|
Oropharyngeal Airway
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
3149566
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
O.R. PROCEDURES FOR OBESITY WITH CC
|
Facility
|
IP
|
$45,185.92
|
|
|
Service Code
|
MSDRG 620
|
| Min. Negotiated Rate |
$12,762.18 |
| Max. Negotiated Rate |
$45,185.92 |
| Rate for Payer: Aetna Managed Medicare |
$12,762.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34,917.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,763.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,427.36
|
| Rate for Payer: Anthem Medicare Advantage |
$12,762.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,762.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,762.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,762.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28,226.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,762.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,898.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,762.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,762.18
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,762.18
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,762.18
|
| Rate for Payer: NAPHCARE Commercial |
$19,143.27
|
| Rate for Payer: Quartz Medicare Advantage |
$12,762.18
|
| Rate for Payer: The Alliance Commercial |
$45,185.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,762.18
|
| Rate for Payer: United Healthcare PPO |
$25,611.68
|
| Rate for Payer: Wellcare Medicare |
$12,762.18
|
|
|
O.R. PROCEDURES FOR OBESITY WITH MCC
|
Facility
|
IP
|
$72,290.40
|
|
|
Service Code
|
MSDRG 619
|
| Min. Negotiated Rate |
$22,619.06 |
| Max. Negotiated Rate |
$72,290.40 |
| Rate for Payer: Aetna Managed Medicare |
$22,619.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63,000.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48,289.57
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45,878.25
|
| Rate for Payer: Anthem Medicare Advantage |
$22,619.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22,619.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22,619.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$22,619.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50,929.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$22,619.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52,494.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22,619.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22,619.06
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$22,619.06
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$22,619.06
|
| Rate for Payer: NAPHCARE Commercial |
$33,928.60
|
| Rate for Payer: Quartz Medicare Advantage |
$22,619.06
|
| Rate for Payer: The Alliance Commercial |
$72,290.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22,619.06
|
| Rate for Payer: United Healthcare PPO |
$40,867.86
|
| Rate for Payer: Wellcare Medicare |
$22,619.06
|
|
|
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC
|
Facility
|
IP
|
$42,285.36
|
|
|
Service Code
|
MSDRG 621
|
| Min. Negotiated Rate |
$12,058.40 |
| Max. Negotiated Rate |
$42,285.36 |
| Rate for Payer: Aetna Managed Medicare |
$12,058.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32,912.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,226.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23,967.15
|
| Rate for Payer: Anthem Medicare Advantage |
$12,058.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,058.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,058.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,058.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26,605.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,058.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30,770.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,058.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,058.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,058.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,058.40
|
| Rate for Payer: NAPHCARE Commercial |
$18,087.61
|
| Rate for Payer: Quartz Medicare Advantage |
$12,058.40
|
| Rate for Payer: The Alliance Commercial |
$42,285.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,058.40
|
| Rate for Payer: United Healthcare PPO |
$23,955.50
|
| Rate for Payer: Wellcare Medicare |
$12,058.40
|
|
|
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC
|
Facility
|
IP
|
$60,238.88
|
|
|
Service Code
|
MSDRG 940
|
| Min. Negotiated Rate |
$18,403.21 |
| Max. Negotiated Rate |
$60,238.88 |
| Rate for Payer: Aetna Managed Medicare |
$18,403.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50,989.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39,082.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37,131.28
|
| Rate for Payer: Anthem Medicare Advantage |
$18,403.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18,403.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18,403.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18,403.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41,219.13
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18,403.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43,938.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18,403.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18,403.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18,403.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18,403.21
|
| Rate for Payer: NAPHCARE Commercial |
$27,604.81
|
| Rate for Payer: Quartz Medicare Advantage |
$18,403.21
|
| Rate for Payer: The Alliance Commercial |
$60,238.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18,403.21
|
| Rate for Payer: United Healthcare PPO |
$34,206.80
|
| Rate for Payer: Wellcare Medicare |
$18,403.21
|
|
|
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC
|
Facility
|
IP
|
$89,234.08
|
|
|
Service Code
|
MSDRG 939
|
| Min. Negotiated Rate |
$28,294.55 |
| Max. Negotiated Rate |
$89,234.08 |
| Rate for Payer: Aetna Managed Medicare |
$28,294.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79,170.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60,683.90
