|
SIMPLE PNEUMONIA AND PLEURISY WITH CC
|
Facility
|
IP
|
$22,179.00
|
|
|
Service Code
|
MSDRG 194
|
| Min. Negotiated Rate |
$7,978.21 |
| Max. Negotiated Rate |
$22,179.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,978.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,203.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,186.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,527.96
|
| Rate for Payer: Anthem Medicare Advantage |
$7,978.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,978.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,978.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,978.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,907.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,978.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,032.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,978.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,978.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,978.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,978.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,967.32
|
| Rate for Payer: Quartz Medicare Advantage |
$7,978.21
|
| Rate for Payer: The Alliance Commercial |
$22,179.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,978.21
|
| Rate for Payer: United Healthcare PPO |
$12,481.82
|
| Rate for Payer: Wellcare Medicare |
$7,978.21
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH MCC
|
Facility
|
IP
|
$35,589.00
|
|
|
Service Code
|
MSDRG 193
|
| Min. Negotiated Rate |
$12,801.92 |
| Max. Negotiated Rate |
$35,589.00 |
| Rate for Payer: Aetna Managed Medicare |
$12,801.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,903.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,387.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,319.74
|
| Rate for Payer: Anthem Medicare Advantage |
$12,801.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,801.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,801.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,801.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,556.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,801.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,868.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,801.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,801.92
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,801.92
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,801.92
|
| Rate for Payer: NAPHCARE Commercial |
$19,202.88
|
| Rate for Payer: Quartz Medicare Advantage |
$12,801.92
|
| Rate for Payer: The Alliance Commercial |
$35,589.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,801.92
|
| Rate for Payer: United Healthcare PPO |
$20,139.11
|
| Rate for Payer: Wellcare Medicare |
$12,801.92
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC
|
Facility
|
IP
|
$16,953.00
|
|
|
Service Code
|
MSDRG 195
|
| Min. Negotiated Rate |
$6,098.05 |
| Max. Negotiated Rate |
$16,953.00 |
| Rate for Payer: The Alliance Commercial |
$16,953.00
|
| Rate for Payer: Aetna Managed Medicare |
$6,098.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,217.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,131.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,625.14
|
| Rate for Payer: Anthem Medicare Advantage |
$6,098.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,098.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,098.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,098.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,684.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,098.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,199.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,098.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,098.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,098.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,098.05
|
| Rate for Payer: NAPHCARE Commercial |
$9,147.08
|
| Rate for Payer: Quartz Medicare Advantage |
$6,098.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,098.05
|
| Rate for Payer: United Healthcare PPO |
$9,497.23
|
| Rate for Payer: Wellcare Medicare |
$6,098.05
|
|
|
Simple repair of wounds (face, ears, eyelids, nose, lips, mucous membranes) <=2.5cm 12011
|
Professional
|
Both
|
$443.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
2957668
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.71 |
| Max. Negotiated Rate |
$420.85 |
| Rate for Payer: Aetna Commercial |
$420.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$380.98
|
| Rate for Payer: Cash Price |
$132.90
|
| Rate for Payer: Cash Price |
$132.90
|
| Rate for Payer: Cash Price |
$132.90
|
| Rate for Payer: Cigna Commercial |
$420.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$64.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$265.80
|
| Rate for Payer: Health EOS Commercial |
$403.13
|
| Rate for Payer: HFN Commercial |
$420.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$180.07
|
| Rate for Payer: Multiplan Commercial |
$354.40
|
| Rate for Payer: Preferred Network Access Commercial |
$420.85
|
| Rate for Payer: Quartz Beloit One Network |
$194.92
|
| Rate for Payer: Quartz Commercial |
