|
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE
|
Facility
|
IP
|
$125,123.78
|
|
|
Service Code
|
APR-DRG 5933
|
| Min. Negotiated Rate |
$111,142.75 |
| Max. Negotiated Rate |
$125,123.78 |
| Rate for Payer: Anthem Medicaid |
$119,812.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$119,812.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$119,812.92
|
| Rate for Payer: Dean Health Medicaid |
$119,812.92
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$111,142.75
|
| Rate for Payer: Managed Health Services Medicaid |
$125,123.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$119,812.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$119,812.92
|
| Rate for Payer: United Healthcare Medicaid |
$119,812.92
|
|
|
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE
|
Facility
|
IP
|
$100,660.20
|
|
|
Service Code
|
APR-DRG 5932
|
| Min. Negotiated Rate |
$89,412.67 |
| Max. Negotiated Rate |
$100,660.20 |
| Rate for Payer: Anthem Medicaid |
$96,387.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$96,387.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$96,387.69
|
| Rate for Payer: Dean Health Medicaid |
$96,387.69
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$89,412.67
|
| Rate for Payer: Managed Health Services Medicaid |
$100,660.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$96,387.69
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$96,387.69
|
| Rate for Payer: United Healthcare Medicaid |
$96,387.69
|
|
|
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE
|
Facility
|
IP
|
$76,635.03
|
|
|
Service Code
|
APR-DRG 5931
|
| Min. Negotiated Rate |
$68,072.01 |
| Max. Negotiated Rate |
$76,635.03 |
| Rate for Payer: Anthem Medicaid |
$73,382.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$73,382.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73,382.26
|
| Rate for Payer: Dean Health Medicaid |
$73,382.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$68,072.01
|
| Rate for Payer: Managed Health Services Medicaid |
$76,635.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$73,382.26
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$73,382.26
|
| Rate for Payer: United Healthcare Medicaid |
$73,382.26
|
|
|
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE
|
Facility
|
IP
|
$171,069.73
|
|
|
Service Code
|
APR-DRG 5934
|
| Min. Negotiated Rate |
$151,954.81 |
| Max. Negotiated Rate |
$171,069.73 |
| Rate for Payer: Anthem Medicaid |
$163,808.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$163,808.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163,808.69
|
| Rate for Payer: Dean Health Medicaid |
$163,808.69
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$151,954.81
|
| Rate for Payer: Managed Health Services Medicaid |
$171,069.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$163,808.69
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$163,808.69
|
| Rate for Payer: United Healthcare Medicaid |
$163,808.69
|
|
|
NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY
|
Facility
|
IP
|
$50,638.64
|
|
|
Service Code
|
MSDRG 789
|
| Min. Negotiated Rate |
$1,664.00 |
| Max. Negotiated Rate |
$50,638.64 |
| Rate for Payer: Aetna Managed Medicare |
$14,308.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,702.48
|
| Rate for Payer: Anthem Medicare Advantage |
$14,308.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,308.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,308.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,308.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,787.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,308.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,016.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,308.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,308.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,308.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,308.39
|
| Rate for Payer: NAPHCARE Commercial |
$21,462.59
|
| Rate for Payer: Quartz Medicare Advantage |
$14,308.39
|
| Rate for Payer: The Alliance Commercial |
$50,638.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,308.39
|
| Rate for Payer: United Healthcare PPO |
$1,664.00
|
| Rate for Payer: Wellcare Medicare |
$14,308.39
|
|
|
NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE
|
Facility
|
IP
|
$4,910.25
|
|
|
Service Code
|
APR-DRG 5814
|
| Min. Negotiated Rate |
$4,361.59 |
| Max. Negotiated Rate |
$4,910.25 |
| Rate for Payer: Anthem Medicaid |
$4,701.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,701.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,701.84
|
| Rate for Payer: Dean Health Medicaid |
$4,701.84
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4,361.59
|
| Rate for Payer: Managed Health Services Medicaid |
$4,910.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,701.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,701.84
|
| Rate for Payer: United Healthcare Medicaid |
$4,701.84
|
|
|
NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE
|
Facility
|
IP
|
$2,718.18
|
|
|
Service Code
|
APR-DRG 5813
|
