|
PEDI PAD MOLESKIN 101-A
|
Facility
|
IP
|
$3.00
|
|
| Hospital Charge Code |
2970599
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.65
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.87
|
| Rate for Payer: Health EOS Commercial |
$2.78
|
| Rate for Payer: HFN Commercial |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2.87
|
| Rate for Payer: Quartz Beloit One Network |
$1.53
|
| Rate for Payer: Quartz Commercial |
$1.87
|
| Rate for Payer: WEA Trust Commercial |
$1.72
|
| Rate for Payer: WPS Commercial |
$2.31
|
|
|
Peds Observation Per Hour
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040433
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$7,271.68 |
| Rate for Payer: Aetna Commercial |
$58.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.45
|
| Rate for Payer: Aetna Managed Medicare |
$18.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,271.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,271.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,958.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.17
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$59.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.08
|
| Rate for Payer: Health EOS Commercial |
$57.39
|
| Rate for Payer: HFN Commercial |
$59.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.36
|
| Rate for Payer: Multiplan Commercial |
$51.58
|
| Rate for Payer: NAPHCARE Commercial |
$38.69
|
| Rate for Payer: Preferred Network Access Commercial |
$59.32
|
| Rate for Payer: Quartz Beloit One Network |
$31.60
|
| Rate for Payer: Quartz Commercial |
$41.91
|
| Rate for Payer: Quartz Medicare Advantage |
$38.69
|
| Rate for Payer: The Alliance Commercial |
$32.24
|
| Rate for Payer: United Healthcare PPO |
$2,701.92
|
| Rate for Payer: WEA Trust Commercial |
$35.46
|
| Rate for Payer: WPS Commercial |
$47.76
|
|
|
Peds Observation Per Hour
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040433
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$31.60 |
| Max. Negotiated Rate |
$59.32 |
| Rate for Payer: Aetna Commercial |
$58.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.17
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$59.32
|
| Rate for Payer: Health EOS Commercial |
$57.39
|
| Rate for Payer: HFN Commercial |
$59.32
|
| Rate for Payer: Multiplan Commercial |
$51.58
|
| Rate for Payer: Preferred Network Access Commercial |
$59.32
|
| Rate for Payer: Quartz Beloit One Network |
$31.60
|
| Rate for Payer: Quartz Commercial |
$38.69
|
| Rate for Payer: WEA Trust Commercial |
$35.46
|
| Rate for Payer: WPS Commercial |
$47.76
|
|
|
PEG DRILL BIT INBONE TALAR 4MM IB200020
|
Facility
|
OP
|
$1,908.00
|
|
| Hospital Charge Code |
5831729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$555.61 |
| Max. Negotiated Rate |
$1,825.57 |
| Rate for Payer: Aetna Commercial |
$1,785.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,706.52
|
| Rate for Payer: Aetna Managed Medicare |
$555.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,289.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$992.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$952.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,051.69
|
| Rate for Payer: Cash Price |
$572.40
|
| Rate for Payer: Cigna Commercial |
$1,825.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,110.46
|
| Rate for Payer: Health EOS Commercial |
$1,766.04
|
| Rate for Payer: HFN Commercial |
$1,825.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,488.24
|
| Rate for Payer: Multiplan Commercial |
$1,587.46
|
| Rate for Payer: NAPHCARE Commercial |
$1,190.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,825.57
|
| Rate for Payer: Quartz Beloit One Network |
$972.32
|
| Rate for Payer: Quartz Commercial |
$1,289.81
|
| Rate for Payer: Quartz Medicare Advantage |
$1,190.59
|
| Rate for Payer: The Alliance Commercial |
$992.16
|
| Rate for Payer: WEA Trust Commercial |
$1,091.38
|
| Rate for Payer: WPS Commercial |
$1,469.73
|
|
|
PEG DRILL BIT INBONE TALAR 4MM IB200020
|
Facility
|
IP
|
$1,908.00
|
|
| Hospital Charge Code |
5831729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$972.32 |
| Max. Negotiated Rate |
$1,825.57 |
| Rate for Payer: Aetna Commercial |
$1,785.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,706.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,051.69
|
| Rate for Payer: Cash Price |
$572.40
|
| Rate for Payer: Cigna Commercial |
$1,825.57
|
| Rate for Payer: Health EOS Commercial |
$1,766.04
|
| Rate for Payer: HFN Commercial |
$1,825.57
|
| Rate for Payer: Multiplan Commercial |
$1,587.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,825.57
|
| Rate for Payer: Quartz Beloit One Network |
$972.32
|
| Rate for Payer: Quartz Commercial |
$1,190.59
|
| Rate for Payer: WEA Trust Commercial |
$1,091.38
|
| Rate for Payer: WPS Commercial |
$1,469.73
|
|
|
PEG TUBE PULL 24FR ENFIT M00509021/M00509140
|
Facility
|
OP
|
$1,377.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5563453
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$400.98 |
| Max. Negotiated Rate |
$1,317.51 |
| Rate for Payer: Aetna Commercial |
$1,288.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,231.59
|
