|
PROCEDURE PACK DYNACLIP 3000-01-000
|
Facility
|
IP
|
$4,208.00
|
|
| Hospital Charge Code |
6226160
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,144.40 |
| Max. Negotiated Rate |
$4,026.21 |
| Rate for Payer: Aetna Commercial |
$3,938.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,763.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,319.45
|
| Rate for Payer: Cash Price |
$1,262.40
|
| Rate for Payer: Cigna Commercial |
$4,026.21
|
| Rate for Payer: Health EOS Commercial |
$3,894.92
|
| Rate for Payer: HFN Commercial |
$4,026.21
|
| Rate for Payer: Multiplan Commercial |
$3,501.06
|
| Rate for Payer: Preferred Network Access Commercial |
$4,026.21
|
| Rate for Payer: Quartz Beloit One Network |
$2,144.40
|
| Rate for Payer: Quartz Commercial |
$2,625.79
|
| Rate for Payer: WEA Trust Commercial |
$2,406.98
|
| Rate for Payer: WPS Commercial |
$3,241.42
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$19,816.38
|
|
|
Service Code
|
APR-DRG 4033
|
| Min. Negotiated Rate |
$17,602.15 |
| Max. Negotiated Rate |
$19,816.38 |
| Rate for Payer: Anthem Medicaid |
$18,975.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$18,975.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18,975.28
|
| Rate for Payer: Dean Health Medicaid |
$18,975.28
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17,602.15
|
| Rate for Payer: Managed Health Services Medicaid |
$19,816.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,975.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18,975.28
|
| Rate for Payer: United Healthcare Medicaid |
$18,975.28
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$12,012.58
|
|
|
Service Code
|
APR-DRG 4032
|
| Min. Negotiated Rate |
$10,670.33 |
| Max. Negotiated Rate |
$12,012.58 |
| Rate for Payer: Anthem Medicaid |
$11,502.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$11,502.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11,502.71
|
| Rate for Payer: Dean Health Medicaid |
$11,502.71
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$10,670.33
|
| Rate for Payer: Managed Health Services Medicaid |
$12,012.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,502.71
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11,502.71
|
| Rate for Payer: United Healthcare Medicaid |
$11,502.71
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$9,732.82
|
|
|
Service Code
|
APR-DRG 4031
|
| Min. Negotiated Rate |
$8,645.30 |
| Max. Negotiated Rate |
$9,732.82 |
| Rate for Payer: Anthem Medicaid |
$9,319.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,319.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,319.72
|
| Rate for Payer: Dean Health Medicaid |
$9,319.72
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,645.30
|
| Rate for Payer: Managed Health Services Medicaid |
$9,732.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,319.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,319.72
|
| Rate for Payer: United Healthcare Medicaid |
$9,319.72
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$39,369.71
|
|
|
Service Code
|
APR-DRG 4034
|
| Min. Negotiated Rate |
$34,970.63 |
| Max. Negotiated Rate |
$39,369.71 |
| Rate for Payer: Anthem Medicaid |
$37,698.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$37,698.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37,698.67
|
| Rate for Payer: Dean Health Medicaid |
$37,698.67
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$34,970.63
|
| Rate for Payer: Managed Health Services Medicaid |
$39,369.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$37,698.67
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$37,698.67
|
| Rate for Payer: United Healthcare Medicaid |
$37,698.67
|
|
|
PROCEDURES FOR REVISION OR REMOVAL OF NEUROSTIMULATOR DEVICES
|
Facility
|
OP
|
$687.86
|
|
|
Service Code
|
EAPG 00276
|
| Min. Negotiated Rate |
$661.40 |
| Max. Negotiated Rate |
$687.86 |
| Rate for Payer: Anthem Medicaid |
$661.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$661.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$661.40
|
| Rate for Payer: Dean Health Medicaid |
$661.40
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$661.40
|
| Rate for Payer: Managed Health Services Medicaid |
$687.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$661.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$661.40
|
| Rate for Payer: United Healthcare Medicaid |
$661.40
|
|
|
PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES
|
Facility
|
IP
|
$54,012.79
|
|
|
Service Code
|
APR-DRG 8504
|
| Min. Negotiated Rate |
$47,977.53 |
| Max. Negotiated Rate |
$54,012.79 |
| Rate for Payer: Anthem Medicaid |
$51,720.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$51,720.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51,720.22
