|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC
|
Facility
|
IP
|
$23,127.52
|
|
|
Service Code
|
MSDRG 556
|
| Min. Negotiated Rate |
$6,867.69 |
| Max. Negotiated Rate |
$23,127.52 |
| Rate for Payer: Aetna Managed Medicare |
$6,867.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,123.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,891.15
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,197.50
|
| Rate for Payer: Anthem Medicare Advantage |
$6,867.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,867.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,867.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,867.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,650.44
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,867.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,718.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,867.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,867.69
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,867.69
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,867.69
|
| Rate for Payer: NAPHCARE Commercial |
$10,301.54
|
| Rate for Payer: Quartz Medicare Advantage |
$6,867.69
|
| Rate for Payer: The Alliance Commercial |
$23,127.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,867.69
|
| Rate for Payer: United Healthcare PPO |
$13,015.83
|
| Rate for Payer: Wellcare Medicare |
$6,867.69
|
|
|
SIGNS AND SYMPTOMS WITH MCC
|
Facility
|
IP
|
$34,938.80
|
|
|
Service Code
|
MSDRG 947
|
| Min. Negotiated Rate |
$10,228.09 |
| Max. Negotiated Rate |
$34,938.80 |
| Rate for Payer: Aetna Managed Medicare |
$10,228.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,697.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,229.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,169.65
|
| Rate for Payer: Anthem Medicare Advantage |
$10,228.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,228.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,228.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,228.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,390.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,228.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,382.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,228.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,228.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,228.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,228.09
|
| Rate for Payer: NAPHCARE Commercial |
$15,342.13
|
| Rate for Payer: Quartz Medicare Advantage |
$10,228.09
|
| Rate for Payer: The Alliance Commercial |
$34,938.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,228.09
|
| Rate for Payer: United Healthcare PPO |
$19,760.56
|
| Rate for Payer: Wellcare Medicare |
$10,228.09
|
|
|
SIGNS AND SYMPTOMS WITHOUT MCC
|
Facility
|
IP
|
$22,480.64
|
|
|
Service Code
|
MSDRG 948
|
| Min. Negotiated Rate |
$6,637.18 |
| Max. Negotiated Rate |
$22,480.64 |
| Rate for Payer: Aetna Managed Medicare |
$6,637.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,466.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,387.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,719.24
|
| Rate for Payer: Anthem Medicare Advantage |
$6,637.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,637.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,637.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,637.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,119.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,637.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,244.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,637.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,637.18
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,637.18
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,637.18
|
| Rate for Payer: NAPHCARE Commercial |
$9,955.76
|
| Rate for Payer: Quartz Medicare Advantage |
$6,637.18
|
| Rate for Payer: The Alliance Commercial |
$22,480.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,637.18
|
| Rate for Payer: United Healthcare PPO |
$12,646.38
|
| Rate for Payer: Wellcare Medicare |
$6,637.18
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
|
IP
|
$14,643.08
|
|
|
Service Code
|
APR-DRG 8614
|
| Min. Negotiated Rate |
$13,006.90 |
| Max. Negotiated Rate |
$14,643.08 |
| Rate for Payer: Anthem Medicaid |
$14,021.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$14,021.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14,021.55
|
| Rate for Payer: Dean Health Medicaid |
$14,021.55
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13,006.90
|
| Rate for Payer: Managed Health Services Medicaid |
$14,643.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,021.55
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14,021.55
|
| Rate for Payer: United Healthcare Medicaid |
$14,021.55
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
|
IP
|
$4,647.20
|
|
|
Service Code
|
APR-DRG 8611
|
| Min. Negotiated Rate |
$4,127.94 |
| Max. Negotiated Rate |
$4,647.20 |
| Rate for Payer: Anthem Medicaid |
$4,449.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,449.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,449.95
|
| Rate for Payer: Dean Health Medicaid |
$4,449.95
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4,127.94
|
| Rate for Payer: Managed Health Services Medicaid |
$4,647.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,449.95
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,449.95
|
| Rate for Payer: United Healthcare Medicaid |
$4,449.95
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
|
IP
|
$8,943.68
|
|
|
Service Code
|
APR-DRG 8613
|
| Min. Negotiated Rate |
$7,944.33 |
| Max. Negotiated Rate |
$8,943.68 |
| Rate for Payer: Anthem Medicaid |
$8,564.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,564.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,564.06
|
| Rate for Payer: Dean Health Medicaid |
$8,564.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,944.33
|