| Rate for Payer: Aetna Managed Medicare |
$400.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$930.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$687.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$759.00
|
| Rate for Payer: Cash Price |
$413.10
|
| Rate for Payer: Cigna Commercial |
$1,317.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$801.41
|
| Rate for Payer: Health EOS Commercial |
$1,274.55
|
| Rate for Payer: HFN Commercial |
$1,317.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,074.06
|
| Rate for Payer: Multiplan Commercial |
$1,145.66
|
| Rate for Payer: NAPHCARE Commercial |
$859.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,317.51
|
| Rate for Payer: Quartz Beloit One Network |
$701.72
|
| Rate for Payer: Quartz Commercial |
$930.85
|
| Rate for Payer: Quartz Medicare Advantage |
$859.25
|
| Rate for Payer: The Alliance Commercial |
$716.04
|
| Rate for Payer: WEA Trust Commercial |
$787.64
|
| Rate for Payer: WPS Commercial |
$1,060.70
|
|
|
PEG TUBE PULL 24FR ENFIT M00509021/M00509140
|
Facility
|
IP
|
$1,377.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5563453
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$701.72 |
| Max. Negotiated Rate |
$1,317.51 |
| Rate for Payer: Aetna Commercial |
$1,288.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,231.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$759.00
|
| Rate for Payer: Cash Price |
$413.10
|
| Rate for Payer: Cigna Commercial |
$1,317.51
|
| Rate for Payer: Health EOS Commercial |
$1,274.55
|
| Rate for Payer: HFN Commercial |
$1,317.51
|
| Rate for Payer: Multiplan Commercial |
$1,145.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,317.51
|
| Rate for Payer: Quartz Beloit One Network |
$701.72
|
| Rate for Payer: Quartz Commercial |
$859.25
|
| Rate for Payer: WEA Trust Commercial |
$787.64
|
| Rate for Payer: WPS Commercial |
$1,060.70
|
|
|
PEG TUBE PUSH 24FR ENFIT M00509031/M00509150
|
Facility
|
IP
|
$1,377.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5563452
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$701.72 |
| Max. Negotiated Rate |
$1,317.51 |
| Rate for Payer: Aetna Commercial |
$1,288.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,231.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$759.00
|
| Rate for Payer: Cash Price |
$413.10
|
| Rate for Payer: Cigna Commercial |
$1,317.51
|
| Rate for Payer: Health EOS Commercial |
$1,274.55
|
| Rate for Payer: HFN Commercial |
$1,317.51
|
| Rate for Payer: Multiplan Commercial |
$1,145.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,317.51
|
| Rate for Payer: Quartz Beloit One Network |
$701.72
|
| Rate for Payer: Quartz Commercial |
$859.25
|
| Rate for Payer: WEA Trust Commercial |
$787.64
|
| Rate for Payer: WPS Commercial |
$1,060.70
|
|
|
PEG TUBE PUSH 24FR ENFIT M00509031/M00509150
|
Facility
|
OP
|
$1,377.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5563452
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$400.98 |
| Max. Negotiated Rate |
$1,317.51 |
| Rate for Payer: Aetna Commercial |
$1,288.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,231.59
|
| Rate for Payer: Aetna Managed Medicare |
$400.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$930.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$687.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$759.00
|
| Rate for Payer: Cash Price |
$413.10
|
| Rate for Payer: Cigna Commercial |
$1,317.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$801.41
|
| Rate for Payer: Health EOS Commercial |
$1,274.55
|
| Rate for Payer: HFN Commercial |
$1,317.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,074.06
|
| Rate for Payer: Multiplan Commercial |
$1,145.66
|
| Rate for Payer: NAPHCARE Commercial |
$859.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,317.51
|
| Rate for Payer: Quartz Beloit One Network |
$701.72
|
| Rate for Payer: Quartz Commercial |
$930.85
|
| Rate for Payer: Quartz Medicare Advantage |
$859.25
|
| Rate for Payer: The Alliance Commercial |
$716.04
|
| Rate for Payer: WEA Trust Commercial |
$787.64
|
| Rate for Payer: WPS Commercial |
$1,060.70
|
|
|
PEG TUBE REPLACEMENT
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960310
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
PEG TUBE REPLACEMENT
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960310
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
PEG tube - Tube Type
|
Facility
|
OP
|
$1,324.00
|
|
| Hospital Charge Code |
3025915
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$385.55 |
| Max. Negotiated Rate |
$1,266.80 |
| Rate for Payer: Aetna Commercial |
$1,239.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,184.19
|
| Rate for Payer: Aetna Managed Medicare |
$385.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$895.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$688.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$660.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$729.79
|
| Rate for Payer: Cash Price |
$397.20
|
| Rate for Payer: Cigna Commercial |
$1,266.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$770.57
|
| Rate for Payer: Health EOS Commercial |
$1,225.49
|
