|
Simulation Simple
|
Facility
OP
|
$2,036.00
|
|
|
Service Code
|
CPT 77280
|
| Hospital Charge Code |
3040374
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$124.36 |
| 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 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 |
$124.36
|
| 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
|
|
|
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: 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
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT
|
Facility
IP
|
$140,208.00
|
|
|
Service Code
|
MS-DRG 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
|
MS-DRG 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
|
Facility
OP
|
$310.00
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
5593282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.80 |
| Max. Negotiated Rate |
$70,002.00 |
| 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 |
$70,002.00
|
| Rate for Payer: WEA Trust Commercial |
$170.50
|
| Rate for Payer: WPS Commercial |
$324.36
|
|
|
Sincalide
|
Professional
|
$310.00
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
5593282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.74 |
| Max. Negotiated Rate |
$367.24 |
| Rate for Payer: Aetna Commercial |
$294.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$266.60
|
| Rate for Payer: Aetna Managed Medicare |
$133.54
|
| Rate for Payer: Anthem Medicare Advantage |
$133.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$133.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$133.54
|
| 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 |
$155.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.74
|
| Rate for Payer: Health EOS Commercial |
$282.10
|
| 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: Independent Care Health Plan Medicare |
$133.54
|
| 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: Quartz Medicare Advantage |
$133.54
|
| Rate for Payer: The Alliance Commercial |
$367.24
|
| Rate for Payer: United Healthcare Medicaid |
$129.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$133.54
|
| 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: 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
|
|
|
Single Biopatch used - Arterial Line Dressing:
|
Facility
OP
|
$196.00
|
|
| Hospital Charge Code |
3025894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$784.00 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Aetna Managed Medicare |
$54.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$127.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$98.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.68
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.00
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$127.40
|
| Rate for Payer: Quartz Medicare Advantage |
$117.60
|
| Rate for Payer: The Alliance Commercial |
$784.00
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
Single Biopatch used - Arterial Line Dressing:
|
Facility
IP
|
$196.00
|
|
| Hospital Charge Code |
3025894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$96.04 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$117.60
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
Single Biopatch used - Central IV Dressing:
|
Facility
OP
|
$188.00
|
|
| Hospital Charge Code |
3025904
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.64 |
| Max. Negotiated Rate |
$752.00 |
| Rate for Payer: Aetna Commercial |
$169.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.68
|
| Rate for Payer: Aetna Managed Medicare |
$52.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$122.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$94.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$90.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.64
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$172.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.20
|
| Rate for Payer: Health EOS Commercial |
$167.32
|
| Rate for Payer: HFN Commercial |
$172.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.00
|
| Rate for Payer: Multiplan Commercial |
$150.40
|
| Rate for Payer: NAPHCARE Commercial |
$112.80
|
| Rate for Payer: Preferred Network Access Commercial |
$172.96
|
| Rate for Payer: Quartz Beloit One Network |
$92.12
|
| Rate for Payer: Quartz Commercial |
$122.20
|
| Rate for Payer: Quartz Medicare Advantage |
$112.80
|
| Rate for Payer: The Alliance Commercial |
$752.00
|
| Rate for Payer: WEA Trust Commercial |
$103.40
|
| Rate for Payer: WPS Commercial |
$139.25
|
|
|
Single Biopatch used - Central IV Dressing:
|
Facility
IP
|
$188.00
|
|
| Hospital Charge Code |
3025904
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$92.12 |
| Max. Negotiated Rate |
$172.96 |
| Rate for Payer: Aetna Commercial |