|
| Rate for Payer: Dean Health Medicaid |
$51,720.22
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$47,977.53
|
| Rate for Payer: Managed Health Services Medicaid |
$54,012.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$51,720.22
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$51,720.22
|
| Rate for Payer: United Healthcare Medicaid |
$51,720.22
|
|
|
PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES
|
Facility
|
IP
|
$12,977.10
|
|
|
Service Code
|
APR-DRG 8501
|
| Min. Negotiated Rate |
$11,527.07 |
| Max. Negotiated Rate |
$12,977.10 |
| Rate for Payer: Anthem Medicaid |
$12,426.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12,426.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12,426.29
|
| Rate for Payer: Dean Health Medicaid |
$12,426.29
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11,527.07
|
| Rate for Payer: Managed Health Services Medicaid |
$12,977.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,426.29
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12,426.29
|
| Rate for Payer: United Healthcare Medicaid |
$12,426.29
|
|
|
PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES
|
Facility
|
IP
|
$20,342.48
|
|
|
Service Code
|
APR-DRG 8502
|
| Min. Negotiated Rate |
$18,069.46 |
| Max. Negotiated Rate |
$20,342.48 |
| Rate for Payer: Anthem Medicaid |
$19,479.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$19,479.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19,479.04
|
| Rate for Payer: Dean Health Medicaid |
$19,479.04
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18,069.46
|
| Rate for Payer: Managed Health Services Medicaid |
$20,342.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,479.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19,479.04
|
| Rate for Payer: United Healthcare Medicaid |
$19,479.04
|
|
|
PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES
|
Facility
|
IP
|
$30,426.04
|
|
|
Service Code
|
APR-DRG 8503
|
| Min. Negotiated Rate |
$27,026.30 |
| Max. Negotiated Rate |
$30,426.04 |
| Rate for Payer: Anthem Medicaid |
$29,134.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$29,134.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29,134.61
|
| Rate for Payer: Dean Health Medicaid |
$29,134.61
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$27,026.30
|
| Rate for Payer: Managed Health Services Medicaid |
$30,426.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$29,134.61
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$29,134.61
|
| Rate for Payer: United Healthcare Medicaid |
$29,134.61
|
|
|
Procollagen Type 1 Intact Terminal Propeptide
|
Facility
|
IP
|
$506.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
5613544
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$257.86 |
| Max. Negotiated Rate |
$484.14 |
| Rate for Payer: Aetna Commercial |
$473.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$452.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$278.91
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cigna Commercial |
$484.14
|
| Rate for Payer: Health EOS Commercial |
$468.35
|
| Rate for Payer: HFN Commercial |
$484.14
|
| Rate for Payer: Multiplan Commercial |
$420.99
|
| Rate for Payer: Preferred Network Access Commercial |
$484.14
|
| Rate for Payer: Quartz Beloit One Network |
$257.86
|
| Rate for Payer: Quartz Commercial |
$315.74
|
| Rate for Payer: WEA Trust Commercial |
$289.43
|
| Rate for Payer: WPS Commercial |
$389.77
|
|
|
Procollagen Type 1 Intact Terminal Propeptide
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
5613544
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$484.14 |
| Rate for Payer: Aetna Commercial |
$473.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$452.57
|
| Rate for Payer: Aetna Managed Medicare |
$19.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.49
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.77
|
| Rate for Payer: Anthem Medicare Advantage |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$278.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.14
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cigna Commercial |
$484.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$294.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$468.35
|
| Rate for Payer: HFN Commercial |
$484.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$420.99
|
| Rate for Payer: NAPHCARE Commercial |
$28.70
|
| Rate for Payer: Preferred Network Access Commercial |
$484.14
|
| Rate for Payer: Quartz Beloit One Network |
$257.86
|
| Rate for Payer: Quartz Commercial |
$342.06
|
| Rate for Payer: Quartz Medicare Advantage |
$19.14
|
| Rate for Payer: The Alliance Commercial |
$76.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.14
|