| Rate for Payer: HFN Commercial |
$1,266.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,032.72
|
| Rate for Payer: Multiplan Commercial |
$1,101.57
|
| Rate for Payer: NAPHCARE Commercial |
$826.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,266.80
|
| Rate for Payer: Quartz Beloit One Network |
$674.71
|
| Rate for Payer: Quartz Commercial |
$895.02
|
| Rate for Payer: Quartz Medicare Advantage |
$826.18
|
| Rate for Payer: The Alliance Commercial |
$688.48
|
| Rate for Payer: WEA Trust Commercial |
$757.33
|
| Rate for Payer: WPS Commercial |
$1,019.88
|
|
|
PEG tube - Tube Type
|
Facility
|
IP
|
$1,324.00
|
|
| Hospital Charge Code |
3025915
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$674.71 |
| Max. Negotiated Rate |
$1,266.80 |
| Rate for Payer: Aetna Commercial |
$1,239.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,184.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$729.79
|
| Rate for Payer: Cash Price |
$397.20
|
| Rate for Payer: Cigna Commercial |
$1,266.80
|
| Rate for Payer: Health EOS Commercial |
$1,225.49
|
| Rate for Payer: HFN Commercial |
$1,266.80
|
| Rate for Payer: Multiplan Commercial |
$1,101.57
|
| Rate for Payer: Preferred Network Access Commercial |
$1,266.80
|
| Rate for Payer: Quartz Beloit One Network |
$674.71
|
| Rate for Payer: Quartz Commercial |
$826.18
|
| Rate for Payer: WEA Trust Commercial |
$757.33
|
| Rate for Payer: WPS Commercial |
$1,019.88
|
|
|
PEG TUBE WITH BIOPSY
|
Facility
|
IP
|
$5,420.00
|
|
| Hospital Charge Code |
4075906
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,762.03 |
| Max. Negotiated Rate |
$5,185.86 |
| Rate for Payer: Aetna Commercial |
$5,073.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,847.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,987.50
|
| Rate for Payer: Cash Price |
$1,626.00
|
| Rate for Payer: Cigna Commercial |
$5,185.86
|
| Rate for Payer: Health EOS Commercial |
$5,016.75
|
| Rate for Payer: HFN Commercial |
$5,185.86
|
| Rate for Payer: Multiplan Commercial |
$4,509.44
|
| Rate for Payer: Preferred Network Access Commercial |
$5,185.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,762.03
|
| Rate for Payer: Quartz Commercial |
$3,382.08
|
| Rate for Payer: WEA Trust Commercial |
$3,100.24
|
| Rate for Payer: WPS Commercial |
$4,175.03
|
|
|
PEG TUBE WITH BIOPSY
|
Facility
|
OP
|
$5,420.00
|
|
| Hospital Charge Code |
4075906
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1,578.30 |
| Max. Negotiated Rate |
$5,185.86 |
| Rate for Payer: Aetna Commercial |
$5,073.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,847.65
|
| Rate for Payer: Aetna Managed Medicare |
$1,578.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,663.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,818.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,705.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,987.50
|
| Rate for Payer: Cash Price |
$1,626.00
|
| Rate for Payer: Cigna Commercial |
$5,185.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,154.44
|
| Rate for Payer: Health EOS Commercial |
$5,016.75
|
| Rate for Payer: HFN Commercial |
$5,185.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,227.60
|
| Rate for Payer: Multiplan Commercial |
$4,509.44
|
| Rate for Payer: NAPHCARE Commercial |
$3,382.08
|
| Rate for Payer: Preferred Network Access Commercial |
$5,185.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,762.03
|
| Rate for Payer: Quartz Commercial |
$3,663.92
|
| Rate for Payer: Quartz Medicare Advantage |
$3,382.08
|
| Rate for Payer: The Alliance Commercial |
$2,818.40
|
| Rate for Payer: WEA Trust Commercial |
$3,100.24
|
| Rate for Payer: WPS Commercial |
$4,175.03
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC
|
Facility
|
IP
|
$60,432.32
|
|
|
Service Code
|
MSDRG 734
|
| Min. Negotiated Rate |
$16,818.74 |
| Max. Negotiated Rate |
$60,432.32 |
| Rate for Payer: Aetna Managed Medicare |
$16,818.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46,474.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35,622.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33,843.83
|
| Rate for Payer: Anthem Medicare Advantage |
$16,818.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,818.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,818.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,818.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37,569.75
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,818.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44,080.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,818.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,818.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,818.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,818.74
|
| Rate for Payer: NAPHCARE Commercial |
$25,228.12
|
| Rate for Payer: Quartz Medicare Advantage |
$16,818.74
|
| Rate for Payer: The Alliance Commercial |
$60,432.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,818.74
|
| Rate for Payer: United Healthcare PPO |
$34,317.32
|
| Rate for Payer: Wellcare Medicare |
$16,818.74
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC
|
Facility
|
IP
|
$35,176.96
|
|
|
Service Code
|
MSDRG 735
