|
PAD XXL BODY PREVALON AIRTAP 7260
|
Facility
|
OP
|
$495.00
|
|
| Hospital Charge Code |
5414960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$138.60 |
| Max. Negotiated Rate |
$1,980.00 |
| Rate for Payer: Aetna Commercial |
$445.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Aetna Managed Medicare |
$138.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$321.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$247.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$237.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.35
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$455.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$277.00
|
| Rate for Payer: Health EOS Commercial |
$440.55
|
| Rate for Payer: HFN Commercial |
$455.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$371.25
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: NAPHCARE Commercial |
$297.00
|
| Rate for Payer: Preferred Network Access Commercial |
$455.40
|
| Rate for Payer: Quartz Beloit One Network |
$242.55
|
| Rate for Payer: Quartz Commercial |
$321.75
|
| Rate for Payer: Quartz Medicare Advantage |
$297.00
|
| Rate for Payer: The Alliance Commercial |
$1,980.00
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
PAD XXL BODY PREVALON AIRTAP 7260
|
Facility
|
IP
|
$495.00
|
|
| Hospital Charge Code |
5414960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$242.55 |
| Max. Negotiated Rate |
$455.40 |
| Rate for Payer: Aetna Commercial |
$445.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.35
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$455.40
|
| Rate for Payer: Health EOS Commercial |
$440.55
|
| Rate for Payer: HFN Commercial |
$455.40
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: NAPHCARE Commercial |
$297.00
|
| Rate for Payer: Preferred Network Access Commercial |
$455.40
|
| Rate for Payer: Quartz Beloit One Network |
$242.55
|
| Rate for Payer: Quartz Commercial |
$297.00
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
PAI-A INTRODUCTORY KIT
|
Facility
|
OP
|
$3,843.00
|
|
| Hospital Charge Code |
2973444
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,076.04 |
| Max. Negotiated Rate |
$15,372.00 |
| Rate for Payer: Aetna Commercial |
$3,458.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,304.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,076.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,497.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,921.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,844.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,036.79
|
| Rate for Payer: Cash Price |
$1,152.90
|
| Rate for Payer: Cigna Commercial |
$3,535.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,150.54
|
| Rate for Payer: Health EOS Commercial |
$3,420.27
|
| Rate for Payer: HFN Commercial |
$3,535.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,882.25
|
| Rate for Payer: Multiplan Commercial |
$3,074.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,305.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,535.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,883.07
|
| Rate for Payer: Quartz Commercial |
$2,497.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,305.80
|
| Rate for Payer: The Alliance Commercial |
$15,372.00
|
| Rate for Payer: WEA Trust Commercial |
$2,113.65
|
| Rate for Payer: WPS Commercial |
$2,846.51
|
|
|
PAI-A INTRODUCTORY KIT
|
Facility
|
IP
|
$3,843.00
|
|
| Hospital Charge Code |
2973444
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,883.07 |
| Max. Negotiated Rate |
$3,535.56 |
| Rate for Payer: Aetna Commercial |
$3,458.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,304.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,036.79
|
| Rate for Payer: Cash Price |
$1,152.90
|
| Rate for Payer: Cigna Commercial |
$3,535.56
|
| Rate for Payer: Health EOS Commercial |
$3,420.27
|
| Rate for Payer: HFN Commercial |
$3,535.56
|
| Rate for Payer: Multiplan Commercial |
$3,074.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,305.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,535.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,883.07
|
| Rate for Payer: Quartz Commercial |
$2,305.80
|
| Rate for Payer: WEA Trust Commercial |
$2,113.65
|
| Rate for Payer: WPS Commercial |
$2,846.51
|
|
|
Pain Management Profile 1, Urine
|
Facility
|
OP
|
$291.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
5358629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.14 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: Aetna Commercial |
$261.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Aetna Managed Medicare |
$62.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$233.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$108.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$103.15
|
| Rate for Payer: Anthem Medicaid |
$63.40
|
| Rate for Payer: Anthem Medicare Advantage |
$62.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.14
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$267.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$62.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$63.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.84
|
| Rate for Payer: Dean Health Medicaid |
$63.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$62.14
|
| Rate for Payer: Health EOS Commercial |
$258.99
|
| Rate for Payer: HFN Commercial |
$267.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$231.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.14
