|
SPEP Interpretation
|
Facility
|
IP
|
$213.00
|
|
|
Service Code
|
CPT 84165
|
| Hospital Charge Code |
2942977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$108.54 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$132.91
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
SPEP Interpretation
|
Professional
|
Both
|
$213.00
|
|
|
Service Code
|
CPT 84165
|
| Hospital Charge Code |
2942977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.17 |
| Max. Negotiated Rate |
$210.44 |
| Rate for Payer: Aetna Commercial |
$210.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Aetna Managed Medicare |
$11.17
|
| Rate for Payer: Anthem Commercial |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$11.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.17
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$210.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$110.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.17
|
| Rate for Payer: Health EOS Commercial |
$201.58
|
| Rate for Payer: HFN Commercial |
$210.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.17
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: NAPHCARE Commercial |
$16.75
|
| Rate for Payer: Preferred Network Access Commercial |
$210.44
|
| Rate for Payer: Quartz Beloit One Network |
$97.47
|
| Rate for Payer: Quartz Commercial |
$126.27
|
| Rate for Payer: Quartz Medicare Advantage |
$11.17
|
| Rate for Payer: The Alliance Commercial |
$44.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.17
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$49.15
|
|
|
SPEP Interpretation
|
Facility
|
OP
|
$213.00
|
|
|
Service Code
|
CPT 84165
|
| Hospital Charge Code |
2942977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.17 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Aetna Managed Medicare |
$11.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.55
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.54
|
| Rate for Payer: Anthem Medicare Advantage |
$11.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.17
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.17
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.17
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: NAPHCARE Commercial |
$16.75
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$143.99
|
| Rate for Payer: Quartz Medicare Advantage |
$11.17
|
| Rate for Payer: The Alliance Commercial |
$44.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.17
|
| Rate for Payer: United Healthcare PPO |
$166.14
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: Wellcare Medicare |
$11.17
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
SPERMATOCELE/EPIDIDYMECTOMY
|
Facility
|
IP
|
$1,129.00
|
|
| Hospital Charge Code |
2960013
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$575.34 |
| Max. Negotiated Rate |
$1,080.23 |
| Rate for Payer: Aetna Commercial |
$1,056.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,009.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$622.30
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,080.23
|
| Rate for Payer: Health EOS Commercial |
$1,045.00
|
| Rate for Payer: HFN Commercial |
$1,080.23
|
| Rate for Payer: Multiplan Commercial |
$939.33
|
| Rate for Payer: Preferred Network Access Commercial |
$1,080.23
|
| Rate for Payer: Quartz Beloit One Network |
$575.34
|
| Rate for Payer: Quartz Commercial |
$704.50
|
| Rate for Payer: WEA Trust Commercial |
$645.79
|
| Rate for Payer: WPS Commercial |
$869.67
|
|
|
SPERMATOCELE/EPIDIDYMECTOMY
|
Facility
|
OP
|
$1,129.00
|
|
| Hospital Charge Code |
2960013
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$328.76 |
| Max. Negotiated Rate |
$1,080.23 |
| Rate for Payer: Aetna Commercial |
$1,056.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,009.78
|
| Rate for Payer: Aetna Managed Medicare |
$328.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$763.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$587.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$563.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$622.30
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,080.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$657.08
|
| Rate for Payer: Health EOS Commercial |
$1,045.00
|
| Rate for Payer: HFN Commercial |
$1,080.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$880.62
|
| Rate for Payer: Multiplan Commercial |
$939.33
|