$252.51
|
| Rate for Payer: The Alliance Commercial |
$221.50
|
| Rate for Payer: United Healthcare Medicaid |
$64.71
|
| Rate for Payer: WEA Trust Commercial |
$243.65
|
| Rate for Payer: WPS Commercial |
$328.13
|
|
|
Simple repair of wounds (face, ears, eyelids, nose, lips, mucous membranes) 2.6-5.0cm 12013
|
Professional
|
Both
|
$565.00
|
|
|
Service Code
|
CPT 12013
|
| Hospital Charge Code |
3013587
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.42 |
| Max. Negotiated Rate |
$536.75 |
| Rate for Payer: Aetna Commercial |
$536.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$485.90
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$536.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$339.00
|
| Rate for Payer: Health EOS Commercial |
$514.15
|
| Rate for Payer: HFN Commercial |
$536.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$188.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$188.82
|
| Rate for Payer: Multiplan Commercial |
$452.00
|
| Rate for Payer: Preferred Network Access Commercial |
$536.75
|
| Rate for Payer: Quartz Beloit One Network |
$248.60
|
| Rate for Payer: Quartz Commercial |
$322.05
|
| Rate for Payer: The Alliance Commercial |
$282.50
|
| Rate for Payer: United Healthcare Medicaid |
$75.42
|
| Rate for Payer: WEA Trust Commercial |
$310.75
|
| Rate for Payer: WPS Commercial |
$418.50
|
|
|
Simple repair of wounds (face, ears, eyelids, nose, lips, mucous membranes) 5.1-7.5cm 12014
|
Professional
|
Both
|
$711.00
|
|
|
Service Code
|
CPT 12014
|
| Hospital Charge Code |
3013588
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$90.50 |
| Max. Negotiated Rate |
$675.45 |
| Rate for Payer: Aetna Commercial |
$675.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$611.46
|
| Rate for Payer: Cash Price |
$213.30
|
| Rate for Payer: Cash Price |
$213.30
|
| Rate for Payer: Cash Price |
$213.30
|
| Rate for Payer: Cigna Commercial |
$675.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$90.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$426.60
|
| Rate for Payer: Health EOS Commercial |
$647.01
|
| Rate for Payer: HFN Commercial |
$675.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$242.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.62
|
| Rate for Payer: Multiplan Commercial |
$568.80
|
| Rate for Payer: Preferred Network Access Commercial |
$675.45
|
| Rate for Payer: Quartz Beloit One Network |
$312.84
|
| Rate for Payer: Quartz Commercial |
$405.27
|
| Rate for Payer: The Alliance Commercial |
$355.50
|
| Rate for Payer: United Healthcare Medicaid |
$90.50
|
| Rate for Payer: WEA Trust Commercial |
$391.05
|
| Rate for Payer: WPS Commercial |
$526.64
|
|
|
Simple repair of wounds (face, ears, eyelids, nose, lips, mucous membranes) 7.6-12.5cm 12015
|
Professional
|
Both
|
$840.00
|
|
|
Service Code
|
CPT 12015
|
| Hospital Charge Code |
3013589
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$136.47 |
| Max. Negotiated Rate |
$798.00 |
| Rate for Payer: Aetna Commercial |
$798.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$722.40
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cigna Commercial |
$798.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$136.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$504.00
|
| Rate for Payer: Health EOS Commercial |
$764.40
|
| Rate for Payer: HFN Commercial |
$798.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$306.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$306.47
|
| Rate for Payer: Multiplan Commercial |
$672.00
|
| Rate for Payer: Preferred Network Access Commercial |
$798.00
|
| Rate for Payer: Quartz Beloit One Network |
$369.60
|
| Rate for Payer: Quartz Commercial |
$478.80
|
| Rate for Payer: The Alliance Commercial |
$420.00
|
| Rate for Payer: United Healthcare Medicaid |
$136.47
|
| Rate for Payer: WEA Trust Commercial |
$462.00
|
| Rate for Payer: WPS Commercial |
$622.19
|
|
|
Simple repair of wounds (scalp, neck, axillae, external genitalia, trunk) 12.6-20.0cm 12005
|
Professional
|
Both
|
$791.00
|
|
|
Service Code
|
CPT 12005
|
| Hospital Charge Code |
3013585
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$139.71 |
| Max. Negotiated Rate |
$751.45 |
| Rate for Payer: Aetna Commercial |
$751.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$680.26
|
| Rate for Payer: Cash Price |
$237.30
|
| Rate for Payer: Cash Price |
$237.30
|
| Rate for Payer: Cash Price |
$237.30
|
| Rate for Payer: Cigna Commercial |
$751.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$139.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$474.60
|
| Rate for Payer: Health EOS Commercial |
$719.81
|
| Rate for Payer: HFN Commercial |
$751.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$309.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$309.86
|
| Rate for Payer: Multiplan Commercial |
$632.80
|
| Rate for Payer: Preferred Network Access Commercial |
$751.45
|
| Rate for Payer: Quartz Beloit One Network |
$348.04
|
| Rate for Payer: Quartz Commercial |
$450.87
|
| Rate for Payer: The Alliance Commercial |
$395.50
|
| Rate for Payer: United Healthcare Medicaid |
$139.71
|
| Rate for Payer: WEA Trust Commercial |
