|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 14MM RT 42-5224-004-14
|
Facility
|
IP
|
$9,089.00
|
|
| Hospital Charge Code |
5286608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,631.75 |
| Max. Negotiated Rate |
$8,696.36 |
| Rate for Payer: Aetna Commercial |
$8,507.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,129.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,009.86
|
| Rate for Payer: Cash Price |
$2,726.70
|
| Rate for Payer: Cigna Commercial |
$8,696.36
|
| Rate for Payer: Health EOS Commercial |
$8,412.78
|
| Rate for Payer: HFN Commercial |
$8,696.36
|
| Rate for Payer: Multiplan Commercial |
$7,562.05
|
| Rate for Payer: Preferred Network Access Commercial |
$8,696.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,631.75
|
| Rate for Payer: Quartz Commercial |
$5,671.54
|
| Rate for Payer: WEA Trust Commercial |
$5,198.91
|
| Rate for Payer: WPS Commercial |
$7,001.26
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 14MM RT 42-5224-004-14
|
Facility
|
OP
|
$9,089.00
|
|
| Hospital Charge Code |
5286608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,646.72 |
| Max. Negotiated Rate |
$8,696.36 |
| Rate for Payer: Aetna Commercial |
$8,507.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,129.20
|
| Rate for Payer: Aetna Managed Medicare |
$2,646.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,144.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,726.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,537.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,009.86
|
| Rate for Payer: Cash Price |
$2,726.70
|
| Rate for Payer: Cigna Commercial |
$8,696.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,289.80
|
| Rate for Payer: Health EOS Commercial |
$8,412.78
|
| Rate for Payer: HFN Commercial |
$8,696.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,089.42
|
| Rate for Payer: Multiplan Commercial |
$7,562.05
|
| Rate for Payer: NAPHCARE Commercial |
$5,671.54
|
| Rate for Payer: Preferred Network Access Commercial |
$8,696.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,631.75
|
| Rate for Payer: Quartz Commercial |
$6,144.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,671.54
|
| Rate for Payer: The Alliance Commercial |
$4,726.28
|
| Rate for Payer: WEA Trust Commercial |
$5,198.91
|
| Rate for Payer: WPS Commercial |
$7,001.26
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 16MM 42-5224-004-16
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 16MM 42-5224-004-16
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 18MM 42-5224-004-18
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 18MM 42-5224-004-18
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 20MM 42-5224-004-20
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 20MM 42-5224-004-20
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONALITY AND IMPULSE CONTROL DIAGNOSES
|
Facility
|
OP
|
$86.48
|
|
|
Service Code
|
EAPG 00822
|
| Min. Negotiated Rate |
$83.15 |
| Max. Negotiated Rate |
$86.48 |
| Rate for Payer: Anthem Medicaid |
$83.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$83.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$83.15
|
| Rate for Payer: Dean Health Medicaid |
$83.15
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$83.15
|
| Rate for Payer: Managed Health Services Medicaid |
$86.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$83.15
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$83.15
|
| Rate for Payer: United Healthcare Medicaid |
$83.15
|
|
|
PERSONALITY DISORDERS
|
Facility
|
IP
|
$9,995.87
|
|
|
Service Code
|
APR-DRG 7523
|
| Min. Negotiated Rate |
$8,878.96 |
| Max. Negotiated Rate |
$9,995.87 |
| Rate for Payer: Anthem Medicaid |
$9,571.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,571.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,571.60
|
| Rate for Payer: Dean Health Medicaid |
$9,571.60
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,878.96
|
| Rate for Payer: Managed Health Services Medicaid |
$9,995.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,571.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,571.60
|
| Rate for Payer: United Healthcare Medicaid |
$9,571.60
|
|
|
PERSONALITY DISORDERS
|
Facility
|
IP
|
$23,762.12
|
|
|
Service Code
|
APR-DRG 7524
|
| Min. Negotiated Rate |
$21,107.00 |
| Max. Negotiated Rate |
$23,762.12 |
| Rate for Payer: Anthem Medicaid |
$22,753.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$22,753.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22,753.54
|
| Rate for Payer: Dean Health Medicaid |
$22,753.54
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21,107.00
|
| Rate for Payer: Managed Health Services Medicaid |
$23,762.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$22,753.54
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$22,753.54
|
| Rate for Payer: United Healthcare Medicaid |
$22,753.54
|
|
|
PERSONALITY DISORDERS
|
Facility
|
IP
|
$4,471.84
|
|
|
Service Code
|
APR-DRG 7522
|
| Min. Negotiated Rate |
$3,972.17 |
| Max. Negotiated Rate |
$4,471.84 |
| Rate for Payer: Anthem Medicaid |
$4,282.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,282.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,282.03
|
| Rate for Payer: Dean Health Medicaid |
