|
Nonesterified Fatty Acids (Free Fatty Acids)
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
CPT 82725
|
| Hospital Charge Code |
3328196
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.30 |
| Max. Negotiated Rate |
$85.89 |
| Rate for Payer: Aetna Commercial |
$39.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Aetna Managed Medicare |
$19.52
|
| Rate for Payer: Anthem Medicare Advantage |
$19.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.52
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$39.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.52
|
| Rate for Payer: Health EOS Commercial |
$37.86
|
| Rate for Payer: HFN Commercial |
$39.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.52
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: NAPHCARE Commercial |
$29.28
|
| Rate for Payer: Preferred Network Access Commercial |
$39.52
|
| Rate for Payer: Quartz Beloit One Network |
$18.30
|
| Rate for Payer: Quartz Commercial |
$23.71
|
| Rate for Payer: Quartz Medicare Advantage |
$19.52
|
| Rate for Payer: The Alliance Commercial |
$77.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.52
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$85.89
|
|
|
Nonesterified Fatty Acids (Free Fatty Acids)
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 82725
|
| Hospital Charge Code |
3328196
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$38.27 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$24.96
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
Nonesterified Fatty Acids (Free Fatty Acids)
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 82725
|
| Hospital Charge Code |
3328196
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.52 |
| Max. Negotiated Rate |
$78.08 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Aetna Managed Medicare |
$19.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$73.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.40
|
| Rate for Payer: Anthem Medicare Advantage |
$19.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.52
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.52
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.52
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: NAPHCARE Commercial |
$29.28
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$27.04
|
| Rate for Payer: Quartz Medicare Advantage |
$19.52
|
| Rate for Payer: The Alliance Commercial |
$78.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.52
|
| Rate for Payer: United Healthcare PPO |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: Wellcare Medicare |
$19.52
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
NON-EXTENSIVE BURNS
|
Facility
|
IP
|
$56,768.40
|
|
|
Service Code
|
MSDRG 935
|
| Min. Negotiated Rate |
$16,282.67 |
| Max. Negotiated Rate |
$56,768.40 |
| Rate for Payer: Aetna Managed Medicare |
$16,282.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44,947.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34,451.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32,731.59
|
| Rate for Payer: Anthem Medicare Advantage |
$16,282.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,282.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,282.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,282.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36,335.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,282.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41,393.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,282.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,282.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,282.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,282.67
|
| Rate for Payer: NAPHCARE Commercial |
$24,424.00
|
| Rate for Payer: Quartz Medicare Advantage |
$16,282.67
|
| Rate for Payer: The Alliance Commercial |
$56,768.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,282.67
|
| Rate for Payer: United Healthcare PPO |
$32,225.38
|
| Rate for Payer: Wellcare Medicare |
$16,282.67
|
|
|
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$32,267.38
|
|
|
Service Code
|
APR-DRG 7944
|
| Min. Negotiated Rate |
$28,661.90 |
| Max. Negotiated Rate |
$32,267.38 |
| Rate for Payer: Anthem Medicaid |
$30,897.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$30,897.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30,897.80
|
| Rate for Payer: Dean Health Medicaid |
$30,897.80
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$28,661.90
|
| Rate for Payer: Managed Health Services Medicaid |
$32,267.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$30,897.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$30,897.80
|
| Rate for Payer: United Healthcare Medicaid |
$30,897.80
|
|
|
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$15,519.91
|
|
|
Service Code
|
APR-DRG 7943
|
| Min. Negotiated Rate |
$13,785.75 |
| Max. Negotiated Rate |
$15,519.91 |
| Rate for Payer: Anthem Medicaid |
$14,861.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$14,861.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14,861.17
|
| Rate for Payer: Dean Health Medicaid |
$14,861.17
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13,785.75
|
| Rate for Payer: Managed Health Services Medicaid |
$15,519.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,861.17
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14,861.17
|
| Rate for Payer: United Healthcare Medicaid |
$14,861.17
|
|
|
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$10,785.02
|
|
|
Service Code
|
APR-DRG 7942
|