| Rate for Payer: NAPHCARE Commercial |
$704.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,080.23
|
| Rate for Payer: Quartz Beloit One Network |
$575.34
|
| Rate for Payer: Quartz Commercial |
$763.20
|
| Rate for Payer: Quartz Medicare Advantage |
$704.50
|
| Rate for Payer: The Alliance Commercial |
$587.08
|
| Rate for Payer: WEA Trust Commercial |
$645.79
|
| Rate for Payer: WPS Commercial |
$869.67
|
|
|
SPHENOPALATIME ARTERY LIGATION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960381
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
SPHENOPALATIME ARTERY LIGATION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960381
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
SPHERE MARKER OPTICAL PM8005
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2965209
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
SPHERE MARKER OPTICAL PM8005
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2965209
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
|
|
SPHINCTEROTOME JAGTOME RX39 M00573080
|
Facility
|
OP
|
$3,649.00
|
|
| Hospital Charge Code |
2973416
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,062.59 |
| Max. Negotiated Rate |
$3,491.36 |
| Rate for Payer: Aetna Commercial |
$3,415.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,263.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,062.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,466.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,897.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,821.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,011.33
|
| Rate for Payer: Cash Price |
$1,094.70
|
| Rate for Payer: Cigna Commercial |
$3,491.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,123.72
|
| Rate for Payer: Health EOS Commercial |
$3,377.51
|
| Rate for Payer: HFN Commercial |
$3,491.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,846.22
|
| Rate for Payer: Multiplan Commercial |
$3,035.97
|
| Rate for Payer: NAPHCARE Commercial |
$2,276.98
|
| Rate for Payer: Preferred Network Access Commercial |
$3,491.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,859.53
|
| Rate for Payer: Quartz Commercial |
$2,466.72
|
| Rate for Payer: Quartz Medicare Advantage |
$2,276.98
|
| Rate for Payer: The Alliance Commercial |
$1,897.48
|
| Rate for Payer: WEA Trust Commercial |
$2,087.23
|
| Rate for Payer: WPS Commercial |
$2,810.82
|
|
|
SPHINCTEROTOME JAGTOME RX39 M00573080
|
Facility
|
IP
|
$3,649.00
|
|
| Hospital Charge Code |
2973416
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,859.53 |
| Max. Negotiated Rate |
$3,491.36 |
| Rate for Payer: Aetna Commercial |
$3,415.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,263.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,011.33
|
| Rate for Payer: Cash Price |
$1,094.70
|
| Rate for Payer: Cigna Commercial |
$3,491.36
|
| Rate for Payer: Health EOS Commercial |
$3,377.51
|
| Rate for Payer: HFN Commercial |
$3,491.36
|
| Rate for Payer: Multiplan Commercial |
$3,035.97
|
| Rate for Payer: Preferred Network Access Commercial |
$3,491.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,859.53
|
| Rate for Payer: Quartz Commercial |
$2,276.98
|
| Rate for Payer: WEA Trust Commercial |
$2,087.23
|
| Rate for Payer: WPS Commercial |
$2,810.82
|
|
|
SPHYGMOMANOMETER ADULT CUFF
|
Facility
|
IP
|
$762.00
|
|
| Hospital Charge Code |
2971610
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$388.32 |
| Max. Negotiated Rate |
$729.08 |
| Rate for Payer: Aetna Commercial |
$713.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$681.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$420.01
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cigna Commercial |
$729.08
|
| Rate for Payer: Health EOS Commercial |
$705.31
|
| Rate for Payer: HFN Commercial |
$729.08
|
| Rate for Payer: Multiplan Commercial |
$633.98
|
| Rate for Payer: Preferred Network Access Commercial |
$729.08
|
| Rate for Payer: Quartz Beloit One Network |
$388.32
|
| Rate for Payer: Quartz Commercial |
$475.49
|
| Rate for Payer: WEA Trust Commercial |
$435.86
|
| Rate for Payer: WPS Commercial |
$586.97
|
|
|
SPHYGMOMANOMETER ADULT CUFF
|
Facility
|
OP
|
$762.00
|
|
| Hospital Charge Code |
2971610
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$221.89 |
| Max. Negotiated Rate |
$729.08 |
| Rate for Payer: Aetna Commercial |
$713.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$681.53
|