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.14
|
| Rate for Payer: Managed Health Services Medicaid |
$65.94
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$62.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$62.14
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.21
|
| Rate for Payer: Preferred Network Access Commercial |
$267.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$63.40
|
| Rate for Payer: Quartz Beloit One Network |
$142.59
|
| Rate for Payer: Quartz Commercial |
$189.15
|
| Rate for Payer: Quartz Medicare Advantage |
$62.14
|
| Rate for Payer: The Alliance Commercial |
$248.56
|
| Rate for Payer: United Healthcare Medicaid |
$63.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.14
|
| Rate for Payer: United Healthcare PPO |
$218.25
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: Wellcare Medicare |
$62.14
|
| Rate for Payer: WMAP Medicaid |
$63.40
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
|
Pain Management Profile 1, Urine
|
Facility
|
IP
|
$291.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
5358629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$142.59 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: Aetna Commercial |
$261.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.23
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$267.72
|
| Rate for Payer: Health EOS Commercial |
$258.99
|
| Rate for Payer: HFN Commercial |
$267.72
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: NAPHCARE Commercial |
$174.60
|
| Rate for Payer: Preferred Network Access Commercial |
$267.72
|
| Rate for Payer: Quartz Beloit One Network |
$142.59
|
| Rate for Payer: Quartz Commercial |
$174.60
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
|
Pain Management Profile 1, Urine
|
Professional
|
Both
|
$291.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
5358629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$128.04 |
| Max. Negotiated Rate |
$276.45 |
| Rate for Payer: Aetna Commercial |
$276.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$276.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.60
|
| Rate for Payer: Health EOS Commercial |
$264.81
|
| Rate for Payer: HFN Commercial |
$276.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$219.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$219.35
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: Preferred Network Access Commercial |
$276.45
|
| Rate for Payer: Quartz Beloit One Network |
$128.04
|
| Rate for Payer: Quartz Commercial |
$165.87
|
| Rate for Payer: The Alliance Commercial |
$145.50
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
|
*** PAIN PUMP 275ML 4ML FIXED RATE MC0040LYK5-CP*** DISC ***
|
Facility
|
OP
|
$2,844.00
|
|
| Hospital Charge Code |
2965273
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$796.32 |
| Max. Negotiated Rate |
$11,376.00 |
| Rate for Payer: Aetna Commercial |
$2,559.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,445.84
|
| Rate for Payer: Aetna Managed Medicare |
$796.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,848.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,422.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,365.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,507.32
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cigna Commercial |
$2,616.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,591.50
|
| Rate for Payer: Health EOS Commercial |
$2,531.16
|
| Rate for Payer: HFN Commercial |
$2,616.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,133.00
|
| Rate for Payer: Multiplan Commercial |
$2,275.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,706.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,616.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,393.56
|
| Rate for Payer: Quartz Commercial |
$1,848.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,706.40
|
| Rate for Payer: The Alliance Commercial |
$11,376.00
|
| Rate for Payer: WEA Trust Commercial |
$1,564.20
|
| Rate for Payer: WPS Commercial |
$2,106.55
|
|
|
*** PAIN PUMP 275ML 4ML FIXED RATE MC0040LYK5-CP*** DISC ***
|
Facility
|
IP
|
$2,844.00
|
|
| Hospital Charge Code |
2965273
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,393.56 |
| Max. Negotiated Rate |
$2,616.48 |
| Rate for Payer: Aetna Commercial |
$2,559.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,445.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,507.32
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cigna Commercial |
$2,616.48
|
| Rate for Payer: Health EOS Commercial |
$2,531.16
|
| Rate for Payer: HFN Commercial |
$2,616.48
|
| Rate for Payer: Multiplan Commercial |
$2,275.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,706.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,616.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,393.56
|
| Rate for Payer: Quartz Commercial |
$1,706.40
|
| Rate for Payer: WEA Trust Commercial |
$1,564.20
|
| Rate for Payer: WPS Commercial |
$2,106.55
|
|
|
PAIN PUMP 275ML 4ML FIXED RATE WITH 2ML BOLUS WITH 60 MIN RELOAD MT4060LYK5-CP
|
Facility
|
OP
|
$1,920.00
|
|
| Hospital Charge Code |
5577698
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$537.60 |
| Max. Negotiated Rate |
$7,680.00 |
| Rate for Payer: Aetna Commercial |
$1,728.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,651.20
|
| Rate for Payer: Aetna Managed Medicare |