$4,282.03
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,972.17
|
| Rate for Payer: Managed Health Services Medicaid |
$4,471.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,282.03
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,282.03
|
| Rate for Payer: United Healthcare Medicaid |
$4,282.03
|
|
|
PERSONALITY DISORDERS
|
Facility
|
IP
|
$3,419.64
|
|
|
Service Code
|
APR-DRG 7521
|
| Min. Negotiated Rate |
$3,037.54 |
| Max. Negotiated Rate |
$3,419.64 |
| Rate for Payer: Anthem Medicaid |
$3,274.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$3,274.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,274.49
|
| Rate for Payer: Dean Health Medicaid |
$3,274.49
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,037.54
|
| Rate for Payer: Managed Health Services Medicaid |
$3,419.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,274.49
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3,274.49
|
| Rate for Payer: United Healthcare Medicaid |
$3,274.49
|
|
|
Pertussis toxin IgA
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.35 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$55.54
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
Pertussis toxin IgA
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$13.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.77
|
| Rate for Payer: Anthem Medicare Advantage |
$13.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.72
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.72
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.72
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$20.58
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$60.16
|
| Rate for Payer: Quartz Medicare Advantage |
$13.72
|
| Rate for Payer: The Alliance Commercial |
$54.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.72
|
| Rate for Payer: United Healthcare PPO |
$69.42
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: Wellcare Medicare |
$13.72
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
Pertussis toxin IgA
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$87.93 |
| Rate for Payer: Aetna Commercial |
$87.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$13.72
|
| Rate for Payer: Anthem Medicare Advantage |
$13.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.72
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$87.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.72
|
| Rate for Payer: Health EOS Commercial |
$84.23
|
| Rate for Payer: HFN Commercial |
$87.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.72
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$20.58
|
| Rate for Payer: Preferred Network Access Commercial |
$87.93
|
| Rate for Payer: Quartz Beloit One Network |
$40.73
|
| Rate for Payer: Quartz Commercial |
$52.76
|
| Rate for Payer: Quartz Medicare Advantage |
$13.72
|
| Rate for Payer: The Alliance Commercial |
$54.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.72
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$60.36
|
|
|
Pertussis toxin IgG
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$87.93 |
| Rate for Payer: Aetna Commercial |
$87.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$13.72
|
| Rate for Payer: Anthem Medicare Advantage |
$13.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.72
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$87.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.72
|
| Rate for Payer: Health EOS Commercial |
$84.23
|
| Rate for Payer: HFN Commercial |
$87.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.72
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$20.58
|
| Rate for Payer: Preferred Network Access Commercial |
$87.93
|
| Rate for Payer: Quartz Beloit One Network |
$40.73
|
| Rate for Payer: Quartz Commercial |
$52.76
|
| Rate for Payer: Quartz Medicare Advantage |
$13.72
|
| Rate for Payer: The Alliance Commercial |
$54.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.72
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$60.36
|
|
|
Pertussis toxin IgG
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$13.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.77
|
| Rate for Payer: Anthem Medicare Advantage |
$13.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.72
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.72
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.72
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$20.58
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$60.16
|
| Rate for Payer: Quartz Medicare Advantage |
$13.72
|
| Rate for Payer: The Alliance Commercial |
$54.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.72
|
| Rate for Payer: United Healthcare PPO |
$69.42
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: Wellcare Medicare |
$13.72
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
Pertussis toxin IgG
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.35 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$55.54
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
Pessary, non rubber, any type A4562
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
3142835
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$301.89 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Aetna Managed Medicare |