$169.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.64
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$172.96
|
| Rate for Payer: Health EOS Commercial |
$167.32
|
| Rate for Payer: HFN Commercial |
$172.96
|
| Rate for Payer: Multiplan Commercial |
$150.40
|
| Rate for Payer: NAPHCARE Commercial |
$112.80
|
| Rate for Payer: Preferred Network Access Commercial |
$172.96
|
| Rate for Payer: Quartz Beloit One Network |
$92.12
|
| Rate for Payer: Quartz Commercial |
$112.80
|
| Rate for Payer: WEA Trust Commercial |
$103.40
|
| Rate for Payer: WPS Commercial |
$139.25
|
|
|
Single Biopatch used - IABP Dressing/Activity
|
Facility
OP
|
$196.00
|
|
| Hospital Charge Code |
3025921
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$784.00 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Aetna Managed Medicare |
$54.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$127.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$98.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.68
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.00
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$127.40
|
| Rate for Payer: Quartz Medicare Advantage |
$117.60
|
| Rate for Payer: The Alliance Commercial |
$784.00
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
Single Biopatch used - IABP Dressing/Activity
|
Facility
IP
|
$196.00
|
|
| Hospital Charge Code |
3025921
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$96.04 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$117.60
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
Single Biopatch used - PA Line Dressing/Activity
|
Facility
IP
|
$196.00
|
|
| Hospital Charge Code |
3025925
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$96.04 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$117.60
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
Single Biopatch used - PA Line Dressing/Activity
|
Facility
OP
|
$196.00
|
|
| Hospital Charge Code |
3025925
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$784.00 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Aetna Managed Medicare |
$54.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$127.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$98.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.68
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.00
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$127.40
|
| Rate for Payer: Quartz Medicare Advantage |
$117.60
|
| Rate for Payer: The Alliance Commercial |
$784.00
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
SINGLE DUAL OR MULTIPLE LEAD IMPLANTABLE 9328726
|
Professional
|
$389.00
|
|
|
Service Code
|
CPT 93287 26
|
| Hospital Charge Code |
3015362
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$21.47 |
| Max. Negotiated Rate |
$369.55 |
| Rate for Payer: Aetna Commercial |
$369.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$334.54
|
| Rate for Payer: Aetna Managed Medicare |
$21.47
|
| Rate for Payer: Anthem Medicare Advantage |
$21.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.47
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$369.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$194.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.47
|
| Rate for Payer: Health EOS Commercial |
$353.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$78.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.47
|
| Rate for Payer: Multiplan Commercial |
$311.20
|
| Rate for Payer: Preferred Network Access Commercial |
$369.55
|
| Rate for Payer: Quartz Beloit One Network |
$171.16
|
| Rate for Payer: Quartz Commercial |
$221.73
|
| Rate for Payer: Quartz Medicare Advantage |
$21.47
|
| Rate for Payer: The Alliance Commercial |
$81.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.47
|
| Rate for Payer: WEA Trust Commercial |
$213.95
|
| Rate for Payer: WPS Commercial |
$85.88
|
|
|
SINU-KNIT NASAL DRESSING RR600
|
Facility
IP
|
$1,016.00
|
|
| Hospital Charge Code |
3092805
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.84 |
| Max. Negotiated Rate |
$934.72 |
| Rate for Payer: Aetna Commercial |
$914.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$538.48
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$934.72
|
| Rate for Payer: Health EOS Commercial |
$904.24
|
| Rate for Payer: HFN Commercial |
$934.72
|
| Rate for Payer: Multiplan Commercial |
$812.80
|
| Rate for Payer: NAPHCARE Commercial |
$609.60
|
| Rate for Payer: Preferred Network Access Commercial |
$934.72
|
| Rate for Payer: Quartz Beloit One Network |
$497.84
|
| Rate for Payer: Quartz Commercial |
$609.60
|
| Rate for Payer: WEA Trust Commercial |
$558.80
|
| Rate for Payer: WPS Commercial |
$752.55
|
|
|
SINU-KNIT NASAL DRESSING RR600
|
Facility
OP
|
$1,016.00
|
|
| Hospital Charge Code |
3092805