$537.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,248.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$960.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$921.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,017.60
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cigna Commercial |
$1,766.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,074.43
|
| Rate for Payer: Health EOS Commercial |
$1,708.80
|
| Rate for Payer: HFN Commercial |
$1,766.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,440.00
|
| Rate for Payer: Multiplan Commercial |
$1,536.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,152.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,766.40
|
| Rate for Payer: Quartz Beloit One Network |
$940.80
|
| Rate for Payer: Quartz Commercial |
$1,248.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,152.00
|
| Rate for Payer: The Alliance Commercial |
$7,680.00
|
| Rate for Payer: WEA Trust Commercial |
$1,056.00
|
| Rate for Payer: WPS Commercial |
$1,422.14
|
|
|
PAIN PUMP 275ML 4ML FIXED RATE WITH 2ML BOLUS WITH 60 MIN RELOAD MT4060LYK5-CP
|
Facility
|
IP
|
$1,920.00
|
|
| Hospital Charge Code |
5577698
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$940.80 |
| Max. Negotiated Rate |
$1,766.40 |
| Rate for Payer: Aetna Commercial |
$1,728.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,651.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,017.60
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cigna Commercial |
$1,766.40
|
| Rate for Payer: Health EOS Commercial |
$1,708.80
|
| Rate for Payer: HFN Commercial |
$1,766.40
|
| Rate for Payer: Multiplan Commercial |
$1,536.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,152.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,766.40
|
| Rate for Payer: Quartz Beloit One Network |
$940.80
|
| Rate for Payer: Quartz Commercial |
$1,152.00
|
| Rate for Payer: WEA Trust Commercial |
$1,056.00
|
| Rate for Payer: WPS Commercial |
$1,422.14
|
|
|
PAIRED HELICAL 2.4FR X 120CM 3 WIRE M0063303060
|
Facility
|
IP
|
$2,660.00
|
|
| Hospital Charge Code |
4520071
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,303.40 |
| Max. Negotiated Rate |
$2,447.20 |
| Rate for Payer: Aetna Commercial |
$2,394.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,287.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,409.80
|
| Rate for Payer: Cash Price |
$798.00
|
| Rate for Payer: Cigna Commercial |
$2,447.20
|
| Rate for Payer: Health EOS Commercial |
$2,367.40
|
| Rate for Payer: HFN Commercial |
$2,447.20
|
| Rate for Payer: Multiplan Commercial |
$2,128.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,596.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,447.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,303.40
|
| Rate for Payer: Quartz Commercial |
$1,596.00
|
| Rate for Payer: WEA Trust Commercial |
$1,463.00
|
| Rate for Payer: WPS Commercial |
$1,970.26
|
|
|
PAIRED HELICAL 2.4FR X 120CM 3 WIRE M0063303060
|
Facility
|
OP
|
$2,660.00
|
|
| Hospital Charge Code |
4520071
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$744.80 |
| Max. Negotiated Rate |
$10,640.00 |
| Rate for Payer: Aetna Commercial |
$2,394.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,287.60
|
| Rate for Payer: Aetna Managed Medicare |
$744.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,729.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,330.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,276.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,409.80
|
| Rate for Payer: Cash Price |
$798.00
|
| Rate for Payer: Cigna Commercial |
$2,447.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,488.54
|
| Rate for Payer: Health EOS Commercial |
$2,367.40
|
| Rate for Payer: HFN Commercial |
$2,447.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,995.00
|
| Rate for Payer: Multiplan Commercial |
$2,128.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,596.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,447.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,303.40
|
| Rate for Payer: Quartz Commercial |
$1,729.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,596.00
|
| Rate for Payer: The Alliance Commercial |
$10,640.00
|
| Rate for Payer: WEA Trust Commercial |
$1,463.00
|
| Rate for Payer: WPS Commercial |
$1,970.26
|
|
|
PALATOPLASTY
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
PALATOPLASTY
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
Paliperidone Level
|
Facility
|
OP
|
$381.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5613543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$350.52 |
| Rate for Payer: Aetna Commercial |
$342.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$327.66
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$201.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cigna Commercial |
$350.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$213.21
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$339.09
|
| Rate for Payer: HFN Commercial |
$350.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$304.80
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$350.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$186.69
|
| Rate for Payer: Quartz Commercial |
$247.65
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$74.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$285.75
|
| Rate for Payer: WEA Trust Commercial |
$209.55
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$282.21
|