| Rate for Payer: Managed Health Services Medicaid |
$8,943.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,564.06
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,564.06
|
| Rate for Payer: United Healthcare Medicaid |
$8,564.06
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
|
OP
|
$91.72
|
|
|
Service Code
|
EAPG 00871
|
| Min. Negotiated Rate |
$88.19 |
| Max. Negotiated Rate |
$91.72 |
| Rate for Payer: Anthem Medicaid |
$88.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$88.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$88.19
|
| Rate for Payer: Dean Health Medicaid |
$88.19
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$88.19
|
| Rate for Payer: Managed Health Services Medicaid |
$91.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$88.19
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$88.19
|
| Rate for Payer: United Healthcare Medicaid |
$88.19
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
|
IP
|
$6,137.82
|
|
|
Service Code
|
APR-DRG 8612
|
| Min. Negotiated Rate |
$5,451.99 |
| Max. Negotiated Rate |
$6,137.82 |
| Rate for Payer: Anthem Medicaid |
$5,877.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,877.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,877.30
|
| Rate for Payer: Dean Health Medicaid |
$5,877.30
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,451.99
|
| Rate for Payer: Managed Health Services Medicaid |
$6,137.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,877.30
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,877.30
|
| Rate for Payer: United Healthcare Medicaid |
$5,877.30
|
|
|
SIG W/BALLOON DILATION 45340
|
Professional
|
Both
|
$742.00
|
|
|
Service Code
|
CPT 45340
|
| Hospital Charge Code |
3014803
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.16 |
| Max. Negotiated Rate |
$733.10 |
| Rate for Payer: Aetna Commercial |
$733.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$663.64
|
| Rate for Payer: Aetna Managed Medicare |
$70.16
|
| Rate for Payer: Anthem Medicare Advantage |
$70.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$70.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$70.16
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cigna Commercial |
$733.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$276.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.16
|
| Rate for Payer: Health EOS Commercial |
$702.23
|
| Rate for Payer: HFN Commercial |
$733.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$268.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$268.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$70.16
|
| Rate for Payer: Multiplan Commercial |
$617.34
|
| Rate for Payer: NAPHCARE Commercial |
$105.24
|
| Rate for Payer: Preferred Network Access Commercial |
$733.10
|
| Rate for Payer: Quartz Beloit One Network |
$339.54
|
| Rate for Payer: Quartz Commercial |
$439.86
|
| Rate for Payer: Quartz Medicare Advantage |
$70.16
|
| Rate for Payer: The Alliance Commercial |
$298.17
|
| Rate for Payer: United Healthcare Medicaid |
$276.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$70.16
|
| Rate for Payer: WEA Trust Commercial |
$424.42
|
| Rate for Payer: WPS Commercial |
$315.71
|
|
|
Silicon Level to Mayo
|
Professional
|
Both
|
$173.00
|
|
|
Service Code
|
CPT 84285
|
| Hospital Charge Code |
5198610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.22 |
| Max. Negotiated Rate |
$170.92 |
| Rate for Payer: Aetna Commercial |
$170.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Aetna Managed Medicare |
$26.22
|
| Rate for Payer: Anthem Medicare Advantage |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26.22
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$170.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.22
|
| Rate for Payer: Health EOS Commercial |
$163.73
|
| Rate for Payer: HFN Commercial |
$170.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$92.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26.22
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: NAPHCARE Commercial |
$39.33
|
| Rate for Payer: Preferred Network Access Commercial |
$170.92
|
| Rate for Payer: Quartz Beloit One Network |
$79.16
|
| Rate for Payer: Quartz Commercial |
$102.55
|
| Rate for Payer: Quartz Medicare Advantage |
$26.22
|
| Rate for Payer: The Alliance Commercial |
$103.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.22
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$115.36
|
|
|
Silicon Level to Mayo
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 84285
|
| Hospital Charge Code |
5198610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$88.16 |
| Max. Negotiated Rate |
$165.53 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.36
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$107.95
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Silicon Level to Mayo
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 84285
|
| Hospital Charge Code |
5198610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.22 |
| Max. Negotiated Rate |
$165.53 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Aetna Managed Medicare |
$26.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.52
|
| Rate for Payer: Anthem Medicare Advantage |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26.22
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$26.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$26.22
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$26.22
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26.22
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$26.22
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$26.22
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: NAPHCARE Commercial |
$39.33
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$116.95
|
| Rate for Payer: Quartz Medicare Advantage |
$26.22
|
| Rate for Payer: The Alliance Commercial |
$104.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.22
|
| Rate for Payer: United Healthcare PPO |
$134.94
