|
Organic Acids, Full Panel, Urine
|
Facility
|
IP
|
$969.00
|
|
|
Service Code
|
CPT 83918
|
| Hospital Charge Code |
978030
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$474.81 |
| Max. Negotiated Rate |
$891.48 |
| Rate for Payer: Aetna Commercial |
$872.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$833.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$513.57
|
| Rate for Payer: Cash Price |
$290.70
|
| Rate for Payer: Cigna Commercial |
$891.48
|
| Rate for Payer: Health EOS Commercial |
$862.41
|
| Rate for Payer: HFN Commercial |
$891.48
|
| Rate for Payer: Multiplan Commercial |
$775.20
|
| Rate for Payer: NAPHCARE Commercial |
$581.40
|
| Rate for Payer: Preferred Network Access Commercial |
$891.48
|
| Rate for Payer: Quartz Beloit One Network |
$474.81
|
| Rate for Payer: Quartz Commercial |
$581.40
|
| Rate for Payer: WEA Trust Commercial |
$532.95
|
| Rate for Payer: WPS Commercial |
$717.74
|
|
|
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY
|
Facility
|
IP
|
$47,029.00
|
|
|
Service Code
|
MSDRG 884
|
| Min. Negotiated Rate |
$16,917.02 |
| Max. Negotiated Rate |
$47,029.00 |
| Rate for Payer: Aetna Managed Medicare |
$16,917.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36,924.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28,302.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26,889.28
|
| Rate for Payer: Anthem Medicare Advantage |
$16,917.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,917.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,917.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,917.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29,849.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,917.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,259.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,917.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,917.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,917.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,917.02
|
| Rate for Payer: NAPHCARE Commercial |
$25,375.53
|
| Rate for Payer: Quartz Medicare Advantage |
$16,917.02
|
| Rate for Payer: The Alliance Commercial |
$47,029.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,917.02
|
| Rate for Payer: United Healthcare PPO |
$26,671.50
|
| Rate for Payer: Wellcare Medicare |
$16,917.02
|
|
|
ORGAN PROCUREMENT
|
Facility
|
OP
|
$4,238.00
|
|
| Hospital Charge Code |
2960261
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,186.64 |
| Max. Negotiated Rate |
$16,952.00 |
| Rate for Payer: Aetna Commercial |
$3,814.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,644.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,186.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,754.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,119.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,034.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,246.14
|
| Rate for Payer: Cash Price |
$1,271.40
|
| Rate for Payer: Cigna Commercial |
$3,898.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,371.58
|
| Rate for Payer: Health EOS Commercial |
$3,771.82
|
| Rate for Payer: HFN Commercial |
$3,898.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,178.50
|
| Rate for Payer: Multiplan Commercial |
$3,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,542.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,898.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,076.62
|
| Rate for Payer: Quartz Commercial |
$2,754.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,542.80
|
| Rate for Payer: The Alliance Commercial |
$16,952.00
|
| Rate for Payer: WEA Trust Commercial |
$2,330.90
|
| Rate for Payer: WPS Commercial |
$3,139.09
|
|
|
ORGAN PROCUREMENT
|
Facility
|
IP
|
$4,238.00
|
|
| Hospital Charge Code |
2960261
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,076.62 |
| Max. Negotiated Rate |
$3,898.96 |
| Rate for Payer: Aetna Commercial |
$3,814.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,644.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,246.14
|
| Rate for Payer: Cash Price |
$1,271.40
|
| Rate for Payer: Cigna Commercial |
$3,898.96
|
| Rate for Payer: Health EOS Commercial |
$3,771.82
|
| Rate for Payer: HFN Commercial |
$3,898.96
|
| Rate for Payer: Multiplan Commercial |
$3,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,542.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,898.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,076.62
|
| Rate for Payer: Quartz Commercial |
$2,542.80
|
| Rate for Payer: WEA Trust Commercial |
$2,330.90
|
| Rate for Payer: WPS Commercial |
$3,139.09
|
|
|
ORISE GEL M00519201
|
Facility
|
IP
|
$1,466.00
|
|
| Hospital Charge Code |
5520803
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$718.34 |
| Max. Negotiated Rate |
$1,348.72 |
| Rate for Payer: Aetna Commercial |
$1,319.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,260.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$776.98
|
| Rate for Payer: Cash Price |
$439.80
|
| Rate for Payer: Cigna Commercial |
$1,348.72
|
| Rate for Payer: Health EOS Commercial |
$1,304.74
|