$30.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.11
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.90
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: NAPHCARE Commercial |
$65.52
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$70.98
|
| Rate for Payer: Quartz Medicare Advantage |
$65.52
|
| Rate for Payer: The Alliance Commercial |
$301.89
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
Pessary, non rubber, any type A4562
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
3142835
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$48.05 |
| Max. Negotiated Rate |
$217.63 |
| Rate for Payer: Aetna Commercial |
$103.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Aetna Managed Medicare |
$75.47
|
| Rate for Payer: Anthem Medicare Advantage |
$75.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.47
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$103.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.47
|
| Rate for Payer: Health EOS Commercial |
$99.37
|
| Rate for Payer: HFN Commercial |
$103.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$217.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.47
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: NAPHCARE Commercial |
$113.21
|
| Rate for Payer: Preferred Network Access Commercial |
$103.74
|
| Rate for Payer: Quartz Beloit One Network |
$48.05
|
| Rate for Payer: Quartz Commercial |
$62.24
|
| Rate for Payer: Quartz Medicare Advantage |
$75.47
|
| Rate for Payer: The Alliance Commercial |
$207.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.47
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$132.08
|
|
|
Pessary, non rubber, any type A4562
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
3142835
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$53.51 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$65.52
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
PESSARY SHAATZ/FOLD PESSARY 3-1/4 MXKPSH3-1/4
|
Facility
|
OP
|
$991.00
|
|
| Hospital Charge Code |
3072500
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$288.58 |
| Max. Negotiated Rate |
$948.19 |
| Rate for Payer: Aetna Commercial |
$927.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$886.35
|
| Rate for Payer: Aetna Managed Medicare |
$288.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$669.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$515.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$494.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.24
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$948.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$576.76
|
| Rate for Payer: Health EOS Commercial |
$917.27
|
| Rate for Payer: HFN Commercial |
$948.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$772.98
|
| Rate for Payer: Multiplan Commercial |
$824.51
|
| Rate for Payer: NAPHCARE Commercial |
$618.38
|
| Rate for Payer: Preferred Network Access Commercial |
$948.19
|
| Rate for Payer: Quartz Beloit One Network |
$505.01
|
| Rate for Payer: Quartz Commercial |
$669.92
|
| Rate for Payer: Quartz Medicare Advantage |
$618.38
|
| Rate for Payer: The Alliance Commercial |
$515.32
|
| Rate for Payer: WEA Trust Commercial |
$566.85
|
| Rate for Payer: WPS Commercial |
$763.37
|
|
|
PESSARY SHAATZ/FOLD PESSARY 3-1/4 MXKPSH3-1/4
|
Facility
|
IP
|
$991.00
|
|
| Hospital Charge Code |
3072500
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$505.01 |
| Max. Negotiated Rate |
$948.19 |
| Rate for Payer: Aetna Commercial |
$927.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$886.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.24
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$948.19
|
| Rate for Payer: Health EOS Commercial |
$917.27
|
| Rate for Payer: HFN Commercial |
$948.19
|
| Rate for Payer: Multiplan Commercial |
$824.51
|
| Rate for Payer: Preferred Network Access Commercial |
$948.19
|
| Rate for Payer: Quartz Beloit One Network |
$505.01
|
| Rate for Payer: Quartz Commercial |
$618.38
|
| Rate for Payer: WEA Trust Commercial |
$566.85
|
| Rate for Payer: WPS Commercial |
$763.37
|
|
|
PET Brain Imaging Metabolic Evaluation
|
Professional
|
Both
|
$3,199.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
2587013
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,463.86 |
| Max. Negotiated Rate |
$8,561.12 |
| Rate for Payer: Aetna Commercial |
$3,160.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,861.19
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cigna Commercial |
$3,160.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,663.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,996.18
|
| Rate for Payer: Health EOS Commercial |
$3,027.53
|
| Rate for Payer: HFN Commercial |
$3,160.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,561.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,561.12
|
| Rate for Payer: Multiplan Commercial |
$2,661.57
|
| Rate for Payer: Preferred Network Access Commercial |
$3,160.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,463.86
|
| Rate for Payer: Quartz Commercial |
$1,896.37
|
| Rate for Payer: The Alliance Commercial |
$1,663.48
|
| Rate for Payer: WEA Trust Commercial |
$1,829.83
|
| Rate for Payer: WPS Commercial |
$2,464.19
|
|