|
| Min. Negotiated Rate |
$10,810.88 |
| Max. Negotiated Rate |
$35,176.96 |
| Rate for Payer: Aetna Managed Medicare |
$10,810.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,357.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,502.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,378.81
|
| Rate for Payer: Anthem Medicare Advantage |
$10,810.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,810.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,810.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,810.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,732.44
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,810.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,556.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,810.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,810.88
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,810.88
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,810.88
|
| Rate for Payer: NAPHCARE Commercial |
$16,216.32
|
| Rate for Payer: Quartz Medicare Advantage |
$10,810.88
|
| Rate for Payer: The Alliance Commercial |
$35,176.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,810.88
|
| Rate for Payer: United Healthcare PPO |
$19,896.34
|
| Rate for Payer: Wellcare Medicare |
$10,810.88
|
|
|
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL)
|
Facility
|
OP
|
$13,626.87
|
|
|
Service Code
|
CPT 57410
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,835.04 |
| Max. Negotiated Rate |
$13,626.87 |
| Rate for Payer: Aetna Managed Medicare |
$3,406.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$3,406.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,406.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,406.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,406.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,406.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,672.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,406.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,406.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,406.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,406.72
|
| Rate for Payer: NAPHCARE Commercial |
$5,110.08
|
| Rate for Payer: Quartz Medicare Advantage |
$3,406.72
|
| Rate for Payer: The Alliance Commercial |
$13,626.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,406.72
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$3,406.72
|
|
|
PELVIC EXAM UNDER ANESTHESIA
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
4075914
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
PELVIC EXAM UNDER ANESTHESIA
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
4075914
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
PELVIC EXPLORATION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960311
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
PELVIC EXPLORATION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960311
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
PELVIC & PARA AORTIC LYMPH NODE DISSECTION
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960312
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,298.75 |
| Max. Negotiated Rate |
$4,267.33 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,298.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,014.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,319.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,226.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,267.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,595.72
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,478.80
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: NAPHCARE Commercial |
$2,783.04
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$3,014.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,783.04
|
| Rate for Payer: The Alliance Commercial |
$2,319.20
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
PELVIC & PARA AORTIC LYMPH NODE DISSECTION
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960312
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,272.82 |
| Max. Negotiated Rate |
$4,267.33 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,267.33
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$2,783.04
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
PELVIC PLATE L STRAIGHT 122.5MM X 8HL 425708
|
Facility
|
IP
|
$4,218.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6198986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,149.49 |
| Max. Negotiated Rate |
$4,035.78 |
| Rate for Payer: Aetna Commercial |
$3,948.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,772.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,324.96
|
| Rate for Payer: Cash Price |
$1,265.40
|
| Rate for Payer: Cigna Commercial |
$4,035.78
|
| Rate for Payer: Health EOS Commercial |
$3,904.18
|
| Rate for Payer: HFN Commercial |
$4,035.78
|
| Rate for Payer: Multiplan Commercial |
$3,509.38
|
| Rate for Payer: Preferred Network Access Commercial |
$4,035.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,149.49
|
| Rate for Payer: Quartz Commercial |
$2,632.03
|
| Rate for Payer: WEA Trust Commercial |
$2,412.70
|
| Rate for Payer: WPS Commercial |
$3,249.13
|
|