| Rate for Payer: United Healthcare PPO |
$394.68
|
| Rate for Payer: WEA Trust Commercial |
$289.43
|
| Rate for Payer: Wellcare Medicare |
$19.14
|
| Rate for Payer: WPS Commercial |
$389.77
|
|
|
Procollagen Type 1 Intact Terminal Propeptide
|
Professional
|
Both
|
$506.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
5613544
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$499.93 |
| Rate for Payer: Aetna Commercial |
$499.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$452.57
|
| Rate for Payer: Aetna Managed Medicare |
$19.14
|
| Rate for Payer: Anthem Medicare Advantage |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.14
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cigna Commercial |
$499.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$263.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$478.88
|
| Rate for Payer: HFN Commercial |
$499.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$67.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$420.99
|
| Rate for Payer: NAPHCARE Commercial |
$28.70
|
| Rate for Payer: Preferred Network Access Commercial |
$499.93
|
| Rate for Payer: Quartz Beloit One Network |
$231.55
|
| Rate for Payer: Quartz Commercial |
$299.96
|
| Rate for Payer: Quartz Medicare Advantage |
$19.14
|
| Rate for Payer: The Alliance Commercial |
$75.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.14
|
| Rate for Payer: WEA Trust Commercial |
$289.43
|
| Rate for Payer: WPS Commercial |
$84.20
|
|
|
Procrit, esrd 1000 units Charge
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
2958985
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.80 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$19.34
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$23.88
|
|
|
Procrit, esrd 1000 units Charge
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
2958985
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$9.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.14
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.18
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$19.34
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$20.96
|
| Rate for Payer: Quartz Medicare Advantage |
$19.34
|
| Rate for Payer: The Alliance Commercial |
$2.87
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$2.15
|
|
|
Procrit, esrd 1000 units Charge
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
2958985
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$30.63 |
| Rate for Payer: Aetna Commercial |
$30.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$0.72
|
| Rate for Payer: Anthem Medicare Advantage |
$0.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.72
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$30.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.86
|
| Rate for Payer: Health EOS Commercial |
$29.34
|
| Rate for Payer: HFN Commercial |
$30.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$1.08
|
| Rate for Payer: Preferred Network Access Commercial |
$30.63
|
| Rate for Payer: Quartz Beloit One Network |
$14.19
|
| Rate for Payer: Quartz Commercial |
$18.38
|
| Rate for Payer: Quartz Medicare Advantage |
$0.72
|
| Rate for Payer: The Alliance Commercial |
$1.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.72
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$2.15
|
|
|
Procrit, non-esrd 1000 units Charge
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
2958984
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.80 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$19.34
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$23.88
|
|
|
Procrit, non-esrd 1000 units Charge
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
2958984
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$7.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.48
|
| Rate for Payer: Anthem Medicare Advantage |
$7.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.16
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7.16
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7.16
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$10.73
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$20.96
|
| Rate for Payer: Quartz Medicare Advantage |
$7.16
|
| Rate for Payer: The Alliance Commercial |
$28.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.16
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: Wellcare Medicare |
$7.16
|
| Rate for Payer: WPS Commercial |
$21.51
|
|
|
Procrit, non-esrd 1000 units Charge
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
2958984
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$30.63 |
| Rate for Payer: Aetna Commercial |
$30.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$7.16
|
| Rate for Payer: Anthem Medicare Advantage |