|
|
Paliperidone Level
|
Facility
|
IP
|
$381.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5613543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$186.69 |
| Max. Negotiated Rate |
$350.52 |
| Rate for Payer: Aetna Commercial |
$342.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$327.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$201.93
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cigna Commercial |
$350.52
|
| Rate for Payer: Health EOS Commercial |
$339.09
|
| Rate for Payer: HFN Commercial |
$350.52
|
| Rate for Payer: Multiplan Commercial |
$304.80
|
| Rate for Payer: NAPHCARE Commercial |
$228.60
|
| Rate for Payer: Preferred Network Access Commercial |
$350.52
|
| Rate for Payer: Quartz Beloit One Network |
$186.69
|
| Rate for Payer: Quartz Commercial |
$228.60
|
| Rate for Payer: WEA Trust Commercial |
$209.55
|
| Rate for Payer: WPS Commercial |
$282.21
|
|
|
Paliperidone Level
|
Professional
|
Both
|
$381.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5613543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$361.95 |
| Rate for Payer: Aetna Commercial |
$361.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$327.66
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cigna Commercial |
$361.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$190.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$228.60
|
| Rate for Payer: Health EOS Commercial |
$346.71
|
| Rate for Payer: HFN Commercial |
$361.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Multiplan Commercial |
$304.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.95
|
| Rate for Payer: Quartz Beloit One Network |
$167.64
|
| Rate for Payer: Quartz Commercial |
$217.17
|
| Rate for Payer: The Alliance Commercial |
$190.50
|
| Rate for Payer: WEA Trust Commercial |
$209.55
|
| Rate for Payer: WPS Commercial |
$282.21
|
|
|
pANCA IgG
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
CPT 88346
|
| Hospital Charge Code |
2778806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$124.95 |
| Max. Negotiated Rate |
$675.28 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$219.30
|
| Rate for Payer: Aetna Managed Medicare |
$168.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$633.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.24
|
| Rate for Payer: Anthem Medicare Advantage |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.82
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$168.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$168.82
|
| Rate for Payer: Health EOS Commercial |
$226.95
|
| Rate for Payer: HFN Commercial |
$234.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$628.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$168.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$168.82
|
| Rate for Payer: Multiplan Commercial |
$204.00
|
| Rate for Payer: NAPHCARE Commercial |
$253.23
|
| Rate for Payer: Preferred Network Access Commercial |
$234.60
|
| Rate for Payer: Quartz Beloit One Network |
$124.95
|
| Rate for Payer: Quartz Commercial |
$165.75
|
| Rate for Payer: Quartz Medicare Advantage |
$168.82
|
| Rate for Payer: The Alliance Commercial |
$675.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.82
|
| Rate for Payer: United Healthcare PPO |
$191.25
|
| Rate for Payer: WEA Trust Commercial |
$140.25
|
| Rate for Payer: Wellcare Medicare |
$168.82
|
| Rate for Payer: WPS Commercial |
$188.88
|
|
|
pANCA IgG
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
CPT 88346
|
| Hospital Charge Code |
2778806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.43 |
| Max. Negotiated Rate |
$488.69 |
| Rate for Payer: Aetna Commercial |
$242.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$219.30
|
| Rate for Payer: Anthem Commercial |
$33.43
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$242.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$127.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.00
|
| Rate for Payer: Health EOS Commercial |
$232.05
|
| Rate for Payer: HFN Commercial |
$242.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$488.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$488.69
|
| Rate for Payer: Multiplan Commercial |
$204.00
|
| Rate for Payer: Preferred Network Access Commercial |
$242.25
|
| Rate for Payer: Quartz Beloit One Network |
$112.20
|
| Rate for Payer: Quartz Commercial |
$145.35
|
| Rate for Payer: The Alliance Commercial |
$127.50
|
| Rate for Payer: WEA Trust Commercial |
$140.25
|
| Rate for Payer: WPS Commercial |
$188.88
|
|
|
pANCA IgG
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
CPT 88346
|
| Hospital Charge Code |
2778806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$124.95 |
| Max. Negotiated Rate |
$234.60 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$219.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.15
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: Health EOS Commercial |
$226.95
|
| Rate for Payer: HFN Commercial |
$234.60
|
| Rate for Payer: Multiplan Commercial |
$204.00
|
| Rate for Payer: NAPHCARE Commercial |
$153.00
|
| Rate for Payer: Preferred Network Access Commercial |
$234.60
|
| Rate for Payer: Quartz Beloit One Network |
$124.95
|
| Rate for Payer: Quartz Commercial |
$153.00
|
| Rate for Payer: WEA Trust Commercial |
$140.25
|
| Rate for Payer: WPS Commercial |
$188.88
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC
|
Facility
|
IP
|
$77,085.00
|
|
|
Service Code
|
MSDRG 406
|
