34 |
| Rate for Payer: Aetna Commercial |
$122.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.21
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$125.34
|
| Rate for Payer: Health EOS Commercial |
$121.25
|
| Rate for Payer: HFN Commercial |
$125.34
|
| Rate for Payer: Multiplan Commercial |
$108.99
|
| Rate for Payer: Preferred Network Access Commercial |
$125.34
|
| Rate for Payer: Quartz Beloit One Network |
$66.76
|
| Rate for Payer: Quartz Commercial |
$81.74
|
| Rate for Payer: WEA Trust Commercial |
$74.93
|
| Rate for Payer: WPS Commercial |
$100.91
|
|