| Min. Negotiated Rate |
$9,579.93 |
| Max. Negotiated Rate |
$10,785.02 |
| Rate for Payer: Anthem Medicaid |
$10,327.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$10,327.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,327.25
|
| Rate for Payer: Dean Health Medicaid |
$10,327.25
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9,579.93
|
| Rate for Payer: Managed Health Services Medicaid |
$10,785.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,327.25
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$10,327.25
|
| Rate for Payer: United Healthcare Medicaid |
$10,327.25
|
|
|
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$7,979.16
|
|
|
Service Code
|
APR-DRG 7941
|
| Min. Negotiated Rate |
$7,087.59 |
| Max. Negotiated Rate |
$7,979.16 |
| Rate for Payer: Anthem Medicaid |
$7,640.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$7,640.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,640.49
|
| Rate for Payer: Dean Health Medicaid |
$7,640.49
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,087.59
|
| Rate for Payer: Managed Health Services Medicaid |
$7,979.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,640.49
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7,640.49
|
| Rate for Payer: United Healthcare Medicaid |
$7,640.49
|
|
|
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC
|
Facility
|
IP
|
$47,254.48
|
|
|
Service Code
|
MSDRG 988
|
| Min. Negotiated Rate |
$13,093.80 |
| Max. Negotiated Rate |
$47,254.48 |
| Rate for Payer: Aetna Managed Medicare |
$13,093.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35,862.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27,487.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26,115.36
|
| Rate for Payer: Anthem Medicare Advantage |
$13,093.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13,093.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13,093.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13,093.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28,990.44
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13,093.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,415.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13,093.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13,093.80
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13,093.80
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13,093.80
|
| Rate for Payer: NAPHCARE Commercial |
$19,640.70
|
| Rate for Payer: Quartz Medicare Advantage |
$13,093.80
|
| Rate for Payer: The Alliance Commercial |
$47,254.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13,093.80
|
| Rate for Payer: United Healthcare PPO |
$26,792.65
|
| Rate for Payer: Wellcare Medicare |
$13,093.80
|
|
|
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC
|
Facility
|
IP
|
$93,696.72
|
|
|
Service Code
|
MSDRG 987
|
| Min. Negotiated Rate |
$26,762.14 |
| Max. Negotiated Rate |
$93,696.72 |
| Rate for Payer: Aetna Managed Medicare |
$26,762.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74,804.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57,337.38
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54,474.26
|
| Rate for Payer: Anthem Medicare Advantage |
$26,762.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26,762.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26,762.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$26,762.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60,471.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$26,762.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68,479.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$26,762.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26,762.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$26,762.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$26,762.14
|
| Rate for Payer: NAPHCARE Commercial |
$40,143.21
|
| Rate for Payer: Quartz Medicare Advantage |
$26,762.14
|
| Rate for Payer: The Alliance Commercial |
$93,696.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26,762.14
|
| Rate for Payer: United Healthcare PPO |
$53,312.15
|
| Rate for Payer: Wellcare Medicare |
$26,762.14
|
|
|
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC
|
Facility
|
IP
|
$30,202.64
|
|
|
Service Code
|
MSDRG 989
|
| Min. Negotiated Rate |
$9,690.48 |
| Max. Negotiated Rate |
$30,202.64 |
| Rate for Payer: Aetna Managed Medicare |
$9,690.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26,165.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,055.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19,054.23
|
| Rate for Payer: Anthem Medicare Advantage |
$9,690.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,690.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,690.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,690.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21,151.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,690.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,908.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,690.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,690.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,690.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,690.48
|
| Rate for Payer: NAPHCARE Commercial |
$14,535.72
|
| Rate for Payer: Quartz Medicare Advantage |
$9,690.48
|
| Rate for Payer: The Alliance Commercial |
$30,202.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,690.48
|
| Rate for Payer: United Healthcare PPO |
$17,056.03
|
| Rate for Payer: Wellcare Medicare |
$9,690.48