$435.05
|
| Rate for Payer: WPS Commercial |
$585.89
|
|
|
Simple repair of wounds (scalp, neck, axillae, external genitalia, trunk) 20.1-30.0cm 12006
|
Professional
|
Both
|
$974.00
|
|
|
Service Code
|
CPT 12006
|
| Hospital Charge Code |
3013586
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$184.95 |
| Max. Negotiated Rate |
$925.30 |
| Rate for Payer: Aetna Commercial |
$925.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$837.64
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cigna Commercial |
$925.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$184.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$584.40
|
| Rate for Payer: Health EOS Commercial |
$886.34
|
| Rate for Payer: HFN Commercial |
$925.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$379.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$379.26
|
| Rate for Payer: Multiplan Commercial |
$779.20
|
| Rate for Payer: Preferred Network Access Commercial |
$925.30
|
| Rate for Payer: Quartz Beloit One Network |
$428.56
|
| Rate for Payer: Quartz Commercial |
$555.18
|
| Rate for Payer: The Alliance Commercial |
$487.00
|
| Rate for Payer: United Healthcare Medicaid |
$184.95
|
| Rate for Payer: WEA Trust Commercial |
$535.70
|
| Rate for Payer: WPS Commercial |
$721.44
|
|
|
Simple repair of wounds (scalp, neck, axillae, external genitalia, trunk) <=2.5cm 12001
|
Professional
|
Both
|
$491.00
|
|
|
Service Code
|
CPT 12001
|
| Hospital Charge Code |
2957667
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.36 |
| Max. Negotiated Rate |
$466.45 |
| Rate for Payer: Aetna Commercial |
$466.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$422.26
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$466.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$294.60
|
| Rate for Payer: Health EOS Commercial |
$446.81
|
| Rate for Payer: HFN Commercial |
$466.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$144.91
|
| Rate for Payer: Multiplan Commercial |
$392.80
|
| Rate for Payer: Preferred Network Access Commercial |
$466.45
|
| Rate for Payer: Quartz Beloit One Network |
$216.04
|
| Rate for Payer: Quartz Commercial |
$279.87
|
| Rate for Payer: The Alliance Commercial |
$245.50
|
| Rate for Payer: United Healthcare Medicaid |
$51.36
|
| Rate for Payer: WEA Trust Commercial |
$270.05
|
| Rate for Payer: WPS Commercial |
$363.68
|
|
|
Simple repair of wounds (scalp, neck, axillae, external genitalia, trunk) 2.6-7.5cm 12002
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
CPT 12002
|
| Hospital Charge Code |
3013583
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.04 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Aetna Commercial |
$470.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$470.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$66.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$297.00
|
| Rate for Payer: Health EOS Commercial |
$450.45
|
| Rate for Payer: HFN Commercial |
$470.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$191.01
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: Preferred Network Access Commercial |
$470.25
|
| Rate for Payer: Quartz Beloit One Network |
$217.80
|
| Rate for Payer: Quartz Commercial |
$282.15
|
| Rate for Payer: The Alliance Commercial |
$247.50
|
| Rate for Payer: United Healthcare Medicaid |
$66.04
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
Simple repair of wounds (scalp, neck, axillae, external genitalia, trunk) 7.6-12.5cm 12004
|
Professional
|
Both
|
$614.00
|
|
|
Service Code
|
CPT 12004
|
| Hospital Charge Code |
3013584
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.57 |
| Max. Negotiated Rate |
$583.30 |
| Rate for Payer: Aetna Commercial |
$583.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.04
|
| Rate for Payer: Cash Price |
$184.20
|
| Rate for Payer: Cash Price |
$184.20
|
| Rate for Payer: Cash Price |
$184.20
|
| Rate for Payer: Cigna Commercial |
$583.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$368.40
|
| Rate for Payer: Health EOS Commercial |
$558.74
|
| Rate for Payer: HFN Commercial |
$583.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$237.89
|
| Rate for Payer: Multiplan Commercial |
$491.20
|
| Rate for Payer: Preferred Network Access Commercial |
$583.30
|
| Rate for Payer: Quartz Beloit One Network |
$270.16
|
| Rate for Payer: Quartz Commercial |
$349.98
|
| Rate for Payer: The Alliance Commercial |
$307.00
|
| Rate for Payer: United Healthcare Medicaid |
$87.57
|
| Rate for Payer: WEA Trust Commercial |
$337.70
|
| Rate for Payer: WPS Commercial |
$454.79
|
|
|
SIMS RESPONSE FORM
|
Facility
|
OP
|
$89.00
|
|
| Hospital Charge Code |
2972199
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.92 |
| Max. Negotiated Rate |
$356.00 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Aetna Managed Medicare |
$24.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.75
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$53.40
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$57.85
|
| Rate for Payer: Quartz Medicare Advantage |
$53.40
|
| Rate for Payer: The Alliance Commercial |
$356.00
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