$7.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.16
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$30.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.60
|
| Rate for Payer: Health EOS Commercial |
$29.34
|
| Rate for Payer: HFN Commercial |
$30.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.16
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$10.73
|
| Rate for Payer: Preferred Network Access Commercial |
$30.63
|
| Rate for Payer: Quartz Beloit One Network |
$14.19
|
| Rate for Payer: Quartz Commercial |
$18.38
|
| Rate for Payer: Quartz Medicare Advantage |
$7.16
|
| Rate for Payer: The Alliance Commercial |
$19.68
|
| Rate for Payer: United Healthcare Medicaid |
$8.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.16
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$21.51
|
|
|
PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH
|
Facility
|
OP
|
$12,349.86
|
|
|
Service Code
|
CPT 45541
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,835.04 |
| Max. Negotiated Rate |
$12,349.86 |
| Rate for Payer: Aetna Managed Medicare |
$2,921.08
|
| 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 |
$2,921.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,921.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,921.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,921.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,921.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,866.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,921.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,921.08
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,921.08
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,921.08
|
| Rate for Payer: NAPHCARE Commercial |
$4,381.62
|
| Rate for Payer: Quartz Medicare Advantage |
$2,921.08
|
| Rate for Payer: The Alliance Commercial |
$11,684.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,921.08
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$2,921.08
|
|
|
PROCTOSCOPE LIGHT-SCOPE RECTO MAXI LED & BULB STERILE DISP 800118
|
Facility
|
IP
|
$959.00
|
|
| Hospital Charge Code |
5248711
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$488.71 |
| Max. Negotiated Rate |
$917.57 |
| Rate for Payer: Aetna Commercial |
$897.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$857.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$528.60
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$917.57
|
| Rate for Payer: Health EOS Commercial |
$887.65
|
| Rate for Payer: HFN Commercial |
$917.57
|
| Rate for Payer: Multiplan Commercial |
$797.89
|
| Rate for Payer: Preferred Network Access Commercial |
$917.57
|
| Rate for Payer: Quartz Beloit One Network |
$488.71
|
| Rate for Payer: Quartz Commercial |
$598.42
|
| Rate for Payer: WEA Trust Commercial |
$548.55
|
| Rate for Payer: WPS Commercial |
$738.72
|
|
|
PROCTOSCOPE LIGHT-SCOPE RECTO MAXI LED & BULB STERILE DISP 800118
|
Facility
|
OP
|
$959.00
|
|
| Hospital Charge Code |
5248711
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$279.26 |
| Max. Negotiated Rate |
$917.57 |
| Rate for Payer: Aetna Commercial |
$897.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$857.73
|
| Rate for Payer: Aetna Managed Medicare |
$279.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$648.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$498.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$478.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$528.60
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$917.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$558.14
|
| Rate for Payer: Health EOS Commercial |
$887.65
|
| Rate for Payer: HFN Commercial |
$917.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$748.02
|
| Rate for Payer: Multiplan Commercial |
$797.89
|
| Rate for Payer: NAPHCARE Commercial |
$598.42
|
| Rate for Payer: Preferred Network Access Commercial |
$917.57
|
| Rate for Payer: Quartz Beloit One Network |
$488.71
|
| Rate for Payer: Quartz Commercial |
$648.28
|
| Rate for Payer: Quartz Medicare Advantage |
$598.42
|
| Rate for Payer: The Alliance Commercial |
$498.68
|
| Rate for Payer: WEA Trust Commercial |
$548.55
|
| Rate for Payer: WPS Commercial |
$738.72
|
|
|
PROCTOSCOPY/PROCTOPEXY
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960321
|
|
Hospital Revenue Code
|
360
|
| 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
|
|
|
PROCTOSCOPY/PROCTOPEXY
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960321
|
|
Hospital Revenue Code
|
360
|
| 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
|
|
|
PROCTOSIGMOIDOSCOPY
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960322
|
|
Hospital Revenue Code
|
360
|
| 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
|
|