|
|
|
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$19,202.60
|
|
|
Service Code
|
APR-DRG 9523
|
| Min. Negotiated Rate |
$17,056.95 |
| Max. Negotiated Rate |
$19,202.60 |
| Rate for Payer: Anthem Medicaid |
$18,387.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$18,387.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18,387.55
|
| Rate for Payer: Dean Health Medicaid |
$18,387.55
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17,056.95
|
| Rate for Payer: Managed Health Services Medicaid |
$19,202.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,387.55
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18,387.55
|
| Rate for Payer: United Healthcare Medicaid |
$18,387.55
|
|
|
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$8,943.68
|
|
|
Service Code
|
APR-DRG 9521
|
| Min. Negotiated Rate |
$7,944.33 |
| Max. Negotiated Rate |
$8,943.68 |
| Rate for Payer: Anthem Medicaid |
$8,564.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,564.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,564.06
|
| Rate for Payer: Dean Health Medicaid |
$8,564.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,944.33
|
| Rate for Payer: Managed Health Services Medicaid |
$8,943.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,564.06
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,564.06
|
| Rate for Payer: United Healthcare Medicaid |
$8,564.06
|
|
|
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$12,626.37
|
|
|
Service Code
|
APR-DRG 9522
|
| Min. Negotiated Rate |
$11,215.53 |
| Max. Negotiated Rate |
$12,626.37 |
| Rate for Payer: Anthem Medicaid |
$12,090.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12,090.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12,090.44
|
| Rate for Payer: Dean Health Medicaid |
$12,090.44
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11,215.53
|
| Rate for Payer: Managed Health Services Medicaid |
$12,626.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,090.44
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12,090.44
|
| Rate for Payer: United Healthcare Medicaid |
$12,090.44
|
|
|
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$33,407.26
|
|
|
Service Code
|
APR-DRG 9524
|
| Min. Negotiated Rate |
$29,674.41 |
| Max. Negotiated Rate |
$33,407.26 |
| Rate for Payer: Anthem Medicaid |
$31,989.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$31,989.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31,989.29
|
| Rate for Payer: Dean Health Medicaid |
$31,989.29
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$29,674.41
|
| Rate for Payer: Managed Health Services Medicaid |
$33,407.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$31,989.29
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$31,989.29
|
| Rate for Payer: United Healthcare Medicaid |
$31,989.29
|
|
|
NON-HYPOVOLEMIC SODIUM DISORDERS
|
Facility
|
IP
|
$5,874.77
|
|
|
Service Code
|
APR-DRG 4262
|
| Min. Negotiated Rate |
$5,218.34 |
| Max. Negotiated Rate |
$5,874.77 |
| Rate for Payer: Anthem Medicaid |
$5,625.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,625.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,625.41
|
| Rate for Payer: Dean Health Medicaid |
$5,625.41
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,218.34
|
| Rate for Payer: Managed Health Services Medicaid |
$5,874.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,625.41
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,625.41
|
| Rate for Payer: United Healthcare Medicaid |
$5,625.41
|
|
|
NON-HYPOVOLEMIC SODIUM DISORDERS
|
Facility
|
IP
|
$9,031.36
|
|
|
Service Code
|
APR-DRG 4263
|
| Min. Negotiated Rate |
$8,022.22 |
| Max. Negotiated Rate |
$9,031.36 |
| Rate for Payer: Anthem Medicaid |
$8,648.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,648.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,648.02
|
| Rate for Payer: Dean Health Medicaid |
$8,648.02
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,022.22
|
| Rate for Payer: Managed Health Services Medicaid |
$9,031.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,648.02
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,648.02
|
| Rate for Payer: United Healthcare Medicaid |
$8,648.02
|
|
|
NON-HYPOVOLEMIC SODIUM DISORDERS
|
Facility
|
IP
|
$15,958.32
|
|
|
Service Code
|
APR-DRG 4264
|
| Min. Negotiated Rate |
$14,175.18 |
| Max. Negotiated Rate |
$15,958.32 |
| Rate for Payer: Anthem Medicaid |
$15,280.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$15,280.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15,280.97
|
| Rate for Payer: Dean Health Medicaid |
$15,280.97
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14,175.18
|
| Rate for Payer: Managed Health Services Medicaid |
$15,958.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,280.97
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15,280.97
|
| Rate for Payer: United Healthcare Medicaid |
$15,280.97
|
|
|
NON-HYPOVOLEMIC SODIUM DISORDERS
|
Facility
|
IP
|
$4,384.15
|
|
|
Service Code
|
APR-DRG 4261
|
| Min. Negotiated Rate |
$3,894.28 |
| Max. Negotiated Rate |
$4,384.15 |
| Rate for Payer: Anthem Medicaid |
$4,198.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,198.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,198.07
|
| Rate for Payer: Dean Health Medicaid |
$4,198.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,894.28
|
| Rate for Payer: Managed Health Services Medicaid |
$4,384.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,198.07
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,198.07