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: Wellcare Medicare |
$26.22
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Silver Nitrate Sticks [Med]
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
2974978
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.49
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: The Alliance Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Silver Nitrate Sticks [Med]
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
2974978
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Silver Sulfadiazine Cream 50gm [Med]
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
2974979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Aetna Managed Medicare |
$10.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.95
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.08
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: NAPHCARE Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$24.34
|
| Rate for Payer: Quartz Medicare Advantage |
$22.46
|
| Rate for Payer: The Alliance Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$27.73
|
|
|
Silver Sulfadiazine Cream 50gm [Med]
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
2974979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$22.46
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$27.73
|
|
|
Simple Dressing - Incision, Wound Dressing:
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3003560
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.00 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
Simple Dressing - Incision, Wound Dressing:
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3003560
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.28 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Aetna Managed Medicare |
$30.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.53
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.12
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: NAPHCARE Commercial |
$64.90
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$70.30
|
| Rate for Payer: Quartz Medicare Advantage |
$64.90
|
| Rate for Payer: The Alliance Commercial |
$30.74
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH CC
|
Facility
|
IP
|
$23,066.16
|
|
|
Service Code
|
MSDRG 194
|
| Min. Negotiated Rate |
$6,678.52 |
| Max. Negotiated Rate |
$23,066.16 |
| Rate for Payer: Aetna Managed Medicare |
$6,678.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,584.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,478.07
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,805.04
|
| Rate for Payer: Anthem Medicare Advantage |
$6,678.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,678.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,678.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,678.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,214.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,678.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,674.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,678.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,678.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,678.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,678.52
|
| Rate for Payer: NAPHCARE Commercial |
$10,017.77
|
| Rate for Payer: Quartz Medicare Advantage |
$6,678.52
|
| Rate for Payer: The Alliance Commercial |
$23,066.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,678.52
|
| Rate for Payer: United Healthcare PPO |
$12,981.09
|
| Rate for Payer: Wellcare Medicare |
$6,678.52
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH MCC
|
Facility
|
IP
|
$37,012.56
|
|
|
Service Code
|
MSDRG 193
|
| Min. Negotiated Rate |
$10,572.71 |
| Max. Negotiated Rate |
$37,012.56 |
| Rate for Payer: Aetna Managed Medicare |
$10,572.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,679.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,982.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,884.66
|
| Rate for Payer: Anthem Medicare Advantage |
$10,572.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,572.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,572.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,572.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,183.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,572.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,903.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,572.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,572.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,572.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,572.71
|
| Rate for Payer: NAPHCARE Commercial |
$15,859.07
|
| Rate for Payer: Quartz Medicare Advantage |
$10,572.71
|
| Rate for Payer: The Alliance Commercial |
$37,012.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,572.71
|
| Rate for Payer: United Healthcare PPO |
$20,944.67
|
| Rate for Payer: Wellcare Medicare |
$10,572.71
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC
|
Facility
|
IP
|
$17,631.12
|
|
|
Service Code
|
MSDRG 195
|
| Min. Negotiated Rate |
$5,319.95 |
| Max. Negotiated Rate |
$17,631.12 |
| Rate for Payer: Aetna Managed Medicare |
$5,319.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,713.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,511.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,986.31
|
| Rate for Payer: Anthem Medicare Advantage |
$5,319.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,319.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,319.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,319.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,085.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,319.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,687.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,319.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,319.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,319.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,319.95
|