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57,653.67
|
| Rate for Payer: Anthem Medicare Advantage |
$28,294.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28,294.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28,294.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$28,294.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64,000.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$28,294.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65,206.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28,294.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28,294.55
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$28,294.55
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$28,294.55
|
| Rate for Payer: NAPHCARE Commercial |
$42,441.83
|
| Rate for Payer: Quartz Medicare Advantage |
$28,294.55
|
| Rate for Payer: The Alliance Commercial |
$89,234.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28,294.55
|
| Rate for Payer: United Healthcare PPO |
$50,763.93
|
| Rate for Payer: Wellcare Medicare |
$28,294.55
|
|
|
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC
|
Facility
|
IP
|
$51,650.56
|
|
|
Service Code
|
MSDRG 941
|
| Min. Negotiated Rate |
$16,035.31 |
| Max. Negotiated Rate |
$51,650.56 |
| Rate for Payer: Aetna Managed Medicare |
$16,035.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44,242.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33,911.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32,218.37
|
| Rate for Payer: Anthem Medicare Advantage |
$16,035.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,035.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,035.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,035.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35,765.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,035.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37,639.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,035.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,035.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,035.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,035.31
|
| Rate for Payer: NAPHCARE Commercial |
$24,052.97
|
| Rate for Payer: Quartz Medicare Advantage |
$16,035.31
|
| Rate for Payer: The Alliance Commercial |
$51,650.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,035.31
|
| Rate for Payer: United Healthcare PPO |
$29,302.98
|
| Rate for Payer: Wellcare Medicare |
$16,035.31
|
|
|
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS
|
Facility
|
IP
|
$103,507.04
|
|
|
Service Code
|
MSDRG 876
|
| Min. Negotiated Rate |
$30,104.95 |
| Max. Negotiated Rate |
$103,507.04 |
| Rate for Payer: Aetna Managed Medicare |
$30,104.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$84,329.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64,637.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61,409.86
|
| Rate for Payer: Anthem Medicare Advantage |
$30,104.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30,104.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30,104.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30,104.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68,170.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30,104.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30,104.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30,104.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30,104.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30,104.95
|
| Rate for Payer: NAPHCARE Commercial |
$45,157.43
|
| Rate for Payer: Quartz Medicare Advantage |
$30,104.95
|
| Rate for Payer: The Alliance Commercial |
$103,507.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30,104.95
|
| Rate for Payer: United Healthcare PPO |
$58,913.82
|
| Rate for Payer: Wellcare Medicare |
$30,104.95
|
|
|
Orth Dev Repair/Repl Minor L4210
|
Professional
|
Both
|
$47.00
|
|
|
Service Code
|
HCPCS L4210
|
| Hospital Charge Code |
4534660
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$21.51 |
| Max. Negotiated Rate |
$46.44 |
| Rate for Payer: Aetna Commercial |
$46.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.04
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$46.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.33
|
| Rate for Payer: Health EOS Commercial |
$44.48
|
| Rate for Payer: HFN Commercial |
$46.44
|
| Rate for Payer: Multiplan Commercial |
$39.10
|
| Rate for Payer: Preferred Network Access Commercial |
$46.44
|
| Rate for Payer: Quartz Beloit One Network |
$21.51
|
| Rate for Payer: Quartz Commercial |
$27.86
|
| Rate for Payer: The Alliance Commercial |
$24.44
|
| Rate for Payer: WEA Trust Commercial |
$26.88
|
| Rate for Payer: WPS Commercial |
$36.20
|
|
|
Orth Dev Repair/Repl Minor L4210
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
HCPCS L4210
|
| Hospital Charge Code |
4534660
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$23.95 |
| Max. Negotiated Rate |
$44.97 |
| Rate for Payer: Aetna Commercial |
$43.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.91
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$44.97
|
| Rate for Payer: Health EOS Commercial |
$43.50
|
| Rate for Payer: HFN Commercial |
$44.97
|
| Rate for Payer: Multiplan Commercial |
$39.10
|
| Rate for Payer: Preferred Network Access Commercial |
$44.97
|
| Rate for Payer: Quartz Beloit One Network |
$23.95
|
| Rate for Payer: Quartz Commercial |
$29.33
|
| Rate for Payer: WEA Trust Commercial |
$26.88
|
| Rate for Payer: WPS Commercial |
$36.20
|
|
|
Orth Dev Repair/Repl Minor L4210
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
HCPCS L4210
|
| Hospital Charge Code |
4534660
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$13.69 |
| Max. Negotiated Rate |
$44.97 |
| Rate for Payer: Aetna Commercial |
$43.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.04
|
| Rate for Payer: Aetna Managed Medicare |
$13.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.91
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$44.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.35