SIMS RESPONSE FORM
|
Facility
|
IP
|
$89.00
|
|
| Hospital Charge Code |
2972199
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$53.40
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Simulation Complex
|
Facility
|
IP
|
$4,761.00
|
|
|
Service Code
|
CPT 77290
|
| Hospital Charge Code |
3040376
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$2,332.89 |
| Max. Negotiated Rate |
$4,380.12 |
| Rate for Payer: Aetna Commercial |
$4,284.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,094.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,523.33
|
| Rate for Payer: Cash Price |
$1,428.30
|
| Rate for Payer: Cigna Commercial |
$4,380.12
|
| Rate for Payer: Health EOS Commercial |
$4,237.29
|
| Rate for Payer: HFN Commercial |
$4,380.12
|
| Rate for Payer: Multiplan Commercial |
$3,808.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,856.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,380.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,332.89
|
| Rate for Payer: Quartz Commercial |
$2,856.60
|
| Rate for Payer: WEA Trust Commercial |
$2,618.55
|
| Rate for Payer: WPS Commercial |
$3,526.47
|
|
|
Simulation Complex
|
Facility
|
OP
|
$4,761.00
|
|
|
Service Code
|
CPT 77290
|
| Hospital Charge Code |
3040376
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$365.21 |
| Max. Negotiated Rate |
$4,380.12 |
| Rate for Payer: Aetna Commercial |
$4,284.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,094.46
|
| Rate for Payer: Aetna Managed Medicare |
$365.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,369.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,095.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,040.85
|
| Rate for Payer: Anthem Medicare Advantage |
$365.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,523.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$365.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$365.21
|
| Rate for Payer: Cash Price |
$1,428.30
|
| Rate for Payer: Cash Price |
$1,428.30
|
| Rate for Payer: Cigna Commercial |
$4,380.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$365.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,664.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$365.21
|
| Rate for Payer: Health EOS Commercial |
$4,237.29
|
| Rate for Payer: HFN Commercial |
$4,380.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,358.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$365.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$365.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$365.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$365.21
|
| Rate for Payer: Multiplan Commercial |
$3,808.80
|
| Rate for Payer: NAPHCARE Commercial |
$547.82
|
| Rate for Payer: Preferred Network Access Commercial |
$4,380.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,332.89
|
| Rate for Payer: Quartz Commercial |
$3,094.65
|
| Rate for Payer: Quartz Medicare Advantage |
$365.21
|
| Rate for Payer: The Alliance Commercial |
$1,460.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$365.21
|
| Rate for Payer: United Healthcare PPO |
$3,570.75
|
| Rate for Payer: WEA Trust Commercial |
$2,618.55
|
| Rate for Payer: Wellcare Medicare |
$365.21
|
| Rate for Payer: WPS Commercial |
$3,526.47
|
|
|
Simulation Intermediate
|
Facility
|
OP
|
$5,953.00
|
|
|
Service Code
|
CPT 77285
|
| Hospital Charge Code |
3040375
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$365.21 |
| Max. Negotiated Rate |
$5,476.76 |
| Rate for Payer: Aetna Commercial |
$5,357.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,119.58
|
| Rate for Payer: Aetna Managed Medicare |
$365.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,369.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,095.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,040.85
|
| Rate for Payer: Anthem Medicare Advantage |
$365.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,155.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$365.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$365.21
|
| Rate for Payer: Cash Price |
$1,785.90
|
| Rate for Payer: Cash Price |
$1,785.90
|
| Rate for Payer: Cigna Commercial |
$5,476.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$365.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,331.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$365.21
|
| Rate for Payer: Health EOS Commercial |
$5,298.17
|
| Rate for Payer: HFN Commercial |
$5,476.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,358.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$365.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$365.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$365.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$365.21
|
| Rate for Payer: Multiplan Commercial |
$4,762.40
|
| Rate for Payer: NAPHCARE Commercial |
$547.82
|
| Rate for Payer: Preferred Network Access Commercial |
$5,476.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,916.97
|
| Rate for Payer: Quartz Commercial |
$3,869.45
|
| Rate for Payer: Quartz Medicare Advantage |
$365.21
|
| Rate for Payer: The Alliance Commercial |
$1,460.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$365.21