| Rate for Payer: HFN Commercial |
$1,348.72
|
| Rate for Payer: Multiplan Commercial |
$1,172.80
|
| Rate for Payer: NAPHCARE Commercial |
$879.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,348.72
|
| Rate for Payer: Quartz Beloit One Network |
$718.34
|
| Rate for Payer: Quartz Commercial |
$879.60
|
| Rate for Payer: WEA Trust Commercial |
$806.30
|
| Rate for Payer: WPS Commercial |
$1,085.87
|
|
|
ORISE GEL M00519201
|
Facility
|
OP
|
$1,466.00
|
|
| Hospital Charge Code |
5520803
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$410.48 |
| Max. Negotiated Rate |
$5,864.00 |
| Rate for Payer: Aetna Commercial |
$1,319.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,260.76
|
| Rate for Payer: Aetna Managed Medicare |
$410.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$952.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$733.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$703.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$776.98
|
| Rate for Payer: Cash Price |
$439.80
|
| Rate for Payer: Cigna Commercial |
$1,348.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$820.37
|
| Rate for Payer: Health EOS Commercial |
$1,304.74
|
| Rate for Payer: HFN Commercial |
$1,348.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,099.50
|
| Rate for Payer: Multiplan Commercial |
$1,172.80
|
| Rate for Payer: NAPHCARE Commercial |
$879.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,348.72
|
| Rate for Payer: Quartz Beloit One Network |
$718.34
|
| Rate for Payer: Quartz Commercial |
$952.90
|
| Rate for Payer: Quartz Medicare Advantage |
$879.60
|
| Rate for Payer: The Alliance Commercial |
$5,864.00
|
| Rate for Payer: WEA Trust Commercial |
$806.30
|
| Rate for Payer: WPS Commercial |
$1,085.87
|
|
|
Oropharyngeal Airway
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
3149566
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Managed Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.12
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1.20
|
| Rate for Payer: The Alliance Commercial |
$8.00
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
Oropharyngeal Airway
|
Facility
|
IP
|
$2.00
|
|
| Hospital Charge Code |
3149566
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.20
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
O.R. PROCEDURES FOR OBESITY WITH CC
|
Facility
|
IP
|
$43,448.00
|
|
|
Service Code
|
MSDRG 620
|
| Min. Negotiated Rate |
$15,628.84 |
| Max. Negotiated Rate |
$43,448.00 |
| Rate for Payer: Aetna Managed Medicare |
$15,628.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33,987.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,051.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,750.36
|
| Rate for Payer: Anthem Medicare Advantage |
$15,628.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,628.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,628.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,628.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,475.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,628.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,632.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,628.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,628.84
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,628.84
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,628.84
|
| Rate for Payer: NAPHCARE Commercial |
$23,443.26
|
| Rate for Payer: Quartz Medicare Advantage |
$15,628.84
|
| Rate for Payer: The Alliance Commercial |
$43,448.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,628.84
|
| Rate for Payer: United Healthcare PPO |
$24,626.62
|
| Rate for Payer: Wellcare Medicare |
$15,628.84
|
|
|
O.R. PROCEDURES FOR OBESITY WITH MCC
|
Facility
|
IP
|
$69,510.00
|
|
|
Service Code
|
MSDRG 619
|
| Min. Negotiated Rate |
$25,003.74 |
| Max. Negotiated Rate |
$69,510.00 |
| Rate for Payer: Aetna Managed Medicare |
$25,003.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54,338.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41,649.79
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39,570.02
|
| Rate for Payer: Anthem Medicare Advantage |
$25,003.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25,003.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25,003.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25,003.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43,926.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25,003.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50,475.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25,003.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25,003.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25,003.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25,003.74
|
| Rate for Payer: NAPHCARE Commercial |
$37,505.61
|
| Rate for Payer: Quartz Medicare Advantage |
$25,003.74
|
| Rate for Payer: The Alliance Commercial |
$69,510.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25,003.74
|
| Rate for Payer: United Healthcare PPO |
$39,296.02
|
| Rate for Payer: Wellcare Medicare |
$25,003.74
|
|
|