| Min. Negotiated Rate |
$27,728.31 |
| Max. Negotiated Rate |
$77,085.00 |
| Rate for Payer: Aetna Managed Medicare |
$27,728.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60,632.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46,474.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44,153.42
|
| Rate for Payer: Anthem Medicare Advantage |
$27,728.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27,728.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27,728.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$27,728.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49,014.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$27,728.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56,304.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27,728.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27,728.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$27,728.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$27,728.31
|
| Rate for Payer: NAPHCARE Commercial |
$41,592.46
|
| Rate for Payer: Quartz Medicare Advantage |
$27,728.31
|
| Rate for Payer: The Alliance Commercial |
$77,085.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27,728.31
|
| Rate for Payer: United Healthcare PPO |
$43,833.62
|
| Rate for Payer: Wellcare Medicare |
$27,728.31
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC
|
Facility
|
IP
|
$146,681.00
|
|
|
Service Code
|
MSDRG 405
|
| Min. Negotiated Rate |
$52,763.12 |
| Max. Negotiated Rate |
$146,681.00 |
| Rate for Payer: Aetna Managed Medicare |
$52,763.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$115,599.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$88,606.31
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$84,181.78
|
| Rate for Payer: Anthem Medicare Advantage |
$52,763.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$52,763.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$52,763.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$52,763.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93,449.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$52,763.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107,351.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52,763.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$52,763.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$52,763.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$52,763.12
|
| Rate for Payer: NAPHCARE Commercial |
$79,144.68
|
| Rate for Payer: Quartz Medicare Advantage |
$52,763.12
|
| Rate for Payer: The Alliance Commercial |
$146,681.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52,763.12
|
| Rate for Payer: United Healthcare PPO |
$83,574.44
|
| Rate for Payer: Wellcare Medicare |
$52,763.12
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$57,507.00
|
|
|
Service Code
|
MSDRG 407
|
| Min. Negotiated Rate |
$20,685.90 |
| Max. Negotiated Rate |
$57,507.00 |
| Rate for Payer: Aetna Managed Medicare |
$20,685.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45,107.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34,574.15
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32,847.70
|
| Rate for Payer: Anthem Medicare Advantage |
$20,685.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20,685.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20,685.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20,685.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36,463.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20,685.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41,944.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20,685.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20,685.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20,685.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20,685.90
|
| Rate for Payer: NAPHCARE Commercial |
$31,028.85
|
| Rate for Payer: Quartz Medicare Advantage |
$20,685.90
|
| Rate for Payer: The Alliance Commercial |
$57,507.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20,685.90
|
| Rate for Payer: United Healthcare PPO |
$32,654.33
|
| Rate for Payer: Wellcare Medicare |
$20,685.90
|
|
|
PANCREAS TRANSPLANT
|
Facility
|
IP
|
$128,295.00
|
|
|
Service Code
|
MSDRG 010
|
| Min. Negotiated Rate |
$46,149.14 |
| Max. Negotiated Rate |
$128,295.00 |
| Rate for Payer: Aetna Managed Medicare |
$46,149.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$100,913.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$77,349.61
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73,487.18
|
| Rate for Payer: Anthem Medicare Advantage |
$46,149.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46,149.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46,149.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46,149.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81,577.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46,149.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93,865.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46,149.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46,149.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$46,149.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$46,149.14
|
| Rate for Payer: NAPHCARE Commercial |
$69,223.71
|
| Rate for Payer: Quartz Medicare Advantage |
$46,149.14
|
| Rate for Payer: The Alliance Commercial |
$128,295.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46,149.14
|
| Rate for Payer: Wellcare Medicare |
$46,149.14
|
|