|
| Rate for Payer: United Healthcare PPO |
$4,464.75
|
| Rate for Payer: WEA Trust Commercial |
$3,274.15
|
| Rate for Payer: Wellcare Medicare |
$365.21
|
| Rate for Payer: WPS Commercial |
$4,409.39
|
|
|
Simulation Intermediate
|
Facility
|
IP
|
$5,953.00
|
|
|
Service Code
|
CPT 77285
|
| Hospital Charge Code |
3040375
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$2,916.97 |
| Max. Negotiated Rate |
$5,476.76 |
| Rate for Payer: Aetna Commercial |
$5,357.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,119.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,155.09
|
| Rate for Payer: Cash Price |
$1,785.90
|
| Rate for Payer: Cigna Commercial |
$5,476.76
|
| Rate for Payer: Health EOS Commercial |
$5,298.17
|
| Rate for Payer: HFN Commercial |
$5,476.76
|
| Rate for Payer: Multiplan Commercial |
$4,762.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,571.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,476.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,916.97
|
| Rate for Payer: Quartz Commercial |
$3,571.80
|
| Rate for Payer: WEA Trust Commercial |
$3,274.15
|
| Rate for Payer: WPS Commercial |
$4,409.39
|
|
|
Simulation Simple
|
Facility
|
IP
|
$2,036.00
|
|
|
Service Code
|
CPT 77280
|
| Hospital Charge Code |
3040374
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$997.64 |
| Max. Negotiated Rate |
$1,873.12 |
| Rate for Payer: Aetna Commercial |
$1,832.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,750.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,079.08
|
| Rate for Payer: Cash Price |
$610.80
|
| Rate for Payer: Cigna Commercial |
$1,873.12
|
| Rate for Payer: Health EOS Commercial |
$1,812.04
|
| Rate for Payer: HFN Commercial |
$1,873.12
|
| Rate for Payer: Multiplan Commercial |
$1,628.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,221.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,873.12
|
| Rate for Payer: Quartz Beloit One Network |
$997.64
|
| Rate for Payer: Quartz Commercial |
$1,221.60
|
| Rate for Payer: WEA Trust Commercial |
$1,119.80
|
| Rate for Payer: WPS Commercial |
$1,508.07
|
|
|
Simulation Simple
|
Facility
|
OP
|
$2,036.00
|
|
|
Service Code
|
CPT 77280
|
| Hospital Charge Code |
3040374
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$134.11 |
| Max. Negotiated Rate |
$1,873.12 |
| Rate for Payer: Aetna Commercial |
$1,832.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,750.96
|
| Rate for Payer: Aetna Managed Medicare |
$134.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$502.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$402.33
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$382.21
|
| Rate for Payer: Anthem Medicare Advantage |
$134.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,079.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$134.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$134.11
|
| Rate for Payer: Cash Price |
$610.80
|
| Rate for Payer: Cash Price |
$610.80
|
| Rate for Payer: Cigna Commercial |
$1,873.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$134.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,139.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$134.11
|
| Rate for Payer: Health EOS Commercial |
$1,812.04
|
| Rate for Payer: HFN Commercial |
$1,873.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$498.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$134.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$134.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$134.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$134.11
|
| Rate for Payer: Multiplan Commercial |
$1,628.80
|
| Rate for Payer: NAPHCARE Commercial |
$201.16
|
| Rate for Payer: Preferred Network Access Commercial |
$1,873.12
|
| Rate for Payer: Quartz Beloit One Network |
$997.64
|
| Rate for Payer: Quartz Commercial |
$1,323.40
|
| Rate for Payer: Quartz Medicare Advantage |
$134.11
|
| Rate for Payer: The Alliance Commercial |
$536.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$134.11
|
| Rate for Payer: United Healthcare PPO |
$1,527.00
|
| Rate for Payer: WEA Trust Commercial |
$1,119.80
|
| Rate for Payer: Wellcare Medicare |
$134.11
|
| Rate for Payer: WPS Commercial |
$1,508.07
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT
|
Facility
|
IP
|
$140,208.00
|
|
|
Service Code
|
MSDRG 008
|
| Min. Negotiated Rate |
$50,434.46 |
| Max. Negotiated Rate |
$140,208.00 |
| Rate for Payer: Aetna Managed Medicare |
$50,434.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110,354.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$84,586.06
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$80,362.28
|
| Rate for Payer: Anthem Medicare Advantage |
$50,434.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$50,434.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$50,434.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$50,434.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89,209.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$50,434.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102,603.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50,434.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$50,434.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$50,434.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$50,434.46