| Min. Negotiated Rate |
$2,414.45 |
| Max. Negotiated Rate |
$2,718.18 |
| Rate for Payer: Anthem Medicaid |
$2,602.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$2,602.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,602.80
|
| Rate for Payer: Dean Health Medicaid |
$2,602.80
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$2,414.45
|
| Rate for Payer: Managed Health Services Medicaid |
$2,718.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,602.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$2,602.80
|
| Rate for Payer: United Healthcare Medicaid |
$2,602.80
|
|
|
NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE
|
Facility
|
IP
|
$876.83
|
|
|
Service Code
|
APR-DRG 5811
|
| Min. Negotiated Rate |
$778.86 |
| Max. Negotiated Rate |
$876.83 |
| Rate for Payer: Anthem Medicaid |
$839.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$839.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$839.61
|
| Rate for Payer: Dean Health Medicaid |
$839.61
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$778.86
|
| Rate for Payer: Managed Health Services Medicaid |
$876.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$839.61
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$839.61
|
| Rate for Payer: United Healthcare Medicaid |
$839.61
|
|
|
NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE
|
Facility
|
IP
|
$1,402.93
|
|
|
Service Code
|
APR-DRG 5812
|
| Min. Negotiated Rate |
$1,246.17 |
| Max. Negotiated Rate |
$1,402.93 |
| Rate for Payer: Anthem Medicaid |
$1,343.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$1,343.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,343.38
|
| Rate for Payer: Dean Health Medicaid |
$1,343.38
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$1,246.17
|
| Rate for Payer: Managed Health Services Medicaid |
$1,402.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,343.38
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$1,343.38
|
| Rate for Payer: United Healthcare Medicaid |
$1,343.38
|
|
|
NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE
|
Facility
|
IP
|
$10,346.61
|
|
|
Service Code
|
APR-DRG 5804
|
| Min. Negotiated Rate |
$9,190.50 |
| Max. Negotiated Rate |
$10,346.61 |
| Rate for Payer: Anthem Medicaid |
$9,907.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,907.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,907.45
|
| Rate for Payer: Dean Health Medicaid |
$9,907.45
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9,190.50
|
| Rate for Payer: Managed Health Services Medicaid |
$10,346.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,907.45
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,907.45
|
| Rate for Payer: United Healthcare Medicaid |
$9,907.45
|
|
|
NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE
|
Facility
|
IP
|
$2,630.49
|
|
|
Service Code
|
APR-DRG 5801
|
| Min. Negotiated Rate |
$2,336.57 |
| Max. Negotiated Rate |
$2,630.49 |
| Rate for Payer: Anthem Medicaid |
$2,518.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$2,518.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,518.84
|
| Rate for Payer: Dean Health Medicaid |
$2,518.84
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$2,336.57
|
| Rate for Payer: Managed Health Services Medicaid |
$2,630.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,518.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$2,518.84
|
| Rate for Payer: United Healthcare Medicaid |
$2,518.84
|
|
|
NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE
|
Facility
|
IP
|
$8,066.85
|
|
|
Service Code
|
APR-DRG 5803
|
| Min. Negotiated Rate |
$7,165.48 |
| Max. Negotiated Rate |
$8,066.85 |
| Rate for Payer: Anthem Medicaid |
$7,724.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$7,724.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,724.45
|
| Rate for Payer: Dean Health Medicaid |
$7,724.45
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,165.48
|
| Rate for Payer: Managed Health Services Medicaid |
$8,066.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,724.45
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7,724.45
|
| Rate for Payer: United Healthcare Medicaid |
$7,724.45
|
|
|
NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE
|
Facility
|
IP
|
$4,121.11
|
|
|
Service Code
|
APR-DRG 5802
|
| Min. Negotiated Rate |
$3,660.62 |
| Max. Negotiated Rate |
$4,121.11 |
| Rate for Payer: Anthem Medicaid |
$3,946.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$3,946.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,946.19
|
| Rate for Payer: Dean Health Medicaid |
$3,946.19
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,660.62
|
| Rate for Payer: Managed Health Services Medicaid |
$4,121.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,946.19
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3,946.19
|
| Rate for Payer: United Healthcare Medicaid |
$3,946.19
|
|
|
NEONATE WITH ECMO
|
Facility
|
IP
|
$211,930.05
|
|
|
Service Code
|
APR-DRG 5832
|
| Min. Negotiated Rate |
$188,249.50 |
| Max. Negotiated Rate |
$211,930.05 |
| Rate for Payer: Anthem Medicaid |