| Rate for Payer: NAPHCARE Commercial |
$7,979.93
|
| Rate for Payer: Quartz Medicare Advantage |
$5,319.95
|
| Rate for Payer: The Alliance Commercial |
$17,631.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,319.95
|
| Rate for Payer: United Healthcare PPO |
$9,877.12
|
| Rate for Payer: Wellcare Medicare |
$5,319.95
|
|
|
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 |
$50.56 |
| Max. Negotiated Rate |
$437.68 |
| Rate for Payer: Aetna Commercial |
$437.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.22
|
| Rate for Payer: Aetna Managed Medicare |
$50.56
|
| Rate for Payer: Anthem Medicare Advantage |
$50.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$50.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$50.56
|
| 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 |
$437.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.56
|
| Rate for Payer: Health EOS Commercial |
$419.26
|
| Rate for Payer: HFN Commercial |
$437.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$187.27
|
| Rate for Payer: Independent Care Health Plan Medicare |
$50.56
|
| Rate for Payer: Multiplan Commercial |
$368.58
|
| Rate for Payer: NAPHCARE Commercial |
$75.85
|
| Rate for Payer: Preferred Network Access Commercial |
$437.68
|
| Rate for Payer: Quartz Beloit One Network |
$202.72
|
| Rate for Payer: Quartz Commercial |
$262.61
|
| Rate for Payer: Quartz Medicare Advantage |
$50.56
|
| Rate for Payer: The Alliance Commercial |
$214.90
|
| Rate for Payer: United Healthcare Medicaid |
$67.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.56
|
| Rate for Payer: WEA Trust Commercial |
$253.40
|
| Rate for Payer: WPS Commercial |
$227.54
|
|
|
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 |
$51.21 |
| Max. Negotiated Rate |
$558.22 |
| Rate for Payer: Aetna Commercial |
$558.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$505.34
|
| Rate for Payer: Aetna Managed Medicare |
$51.21
|
| Rate for Payer: Anthem Medicare Advantage |
$51.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$51.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$51.21
|
| 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 |
$558.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.21
|
| Rate for Payer: Health EOS Commercial |
$534.72
|
| Rate for Payer: HFN Commercial |
$558.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$196.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$196.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$51.21
|
| Rate for Payer: Multiplan Commercial |
$470.08
|
| Rate for Payer: NAPHCARE Commercial |
$76.81
|
| Rate for Payer: Preferred Network Access Commercial |
$558.22
|
| Rate for Payer: Quartz Beloit One Network |
$258.54
|
| Rate for Payer: Quartz Commercial |
$334.93
|
| Rate for Payer: Quartz Medicare Advantage |
$51.21
|
| Rate for Payer: The Alliance Commercial |
$217.64
|
| Rate for Payer: United Healthcare Medicaid |
$78.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51.21
|
| Rate for Payer: WEA Trust Commercial |
$323.18
|
| Rate for Payer: WPS Commercial |
$230.44
|
|
|
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 |
$65.99 |
| Max. Negotiated Rate |
$702.47 |
| Rate for Payer: Aetna Commercial |
$702.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$635.92
|
| Rate for Payer: Aetna Managed Medicare |
$65.99
|
| Rate for Payer: Anthem Medicare Advantage |
$65.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$65.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$65.99
|
| 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 |
$702.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$94.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.99
|
| Rate for Payer: Health EOS Commercial |
$672.89
|
| Rate for Payer: HFN Commercial |
$702.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$252.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$252.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$65.99
|
| Rate for Payer: Multiplan Commercial |
$591.55
|
| Rate for Payer: NAPHCARE Commercial |
$98.98
|
| Rate for Payer: Preferred Network Access Commercial |
$702.47
|
| Rate for Payer: Quartz Beloit One Network |
$325.35
|
| Rate for Payer: Quartz Commercial |
$421.48
|
| Rate for Payer: Quartz Medicare Advantage |
$65.99
|
| Rate for Payer: The Alliance Commercial |
$280.45
|
| Rate for Payer: United Healthcare Medicaid |
$94.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$65.99
|
| Rate for Payer: WEA Trust Commercial |
$406.69
|
| Rate for Payer: WPS Commercial |
$296.95
|
|
|
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 |
$82.73 |
| Max. Negotiated Rate |
$829.92 |
| Rate for Payer: Aetna Commercial |
$829.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$751.30
|
| Rate for Payer: Aetna Managed Medicare |
$82.73
|
| Rate for Payer: Anthem Medicare Advantage |
$82.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$82.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$82.73
|
| 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 |
$829.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$141.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.73
|
| Rate for Payer: Health EOS Commercial |
$794.98
|
| Rate for Payer: HFN Commercial |
$829.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$318.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$318.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$82.73
|
| Rate for Payer: Multiplan Commercial |
$698.88
|
| Rate for Payer: NAPHCARE Commercial |
$124.10
|
| Rate for Payer: Preferred Network Access Commercial |
$829.92
|
| Rate for Payer: Quartz Beloit One Network |
$384.38
|
| Rate for Payer: Quartz Commercial |
$497.95
|
| Rate for Payer: Quartz Medicare Advantage |
$82.73
|
| Rate for Payer: The Alliance Commercial |
$351.61
|
| Rate for Payer: United Healthcare Medicaid |
$141.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$82.73
|
| Rate for Payer: WEA Trust Commercial |
$480.48
|
| Rate for Payer: WPS Commercial |
$372.29
|
|