|
| Rate for Payer: Health EOS Commercial |
$43.50
|
| Rate for Payer: HFN Commercial |
$44.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.66
|
| Rate for Payer: Multiplan Commercial |
$39.10
|
| Rate for Payer: NAPHCARE Commercial |
$29.33
|
| Rate for Payer: Preferred Network Access Commercial |
$44.97
|
| Rate for Payer: Quartz Beloit One Network |
$23.95
|
| Rate for Payer: Quartz Commercial |
$31.77
|
| Rate for Payer: Quartz Medicare Advantage |
$29.33
|
| Rate for Payer: The Alliance Commercial |
$24.44
|
| Rate for Payer: WEA Trust Commercial |
$26.88
|
| Rate for Payer: WPS Commercial |
$36.20
|
|
|
Ortho dvc repair per 15 min L4205
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS L4205
|
| Hospital Charge Code |
3245520
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$20.97 |
| Max. Negotiated Rate |
$124.47 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Aetna Managed Medicare |
$20.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.90
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.16
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: NAPHCARE Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: Quartz Medicare Advantage |
$44.93
|
| Rate for Payer: The Alliance Commercial |
$124.47
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
Ortho dvc repair per 15 min L4205
|
Professional
|
Both
|
$72.00
|
|
|
Service Code
|
HCPCS L4205
|
| Hospital Charge Code |
3245520
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$31.12 |
| Max. Negotiated Rate |
$87.67 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Aetna Managed Medicare |
$31.12
|
| Rate for Payer: Anthem Medicare Advantage |
$31.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$31.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$31.12
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$71.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.12
|
| Rate for Payer: Health EOS Commercial |
$68.14
|
| Rate for Payer: HFN Commercial |
$71.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$87.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$31.12
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: NAPHCARE Commercial |
$46.68
|
| Rate for Payer: Preferred Network Access Commercial |
$71.14
|
| Rate for Payer: Quartz Beloit One Network |
$32.95
|
| Rate for Payer: Quartz Commercial |
$42.68
|
| Rate for Payer: Quartz Medicare Advantage |
$31.12
|
| Rate for Payer: The Alliance Commercial |
$85.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31.12
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$54.45
|
|
|
Ortho dvc repair per 15 min L4205
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS L4205
|
| Hospital Charge Code |
3245520
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$36.69 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$44.93
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
ORTHO FUSION
|
Facility
|
OP
|
$4,912.00
|
|
| Hospital Charge Code |
2960081
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,430.37 |
| Max. Negotiated Rate |
$4,699.80 |
| Rate for Payer: Aetna Commercial |
$4,597.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,393.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,430.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,320.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,554.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,452.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,707.49
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,699.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,858.78
|
| Rate for Payer: Health EOS Commercial |
$4,546.55
|
| Rate for Payer: HFN Commercial |
$4,699.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,831.36
|
| Rate for Payer: Multiplan Commercial |
$4,086.78
|
| Rate for Payer: NAPHCARE Commercial |
$3,065.09
|
| Rate for Payer: Preferred Network Access Commercial |
$4,699.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,503.16
|
| Rate for Payer: Quartz Commercial |
$3,320.51
|
| Rate for Payer: Quartz Medicare Advantage |
$3,065.09
|
| Rate for Payer: The Alliance Commercial |
$2,554.24
|
| Rate for Payer: WEA Trust Commercial |
$2,809.66
|
| Rate for Payer: WPS Commercial |
$3,783.71
|
|
|
ORTHO FUSION
|
Facility
|
IP
|
$4,912.00
|
|
| Hospital Charge Code |
2960081
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,503.16 |
| Max. Negotiated Rate |
$4,699.80 |
| Rate for Payer: Aetna Commercial |
$4,597.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,393.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,707.49
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,699.80
|
| Rate for Payer: Health EOS Commercial |
$4,546.55
|
| Rate for Payer: HFN Commercial |
$4,699.80
|
| Rate for Payer: Multiplan Commercial |
$4,086.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,699.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,503.16
|
| Rate for Payer: Quartz Commercial |
$3,065.09
|
| Rate for Payer: WEA Trust Commercial |
$2,809.66
|
| Rate for Payer: WPS Commercial |
$3,783.71
|
|
|
ORTHO GLASS ROLL 5x15' #OG-5L2
|
Facility
|
IP
|
$1,452.00
|
|
| Hospital Charge Code |
2969539
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$739.94 |
| Max. Negotiated Rate |
$1,389.27 |
| Rate for Payer: Aetna Commercial |
$1,359.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,298.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$800.34
|
| Rate for Payer: Cash Price |
$435.60
|
| Rate for Payer: Cigna Commercial |
$1,389.27
|
| Rate for Payer: Health EOS Commercial |
$1,343.97
|
| Rate for Payer: HFN Commercial |
$1,389.27
|
| Rate for Payer: Multiplan Commercial |
$1,208.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,389.27
|
| Rate for Payer: Quartz Beloit One Network |
$739.94
|
| Rate for Payer: Quartz Commercial |
$906.05
|
| Rate for Payer: WEA Trust Commercial |
$830.54
|
| Rate for Payer: WPS Commercial |
$1,118.48
|
|
|
ORTHO GLASS ROLL 5x15' #OG-5L2
|
Facility
|
OP
|
$1,452.00
|
|
| Hospital Charge Code |
2969539
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$422.82 |