|
| Rate for Payer: NAPHCARE Commercial |
$75,651.69
|
| Rate for Payer: Quartz Medicare Advantage |
$50,434.46
|
| Rate for Payer: The Alliance Commercial |
$140,208.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50,434.46
|
| Rate for Payer: Wellcare Medicare |
$50,434.46
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS
|
Facility
|
IP
|
$212,835.00
|
|
|
Service Code
|
MSDRG 019
|
| Min. Negotiated Rate |
$76,559.46 |
| Max. Negotiated Rate |
$212,835.00 |
| Rate for Payer: Aetna Managed Medicare |
$76,559.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$167,630.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$128,487.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$122,071.22
|
| Rate for Payer: Anthem Medicare Advantage |
$76,559.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$76,559.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$76,559.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$76,559.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135,510.24
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$76,559.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$155,873.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$76,559.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$76,559.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$76,559.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$76,559.46
|
| Rate for Payer: NAPHCARE Commercial |
$114,839.19
|
| Rate for Payer: Quartz Medicare Advantage |
$76,559.46
|
| Rate for Payer: The Alliance Commercial |
$212,835.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$76,559.46
|
| Rate for Payer: United Healthcare PPO |
$121,349.32
|
| Rate for Payer: Wellcare Medicare |
$76,559.46
|
|
|
Sincalide
|
Professional
|
Both
|
$310.00
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
5593282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.74 |
| Max. Negotiated Rate |
$324.36 |
| Rate for Payer: Aetna Commercial |
$294.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$266.60
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$294.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$129.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.74
|
| Rate for Payer: Health EOS Commercial |
$282.10
|
| Rate for Payer: HFN Commercial |
$294.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$168.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.13
|
| Rate for Payer: Multiplan Commercial |
$248.00
|
| Rate for Payer: Preferred Network Access Commercial |
$294.50
|
| Rate for Payer: Quartz Beloit One Network |
$136.40
|
| Rate for Payer: Quartz Commercial |
$176.70
|
| Rate for Payer: The Alliance Commercial |
$155.00
|
| Rate for Payer: United Healthcare Medicaid |
$129.74
|
| Rate for Payer: WEA Trust Commercial |
$170.50
|
| Rate for Payer: WPS Commercial |
$324.36
|
|
|
Sincalide
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
5593282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$151.90 |
| Max. Negotiated Rate |
$285.20 |
| Rate for Payer: Aetna Commercial |
$279.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$266.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$164.30
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$285.20
|
| Rate for Payer: Health EOS Commercial |
$275.90
|
| Rate for Payer: HFN Commercial |
$285.20
|
| Rate for Payer: Multiplan Commercial |
$248.00
|
| Rate for Payer: NAPHCARE Commercial |
$186.00
|
| Rate for Payer: Preferred Network Access Commercial |
$285.20
|
| Rate for Payer: Quartz Beloit One Network |
$151.90
|
| Rate for Payer: Quartz Commercial |
$186.00
|
| Rate for Payer: WEA Trust Commercial |
$170.50
|
| Rate for Payer: WPS Commercial |
$229.62
|
|
|
Sincalide
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
5593282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.80 |
| Max. Negotiated Rate |
$1,240.00 |
| Rate for Payer: Aetna Commercial |
$279.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$266.60
|
| Rate for Payer: Aetna Managed Medicare |
$86.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$201.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$155.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$148.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$164.30
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$285.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.65
|
| Rate for Payer: Health EOS Commercial |
$275.90
|
| Rate for Payer: HFN Commercial |
$285.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$232.50
|
| Rate for Payer: Multiplan Commercial |
$248.00
|
| Rate for Payer: NAPHCARE Commercial |
$186.00
|
| Rate for Payer: Preferred Network Access Commercial |
$285.20
|
| Rate for Payer: Quartz Beloit One Network |
$151.90
|
| Rate for Payer: Quartz Commercial |
$201.50
|
| Rate for Payer: Quartz Medicare Advantage |
$186.00
|
| Rate for Payer: The Alliance Commercial |
$1,240.00
|
| Rate for Payer: WEA Trust Commercial |
$170.50
|
| Rate for Payer: WPS Commercial |
$324.36
|
|