$202,934.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$202,934.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$202,934.70
|
| Rate for Payer: Dean Health Medicaid |
$202,934.70
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$188,249.50
|
| Rate for Payer: Managed Health Services Medicaid |
$211,930.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$202,934.70
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$202,934.70
|
| Rate for Payer: United Healthcare Medicaid |
$202,934.70
|
|
|
NEONATE WITH ECMO
|
Facility
|
IP
|
$275,938.72
|
|
|
Service Code
|
APR-DRG 5833
|
| Min. Negotiated Rate |
$245,105.98 |
| Max. Negotiated Rate |
$275,938.72 |
| Rate for Payer: Anthem Medicaid |
$264,226.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$264,226.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$264,226.53
|
| Rate for Payer: Dean Health Medicaid |
$264,226.53
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$245,105.98
|
| Rate for Payer: Managed Health Services Medicaid |
$275,938.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$264,226.53
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$264,226.53
|
| Rate for Payer: United Healthcare Medicaid |
$264,226.53
|
|
|
NEONATE WITH ECMO
|
Facility
|
IP
|
$484,536.81
|
|
|
Service Code
|
APR-DRG 5834
|
| Min. Negotiated Rate |
$430,395.83 |
| Max. Negotiated Rate |
$484,536.81 |
| Rate for Payer: Anthem Medicaid |
$463,970.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$463,970.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$463,970.70
|
| Rate for Payer: Dean Health Medicaid |
$463,970.70
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$430,395.83
|
| Rate for Payer: Managed Health Services Medicaid |
$484,536.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$463,970.70
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$463,970.70
|
| Rate for Payer: United Healthcare Medicaid |
$463,970.70
|
|
|
NEONATE WITH ECMO
|
Facility
|
IP
|
$190,184.64
|
|
|
Service Code
|
APR-DRG 5831
|
| Min. Negotiated Rate |
$168,933.87 |
| Max. Negotiated Rate |
$190,184.64 |
| Rate for Payer: Anthem Medicaid |
$182,112.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$182,112.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$182,112.28
|
| Rate for Payer: Dean Health Medicaid |
$182,112.28
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$168,933.87
|
| Rate for Payer: Managed Health Services Medicaid |
$190,184.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$182,112.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$182,112.28
|
| Rate for Payer: United Healthcare Medicaid |
$182,112.28
|
|
|
NEONATE WITH OTHER SIGNIFICANT PROBLEMS
|
Facility
|
IP
|
$41,528.24
|
|
|
Service Code
|
MSDRG 794
|
| Min. Negotiated Rate |
$1,664.00 |
| Max. Negotiated Rate |
$41,528.24 |
| Rate for Payer: Aetna Managed Medicare |
$11,809.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,702.48
|
| Rate for Payer: Anthem Medicare Advantage |
$11,809.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,809.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,809.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,809.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26,032.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,809.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,016.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,809.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,809.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,809.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,809.52
|
| Rate for Payer: NAPHCARE Commercial |
$17,714.28
|
| Rate for Payer: Quartz Medicare Advantage |
$11,809.52
|
| Rate for Payer: The Alliance Commercial |
$41,528.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,809.52
|
| Rate for Payer: United Healthcare PPO |
$1,664.00
|
| Rate for Payer: Wellcare Medicare |
$11,809.52
|
|
|
Neo/Poly/Dexameth Ophth Ointment 3.5gm [Med]
|
Facility
|
OP
|
$62.00
|
|
| Hospital Charge Code |
2974929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$59.32 |
| Rate for Payer: Aetna Commercial |
$58.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.45
|
| Rate for Payer: Aetna Managed Medicare |
$18.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.17
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$59.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.08
|
| Rate for Payer: Health EOS Commercial |
$57.39
|
| Rate for Payer: HFN Commercial |
$59.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.36
|
| Rate for Payer: Multiplan Commercial |
$51.58
|
| Rate for Payer: NAPHCARE Commercial |
$38.69
|
| Rate for Payer: Preferred Network Access Commercial |
$59.32
|
| Rate for Payer: Quartz Beloit One Network |
$31.60
|
| Rate for Payer: Quartz Commercial |
$41.91
|
| Rate for Payer: Quartz Medicare Advantage |
$38.69
|
| Rate for Payer: The Alliance Commercial |
$32.24
|
| Rate for Payer: WEA Trust Commercial |
$35.46
|
| Rate for Payer: WPS Commercial |
$47.76
|
|
|
Neo/Poly/Dexameth Ophth Ointment 3.5gm [Med]
|
Facility
|
IP
|
$62.00
|
|