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC
|
Facility
|
IP
|
$40,659.00
|
|
|
Service Code
|
MSDRG 621
|
| Min. Negotiated Rate |
$14,625.65 |
| Max. Negotiated Rate |
$40,659.00 |
| Rate for Payer: Aetna Managed Medicare |
$14,625.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31,889.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,443.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23,222.56
|
| Rate for Payer: Anthem Medicare Advantage |
$14,625.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,625.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,625.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,625.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25,779.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,625.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,587.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,625.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,625.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,625.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,625.65
|
| Rate for Payer: NAPHCARE Commercial |
$21,938.48
|
| Rate for Payer: Quartz Medicare Advantage |
$14,625.65
|
| Rate for Payer: The Alliance Commercial |
$40,659.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,625.65
|
| Rate for Payer: United Healthcare PPO |
$23,034.13
|
| Rate for Payer: Wellcare Medicare |
$14,625.65
|
|
|
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC
|
Facility
|
IP
|
$57,922.00
|
|
|
Service Code
|
MSDRG 940
|
| Min. Negotiated Rate |
$20,835.10 |
| Max. Negotiated Rate |
$57,922.00 |
| Rate for Payer: Aetna Managed Medicare |
$20,835.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45,526.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34,895.77
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33,153.26
|
| Rate for Payer: Anthem Medicare Advantage |
$20,835.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20,835.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20,835.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20,835.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36,803.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20,835.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42,248.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20,835.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20,835.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20,835.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20,835.10
|
| Rate for Payer: NAPHCARE Commercial |
$31,252.65
|
| Rate for Payer: Quartz Medicare Advantage |
$20,835.10
|
| Rate for Payer: The Alliance Commercial |
$57,922.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20,835.10
|
| Rate for Payer: United Healthcare PPO |
$32,891.15
|
| Rate for Payer: Wellcare Medicare |
$20,835.10
|
|
|
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC
|
Facility
|
IP
|
$85,802.00
|
|
|
Service Code
|
MSDRG 939
|
| Min. Negotiated Rate |
$30,864.12 |
| Max. Negotiated Rate |
$85,802.00 |
| Rate for Payer: Aetna Managed Medicare |
$30,864.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67,555.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51,780.82
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49,195.16
|
| Rate for Payer: Anthem Medicare Advantage |
$30,864.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30,864.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30,864.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30,864.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54,611.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30,864.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62,698.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30,864.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30,864.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30,864.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30,864.12
|
| Rate for Payer: NAPHCARE Commercial |
$46,296.18
|
| Rate for Payer: Quartz Medicare Advantage |
$30,864.12
|
| Rate for Payer: The Alliance Commercial |
$85,802.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30,864.12
|
| Rate for Payer: United Healthcare PPO |
$48,811.47
|
| Rate for Payer: Wellcare Medicare |
$30,864.12
|
|
|
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC
|
Facility
|
IP
|
$49,664.00
|
|
|
Service Code
|
MSDRG 941
|
| Min. Negotiated Rate |
$17,864.74 |
| Max. Negotiated Rate |
$49,664.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,864.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39,022.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,910.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,417.08
|
| Rate for Payer: Anthem Medicare Advantage |
$17,864.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,864.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,864.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,864.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,545.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,864.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36,192.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,864.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,864.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,864.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,864.74