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$284.48 |
| Max. Negotiated Rate |
$4,064.00 |
| Rate for Payer: Aetna Commercial |
$914.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$873.76
|
| Rate for Payer: Aetna Managed Medicare |
$284.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$660.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$508.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$487.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$538.48
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$934.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$568.55
|
| Rate for Payer: Health EOS Commercial |
$904.24
|
| Rate for Payer: HFN Commercial |
$934.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$762.00
|
| Rate for Payer: Multiplan Commercial |
$812.80
|
| Rate for Payer: NAPHCARE Commercial |
$609.60
|
| Rate for Payer: Preferred Network Access Commercial |
$934.72
|
| Rate for Payer: Quartz Beloit One Network |
$497.84
|
| Rate for Payer: Quartz Commercial |
$660.40
|
| Rate for Payer: Quartz Medicare Advantage |
$609.60
|
| Rate for Payer: The Alliance Commercial |
$4,064.00
|
| Rate for Payer: WEA Trust Commercial |
$558.80
|
| Rate for Payer: WPS Commercial |
$752.55
|
|
|
SINUS AND MASTOID PROCEDURES WITH CC/MCC
|
Facility
IP
|
$70,829.00
|
|
|
Service Code
|
MS-DRG 135
|
| Min. Negotiated Rate |
$25,478.07 |
| Max. Negotiated Rate |
$70,829.00 |
| Rate for Payer: Aetna Managed Medicare |
$25,478.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55,597.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42,614.65
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40,486.70
|
| Rate for Payer: Anthem Medicare Advantage |
$25,478.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25,478.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25,478.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25,478.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44,943.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25,478.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51,715.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25,478.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25,478.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25,478.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25,478.07
|
| Rate for Payer: NAPHCARE Commercial |
$38,217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$25,478.07
|
| Rate for Payer: The Alliance Commercial |
$70,829.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25,478.07
|
| Rate for Payer: United Healthcare PPO |
$40,261.53
|
| Rate for Payer: Wellcare Medicare |
$25,478.07
|
|
|
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC
|
Facility
IP
|
$28,084.00
|
|
|
Service Code
|
MS-DRG 136
|
| Min. Negotiated Rate |
$10,102.21 |
| Max. Negotiated Rate |
$28,084.00 |
| Rate for Payer: Aetna Managed Medicare |
$10,102.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,721.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,116.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,361.32
|
| Rate for Payer: Anthem Medicare Advantage |
$10,102.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,102.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,102.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,102.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,942.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,102.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,312.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,102.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,102.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,102.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,102.21
|
| Rate for Payer: NAPHCARE Commercial |
$15,153.32
|
| Rate for Payer: Quartz Medicare Advantage |
$10,102.21
|
| Rate for Payer: The Alliance Commercial |
$28,084.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,102.21
|
| Rate for Payer: United Healthcare PPO |
$14,256.48
|
| Rate for Payer: Wellcare Medicare |
$10,102.21
|
|
|
SINUS BALLOON DILATION TOOL MULTI-SINUS XPRESS ULTRA ENTELLUS 6 X 20 ULF-106
|
Facility
IP
|
$10,926.00
|
|
| Hospital Charge Code |
5432721
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,353.74 |
| Max. Negotiated Rate |
$10,051.92 |
| Rate for Payer: Aetna Commercial |
$9,833.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,790.78
|
| Rate for Payer: Cash Price |
$3,277.80
|
| Rate for Payer: Cigna Commercial |
$10,051.92
|
| Rate for Payer: Health EOS Commercial |
$9,724.14
|
| Rate for Payer: HFN Commercial |
$10,051.92
|
| Rate for Payer: Multiplan Commercial |
$8,740.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,555.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,051.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,353.74