|
| Rate for Payer: United Healthcare Medicaid |
$4,198.07
|
|
|
NONINVASIVE VENTILATION SUPPORT
|
Facility
|
OP
|
$134.96
|
|
|
Service Code
|
EAPG 02020
|
| Min. Negotiated Rate |
$129.77 |
| Max. Negotiated Rate |
$134.96 |
| Rate for Payer: Anthem Medicaid |
$129.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$129.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$129.77
|
| Rate for Payer: Dean Health Medicaid |
$129.77
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$129.77
|
| Rate for Payer: Managed Health Services Medicaid |
$134.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$129.77
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$129.77
|
| Rate for Payer: United Healthcare Medicaid |
$129.77
|
|
|
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC
|
Facility
|
IP
|
$28,687.36
|
|
|
Service Code
|
MSDRG 600
|
| Min. Negotiated Rate |
$8,483.56 |
| Max. Negotiated Rate |
$28,687.36 |
| Rate for Payer: Aetna Managed Medicare |
$8,483.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,726.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,419.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,550.11
|
| Rate for Payer: Anthem Medicare Advantage |
$8,483.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,483.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,483.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,483.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,372.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,483.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,797.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,483.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,483.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,483.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,483.56
|
| Rate for Payer: NAPHCARE Commercial |
$12,725.34
|
| Rate for Payer: Quartz Medicare Advantage |
$8,483.56
|
| Rate for Payer: The Alliance Commercial |
$28,687.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,483.56
|
| Rate for Payer: United Healthcare PPO |
$16,190.84
|
| Rate for Payer: Wellcare Medicare |
$8,483.56
|
|
|
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$17,849.52
|
|
|
Service Code
|
MSDRG 601
|
| Min. Negotiated Rate |
$5,140.00 |
| Max. Negotiated Rate |
$17,849.52 |
| Rate for Payer: Aetna Managed Medicare |
$5,140.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,200.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,118.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,612.92
|
| Rate for Payer: Anthem Medicare Advantage |
$5,140.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,140.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,140.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,140.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,671.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,140.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,626.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,140.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,140.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,140.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,140.00
|
| Rate for Payer: NAPHCARE Commercial |
$7,710.00
|
| Rate for Payer: Quartz Medicare Advantage |
$5,140.00
|
| Rate for Payer: The Alliance Commercial |
$17,849.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,140.00
|
| Rate for Payer: United Healthcare PPO |
$9,829.76
|
| Rate for Payer: Wellcare Medicare |
$5,140.00
|
|
|
NON-PRESSURE CHRONIC SKIN ULCERS
|
Facility
|
OP
|
$112.69
|
|
|
Service Code
|
EAPG 00670
|
| Min. Negotiated Rate |
$108.35 |
| Max. Negotiated Rate |
$112.69 |
| Rate for Payer: Anthem Medicaid |
$108.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$108.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$108.35
|
| Rate for Payer: Dean Health Medicaid |
$108.35
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$108.35
|
| Rate for Payer: Managed Health Services Medicaid |
$112.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$108.35
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$108.35
|
| Rate for Payer: United Healthcare Medicaid |
$108.35
|
|
|
Non-Rebreather Mask - Adult
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
3040337
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.79
|
| Rate for Payer: Aetna Managed Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.10
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.16
|
| Rate for Payer: Health EOS Commercial |
$1.85
|
| Rate for Payer: HFN Commercial |
$1.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: NAPHCARE Commercial |
$1.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1.91
|
| Rate for Payer: Quartz Beloit One Network |
$1.02
|
| Rate for Payer: Quartz Commercial |
$1.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1.25
|
| Rate for Payer: The Alliance Commercial |
$1.04
|
| Rate for Payer: WEA Trust Commercial |
$1.14
|
| Rate for Payer: WPS Commercial |
$1.54
|
|
|
Non-Rebreather Mask - Adult
|
Facility
|
IP
|
$2.00
|
|
| Hospital Charge Code |
3040337
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.10
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.91
|
| Rate for Payer: Health EOS Commercial |
$1.85
|
| Rate for Payer: HFN Commercial |
$1.91
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1.91
|
| Rate for Payer: Quartz Beloit One Network |
$1.02
|
| Rate for Payer: Quartz Commercial |
$1.25
|
| Rate for Payer: WEA Trust Commercial |
$1.14
|
| Rate for Payer: WPS Commercial |
$1.54
|
|