|
| Rate for Payer: NAPHCARE Commercial |
$26,797.11
|
| Rate for Payer: Quartz Medicare Advantage |
$17,864.74
|
| Rate for Payer: The Alliance Commercial |
$49,664.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,864.74
|
| Rate for Payer: United Healthcare PPO |
$28,175.94
|
| Rate for Payer: Wellcare Medicare |
$17,864.74
|
|
|
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS
|
Facility
|
IP
|
$99,526.00
|
|
|
Service Code
|
MSDRG 876
|
| Min. Negotiated Rate |
$35,800.70 |
| Max. Negotiated Rate |
$99,526.00 |
| Rate for Payer: Aetna Managed Medicare |
$35,800.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78,255.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59,982.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56,986.94
|
| Rate for Payer: Anthem Medicare Advantage |
$35,800.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35,800.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35,800.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35,800.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63,260.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35,800.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72,764.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35,800.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35,800.70
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35,800.70
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35,800.70
|
| Rate for Payer: NAPHCARE Commercial |
$53,701.05
|
| Rate for Payer: Quartz Medicare Advantage |
$35,800.70
|
| Rate for Payer: The Alliance Commercial |
$99,526.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35,800.70
|
| Rate for Payer: United Healthcare PPO |
$56,647.90
|
| Rate for Payer: Wellcare Medicare |
$35,800.70
|
|
|
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 |
$20.68 |
| Max. Negotiated Rate |
$44.65 |
| Rate for Payer: Aetna Commercial |
$44.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40.42
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$44.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$23.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.20
|
| Rate for Payer: Health EOS Commercial |
$42.77
|
| Rate for Payer: HFN Commercial |
$44.65
|
| Rate for Payer: Multiplan Commercial |
$37.60
|
| Rate for Payer: Preferred Network Access Commercial |
$44.65
|
| Rate for Payer: Quartz Beloit One Network |
$20.68
|
| Rate for Payer: Quartz Commercial |
$26.79
|
| Rate for Payer: The Alliance Commercial |
$23.50
|
| Rate for Payer: WEA Trust Commercial |
$25.85
|
| Rate for Payer: WPS Commercial |
$34.81
|
|
|
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 |
$13.16 |
| Max. Negotiated Rate |
$188.00 |
| Rate for Payer: Aetna Commercial |
$42.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40.42
|
| Rate for Payer: Aetna Managed Medicare |
$13.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.91
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$43.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.30
|
| Rate for Payer: Health EOS Commercial |
$41.83
|
| Rate for Payer: HFN Commercial |
$43.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35.25
|
| Rate for Payer: Multiplan Commercial |
$37.60
|
| Rate for Payer: NAPHCARE Commercial |
$28.20
|
| Rate for Payer: Preferred Network Access Commercial |
$43.24
|
| Rate for Payer: Quartz Beloit One Network |
$23.03
|
| Rate for Payer: Quartz Commercial |
$30.55
|
| Rate for Payer: Quartz Medicare Advantage |
$28.20
|
| Rate for Payer: The Alliance Commercial |
$188.00
|
| Rate for Payer: WEA Trust Commercial |
$25.85
|
| Rate for Payer: WPS Commercial |
$34.81
|
|
|
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 |
$23.03 |
| Max. Negotiated Rate |
$43.24 |
| Rate for Payer: Aetna Commercial |
$42.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.91
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$43.24
|
| Rate for Payer: Health EOS Commercial |
$41.83
|
| Rate for Payer: HFN Commercial |
$43.24
|
| Rate for Payer: Multiplan Commercial |
$37.60
|
| Rate for Payer: NAPHCARE Commercial |
$28.20
|
| Rate for Payer: Preferred Network Access Commercial |
$43.24
|
| Rate for Payer: Quartz Beloit One Network |
$23.03
|
| Rate for Payer: Quartz Commercial |
$28.20
|
| Rate for Payer: WEA Trust Commercial |
$25.85
|
| Rate for Payer: WPS Commercial |
$34.81
|
|
|
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 |
$35.28 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$43.20
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
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 |
$20.16 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Aetna Managed Medicare |
$20.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.29
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: Quartz Medicare Advantage |
$43.20
|
| Rate for Payer: The Alliance Commercial |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
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 |