|
| Rate for Payer: Quartz Commercial |
$6,555.60
|
| Rate for Payer: WEA Trust Commercial |
$6,009.30
|
| Rate for Payer: WPS Commercial |
$8,092.89
|
|
|
SINUS BALLOON DILATION TOOL MULTI-SINUS XPRESS ULTRA ENTELLUS 6 X 20 ULF-106
|
Facility
OP
|
$10,926.00
|
|
| Hospital Charge Code |
5432721
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,059.28 |
| Max. Negotiated Rate |
$43,704.00 |
| Rate for Payer: Aetna Commercial |
$9,833.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,396.36
|
| Rate for Payer: Aetna Managed Medicare |
$3,059.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,101.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,463.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,244.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,790.78
|
| Rate for Payer: Cash Price |
$3,277.80
|
| Rate for Payer: Cigna Commercial |
$10,051.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,114.19
|
| Rate for Payer: Health EOS Commercial |
$9,724.14
|
| Rate for Payer: HFN Commercial |
$10,051.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,194.50
|
| Rate for Payer: Multiplan Commercial |
$8,740.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,555.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,051.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,353.74
|
| Rate for Payer: Quartz Commercial |
$7,101.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,555.60
|
| Rate for Payer: The Alliance Commercial |
$43,704.00
|
| Rate for Payer: WEA Trust Commercial |
$6,009.30
|
| Rate for Payer: WPS Commercial |
$8,092.89
|
|
|
SINUS BALLOON INFLATOR KIT MEDTRONIC 18INFKIT
|
Facility
OP
|
$2,695.00
|
|
| Hospital Charge Code |
4230456
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$754.60 |
| Max. Negotiated Rate |
$10,780.00 |
| Rate for Payer: Aetna Commercial |
$2,425.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,317.70
|
| Rate for Payer: Aetna Managed Medicare |
$754.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,751.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,347.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,293.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,428.35
|
| Rate for Payer: Cash Price |
$808.50
|
| Rate for Payer: Cigna Commercial |
$2,479.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,508.12
|
| Rate for Payer: Health EOS Commercial |
$2,398.55
|
| Rate for Payer: HFN Commercial |
$2,479.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,021.25
|
| Rate for Payer: Multiplan Commercial |
$2,156.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,617.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,479.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,320.55
|
| Rate for Payer: Quartz Commercial |
$1,751.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,617.00
|
| Rate for Payer: The Alliance Commercial |
$10,780.00
|
| Rate for Payer: WEA Trust Commercial |
$1,482.25
|
| Rate for Payer: WPS Commercial |
$1,996.19
|
|
|
SINUS BALLOON INFLATOR KIT MEDTRONIC 18INFKIT
|
Facility
IP
|
$2,695.00
|
|
| Hospital Charge Code |
4230456
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,320.55 |
| Max. Negotiated Rate |
$2,479.40 |
| Rate for Payer: Aetna Commercial |
$2,425.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,428.35
|
| Rate for Payer: Cash Price |
$808.50
|
| Rate for Payer: Cigna Commercial |
$2,479.40
|
| Rate for Payer: Health EOS Commercial |
$2,398.55
|
| Rate for Payer: HFN Commercial |
$2,479.40
|
| Rate for Payer: Multiplan Commercial |
$2,156.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,617.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,479.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,320.55
|
| Rate for Payer: Quartz Commercial |
$1,617.00
|
| Rate for Payer: WEA Trust Commercial |
$1,482.25
|
| Rate for Payer: WPS Commercial |
$1,996.19
|
|
|
SINUS BALLOON SEEKER EM FRONTAL 6 X 17MM MEDTRONIC 1830617FRT
|
Facility
IP
|
$7,872.00
|
|
| Hospital Charge Code |
4230453
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,857.28 |
| Max. Negotiated Rate |
$7,242.24 |
| Rate for Payer: Aetna Commercial |
$7,084.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,172.16
|
| Rate for Payer: Cash Price |
$2,361.60
|
| Rate for Payer: Cigna Commercial |
$7,242.24
|
| Rate for Payer: Health EOS Commercial |
$7,006.08
|
| Rate for Payer: HFN Commercial |
$7,242.24
|
| Rate for Payer: Multiplan Commercial |
$6,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,723.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,242.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,857.28
|
| Rate for Payer: Quartz Commercial |
$4,723.20
|
| Rate for Payer: WEA Trust Commercial |
$4,329.60
|
| Rate for Payer: WPS Commercial |
$5,830.79
|
|