| Hospital Charge Code |
2974929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.60 |
| Max. Negotiated Rate |
$59.32 |
| Rate for Payer: Aetna Commercial |
$58.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.17
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$59.32
|
| Rate for Payer: Health EOS Commercial |
$57.39
|
| Rate for Payer: HFN Commercial |
$59.32
|
| Rate for Payer: Multiplan Commercial |
$51.58
|
| Rate for Payer: Preferred Network Access Commercial |
$59.32
|
| Rate for Payer: Quartz Beloit One Network |
$31.60
|
| Rate for Payer: Quartz Commercial |
$38.69
|
| Rate for Payer: WEA Trust Commercial |
$35.46
|
| Rate for Payer: WPS Commercial |
$47.76
|
|
|
Neo/Poly/Dexameth Ophth Suspension 5ml [Med]
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
2974930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Aetna Managed Medicare |
$11.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.12
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.64
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: NAPHCARE Commercial |
$23.71
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$25.69
|
| Rate for Payer: Quartz Medicare Advantage |
$23.71
|
| Rate for Payer: The Alliance Commercial |
$19.76
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
Neo/Poly/Dexameth Ophth Suspension 5ml [Med]
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
2974930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.36 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$23.71
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
Nephelometry, Fibrospect II
|
Facility
|
IP
|
$254.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
2776843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$129.44 |
| Max. Negotiated Rate |
$243.03 |
| Rate for Payer: Aetna Commercial |
$237.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.00
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$243.03
|
| Rate for Payer: Health EOS Commercial |
$235.10
|
| Rate for Payer: HFN Commercial |
$243.03
|
| Rate for Payer: Multiplan Commercial |
$211.33
|
| Rate for Payer: Preferred Network Access Commercial |
$243.03
|
| Rate for Payer: Quartz Beloit One Network |
$129.44
|
| Rate for Payer: Quartz Commercial |
$158.50
|
| Rate for Payer: WEA Trust Commercial |
$145.29
|
| Rate for Payer: WPS Commercial |
$195.66
|
|
|
Nephelometry, Fibrospect II
|
Facility
|
OP
|
$254.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
2776843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.14 |
| Max. Negotiated Rate |
$243.03 |
| Rate for Payer: Aetna Commercial |
$237.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.18
|
| Rate for Payer: Aetna Managed Medicare |
$14.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.48
|
| Rate for Payer: Anthem Medicare Advantage |
$14.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.14
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$243.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.14
|
| Rate for Payer: Health EOS Commercial |
$235.10
|
| Rate for Payer: HFN Commercial |
$243.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.14
|
| Rate for Payer: Multiplan Commercial |
$211.33
|
| Rate for Payer: NAPHCARE Commercial |
$21.22
|
| Rate for Payer: Preferred Network Access Commercial |
$243.03
|
| Rate for Payer: Quartz Beloit One Network |
$129.44
|
| Rate for Payer: Quartz Commercial |
$171.70
|
| Rate for Payer: Quartz Medicare Advantage |
$14.14
|
| Rate for Payer: The Alliance Commercial |
$56.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.14
|
| Rate for Payer: United Healthcare PPO |
$198.12
|
| Rate for Payer: WEA Trust Commercial |
$145.29
|
| Rate for Payer: Wellcare Medicare |
$14.14
|
| Rate for Payer: WPS Commercial |
$195.66
|
|
|
Nephelometry, Fibrospect II
|
Professional
|
Both
|
$254.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
2776843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.14 |
| Max. Negotiated Rate |
$250.95 |
| Rate for Payer: Aetna Commercial |
$250.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.18
|
| Rate for Payer: Aetna Managed Medicare |
$14.14
|
| Rate for Payer: Anthem Medicare Advantage |
$14.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.14
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$250.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$132.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.14
|
| Rate for Payer: Health EOS Commercial |
$240.39
|
| Rate for Payer: HFN Commercial |
$250.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.14
|
| Rate for Payer: Multiplan Commercial |
$211.33
|
| Rate for Payer: NAPHCARE Commercial |
$21.22
|
| Rate for Payer: Preferred Network Access Commercial |
$250.95
|
| Rate for Payer: Quartz Beloit One Network |
$116.23
|
| Rate for Payer: Quartz Commercial |
$150.57
|
| Rate for Payer: Quartz Medicare Advantage |
$14.14
|
| Rate for Payer: The Alliance Commercial |
$55.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.14
|
| Rate for Payer: WEA Trust Commercial |
$145.29
|
| Rate for Payer: WPS Commercial |
$62.23
|
|