$31.68 |
| Max. Negotiated Rate |
$84.30 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.20
|
| Rate for Payer: Health EOS Commercial |
$65.52
|
| Rate for Payer: HFN Commercial |
$68.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$84.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$84.30
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: Preferred Network Access Commercial |
$68.40
|
| Rate for Payer: Quartz Beloit One Network |
$31.68
|
| Rate for Payer: Quartz Commercial |
$41.04
|
| Rate for Payer: The Alliance Commercial |
$36.00
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
ORTHO FUSION
|
Facility
|
OP
|
$4,912.00
|
|
| Hospital Charge Code |
2960081
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,375.36 |
| Max. Negotiated Rate |
$19,648.00 |
| Rate for Payer: Aetna Commercial |
$4,420.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,224.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,375.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,192.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,456.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,357.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,603.36
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,519.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,748.76
|
| Rate for Payer: Health EOS Commercial |
$4,371.68
|
| Rate for Payer: HFN Commercial |
$4,519.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,684.00
|
| Rate for Payer: Multiplan Commercial |
$3,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,947.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,519.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,406.88
|
| Rate for Payer: Quartz Commercial |
$3,192.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,947.20
|
| Rate for Payer: The Alliance Commercial |
$19,648.00
|
| Rate for Payer: WEA Trust Commercial |
$2,701.60
|
| Rate for Payer: WPS Commercial |
$3,638.32
|
|
|
ORTHO FUSION
|
Facility
|
IP
|
$4,912.00
|
|
| Hospital Charge Code |
2960081
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,406.88 |
| Max. Negotiated Rate |
$4,519.04 |
| Rate for Payer: Aetna Commercial |
$4,420.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,224.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,603.36
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,519.04
|
| Rate for Payer: Health EOS Commercial |
$4,371.68
|
| Rate for Payer: HFN Commercial |
$4,519.04
|
| Rate for Payer: Multiplan Commercial |
$3,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,947.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,519.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,406.88
|
| Rate for Payer: Quartz Commercial |
$2,947.20
|
| Rate for Payer: WEA Trust Commercial |
$2,701.60
|
| Rate for Payer: WPS Commercial |
$3,638.32
|
|
|
ORTHO GLASS ROLL 5x15' #OG-5L2
|
Facility
|
OP
|
$1,452.00
|
|
| Hospital Charge Code |
2969539
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$406.56 |
| Max. Negotiated Rate |
$5,808.00 |
| Rate for Payer: Aetna Commercial |
$1,306.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,248.72
|
| Rate for Payer: Aetna Managed Medicare |
$406.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$943.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$726.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$696.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$769.56
|
| Rate for Payer: Cash Price |
$435.60
|
| Rate for Payer: Cigna Commercial |
$1,335.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$812.54
|
| Rate for Payer: Health EOS Commercial |
$1,292.28
|
| Rate for Payer: HFN Commercial |
$1,335.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,089.00
|
| Rate for Payer: Multiplan Commercial |
$1,161.60
|
| Rate for Payer: NAPHCARE Commercial |
$871.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,335.84
|
| Rate for Payer: Quartz Beloit One Network |
$711.48
|
| Rate for Payer: Quartz Commercial |
$943.80
|
| Rate for Payer: Quartz Medicare Advantage |
$871.20
|
| Rate for Payer: The Alliance Commercial |
$5,808.00
|
| Rate for Payer: WEA Trust Commercial |
$798.60
|
| Rate for Payer: WPS Commercial |
$1,075.50
|
|
|
ORTHO GLASS ROLL 5x15' #OG-5L2
|
Facility
|
IP
|
$1,452.00
|
|
| Hospital Charge Code |
2969539
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$711.48 |
| Max. Negotiated Rate |
$1,335.84 |
| Rate for Payer: Aetna Commercial |
$1,306.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,248.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$769.56
|
| Rate for Payer: Cash Price |
$435.60
|
| Rate for Payer: Cigna Commercial |
$1,335.84
|
| Rate for Payer: Health EOS Commercial |
$1,292.28
|
| Rate for Payer: HFN Commercial |
$1,335.84
|
| Rate for Payer: Multiplan Commercial |
$1,161.60
|
| Rate for Payer: NAPHCARE Commercial |
$871.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,335.84
|
| Rate for Payer: Quartz Beloit One Network |
$711.48
|
| Rate for Payer: Quartz Commercial |
$871.20
|
| Rate for Payer: WEA Trust Commercial |
$798.60
|
| Rate for Payer: WPS Commercial |
$1,075.50
|
|