| Max. Negotiated Rate |
$1,389.27 |
| Rate for Payer: Aetna Commercial |
$1,359.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,298.67
|
| Rate for Payer: Aetna Managed Medicare |
$422.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$981.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$755.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$724.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$800.34
|
| Rate for Payer: Cash Price |
$435.60
|
| Rate for Payer: Cigna Commercial |
$1,389.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$845.06
|
| Rate for Payer: Health EOS Commercial |
$1,343.97
|
| Rate for Payer: HFN Commercial |
$1,389.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,132.56
|
| Rate for Payer: Multiplan Commercial |
$1,208.06
|
| Rate for Payer: NAPHCARE Commercial |
$906.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,389.27
|
| Rate for Payer: Quartz Beloit One Network |
$739.94
|
| Rate for Payer: Quartz Commercial |
$981.55
|
| Rate for Payer: Quartz Medicare Advantage |
$906.05
|
| Rate for Payer: The Alliance Commercial |
$755.04
|
| Rate for Payer: WEA Trust Commercial |
$830.54
|
| Rate for Payer: WPS Commercial |
$1,118.48
|
|
|
ORTHO GLASS SPLINT 4 x 15' #OG-4L2
|
Facility
|
IP
|
$1,160.00
|
|
| Hospital Charge Code |
2969538
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$591.14 |
| Max. Negotiated Rate |
$1,109.89 |
| Rate for Payer: Aetna Commercial |
$1,085.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,037.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$639.39
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,109.89
|
| Rate for Payer: Health EOS Commercial |
$1,073.70
|
| Rate for Payer: HFN Commercial |
$1,109.89
|
| Rate for Payer: Multiplan Commercial |
$965.12
|
| Rate for Payer: Preferred Network Access Commercial |
$1,109.89
|
| Rate for Payer: Quartz Beloit One Network |
$591.14
|
| Rate for Payer: Quartz Commercial |
$723.84
|
| Rate for Payer: WEA Trust Commercial |
$663.52
|
| Rate for Payer: WPS Commercial |
$893.55
|
|
|
ORTHO GLASS SPLINT 4 x 15' #OG-4L2
|
Facility
|
OP
|
$1,160.00
|
|
| Hospital Charge Code |
2969538
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$337.79 |
| Max. Negotiated Rate |
$1,109.89 |
| Rate for Payer: Aetna Commercial |
$1,085.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,037.50
|
| Rate for Payer: Aetna Managed Medicare |
$337.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$784.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$603.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$579.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$639.39
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,109.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$675.12
|
| Rate for Payer: Health EOS Commercial |
$1,073.70
|
| Rate for Payer: HFN Commercial |
$1,109.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$904.80
|
| Rate for Payer: Multiplan Commercial |
$965.12
|
| Rate for Payer: NAPHCARE Commercial |
$723.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,109.89
|
| Rate for Payer: Quartz Beloit One Network |
$591.14
|
| Rate for Payer: Quartz Commercial |
$784.16
|
| Rate for Payer: Quartz Medicare Advantage |
$723.84
|
| Rate for Payer: The Alliance Commercial |
$603.20
|
| Rate for Payer: WEA Trust Commercial |
$663.52
|
| Rate for Payer: WPS Commercial |
$893.55
|
|
|
Orthopedic mens shoes dpth L3221
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS L3221
|
| Hospital Charge Code |
4538608
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$25.33 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Aetna Managed Medicare |
$25.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.67
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.63
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.86
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: NAPHCARE Commercial |
$54.29
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$58.81
|
| Rate for Payer: Quartz Medicare Advantage |
$54.29
|
| Rate for Payer: The Alliance Commercial |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
Orthopedic mens shoes dpth L3221
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS L3221
|
| Hospital Charge Code |
4538608
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$54.29
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
Orthopedic mens shoes dpth L3221
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
HCPCS L3221
|
| Hospital Charge Code |
4538608
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$39.81 |
| Max. Negotiated Rate |
$313.74 |
| Rate for Payer: Aetna Commercial |
$85.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$85.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.29
|
| Rate for Payer: Health EOS Commercial |
$82.34
|
| Rate for Payer: HFN Commercial |
$85.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$313.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$313.74
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$85.96
|
| Rate for Payer: Quartz Beloit One Network |
$39.81
|
| Rate for Payer: Quartz Commercial |
$51.57
|
| Rate for Payer: The Alliance Commercial |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
ORTHOSIS DEPRESSION #ACM-9202
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2970537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.19 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$40.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.32
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.64
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$86.11
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$93.29
|
| Rate for Payer: Quartz Medicare Advantage |
$86.11
|
| Rate for Payer: The Alliance Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
ORTHOSIS DEPRESSION #ACM-9202
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2970537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.32 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$86.11
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