| Rate for Payer: Aetna Managed Medicare |
$221.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$515.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$396.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$380.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$420.01
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cigna Commercial |
$729.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$443.48
|
| Rate for Payer: Health EOS Commercial |
$705.31
|
| Rate for Payer: HFN Commercial |
$729.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$594.36
|
| Rate for Payer: Multiplan Commercial |
$633.98
|
| Rate for Payer: NAPHCARE Commercial |
$475.49
|
| Rate for Payer: Preferred Network Access Commercial |
$729.08
|
| Rate for Payer: Quartz Beloit One Network |
$388.32
|
| Rate for Payer: Quartz Commercial |
$515.11
|
| Rate for Payer: Quartz Medicare Advantage |
$475.49
|
| Rate for Payer: The Alliance Commercial |
$396.24
|
| Rate for Payer: WEA Trust Commercial |
$435.86
|
| Rate for Payer: WPS Commercial |
$586.97
|
|
|
Spider Distal Protection
|
Facility
|
IP
|
$8,714.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
4139307
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,440.65 |
| Max. Negotiated Rate |
$8,337.56 |
| Rate for Payer: Aetna Commercial |
$8,156.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,793.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,803.16
|
| Rate for Payer: Cash Price |
$2,614.20
|
| Rate for Payer: Cigna Commercial |
$8,337.56
|
| Rate for Payer: Health EOS Commercial |
$8,065.68
|
| Rate for Payer: HFN Commercial |
$8,337.56
|
| Rate for Payer: Multiplan Commercial |
$7,250.05
|
| Rate for Payer: Preferred Network Access Commercial |
$8,337.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,440.65
|
| Rate for Payer: Quartz Commercial |
$5,437.54
|
| Rate for Payer: WEA Trust Commercial |
$4,984.41
|
| Rate for Payer: WPS Commercial |
$6,712.39
|
|
|
Spider Distal Protection
|
Facility
|
OP
|
$8,714.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
4139307
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,537.52 |
| Max. Negotiated Rate |
$8,337.56 |
| Rate for Payer: Aetna Commercial |
$8,156.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,793.80
|
| Rate for Payer: Aetna Managed Medicare |
$2,537.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,890.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,531.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,350.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,803.16
|
| Rate for Payer: Cash Price |
$2,614.20
|
| Rate for Payer: Cigna Commercial |
$8,337.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,071.55
|
| Rate for Payer: Health EOS Commercial |
$8,065.68
|
| Rate for Payer: HFN Commercial |
$8,337.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,796.92
|
| Rate for Payer: Multiplan Commercial |
$7,250.05
|
| Rate for Payer: NAPHCARE Commercial |
$5,437.54
|
| Rate for Payer: Preferred Network Access Commercial |
$8,337.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,440.65
|
| Rate for Payer: Quartz Commercial |
$5,890.66
|
| Rate for Payer: Quartz Medicare Advantage |
$5,437.54
|
| Rate for Payer: The Alliance Commercial |
$4,531.28
|
| Rate for Payer: WEA Trust Commercial |
$4,984.41
|
| Rate for Payer: WPS Commercial |
$6,712.39
|
|
|
SPIDER PLATE LT 814100002
|
Facility
|
OP
|
$1,714.00
|
|
| Hospital Charge Code |
2965023
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$499.12 |
| Max. Negotiated Rate |
$1,639.96 |
| Rate for Payer: Aetna Commercial |
$1,604.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,533.00
|
| Rate for Payer: Aetna Managed Medicare |
$499.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,158.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$891.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$855.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$944.76
|
| Rate for Payer: Cash Price |
$514.20
|
| Rate for Payer: Cigna Commercial |
$1,639.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$997.55
|
| Rate for Payer: Health EOS Commercial |
$1,586.48
|
| Rate for Payer: HFN Commercial |
$1,639.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,336.92
|
| Rate for Payer: Multiplan Commercial |
$1,426.05
|
| Rate for Payer: NAPHCARE Commercial |
$1,069.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,639.96
|
| Rate for Payer: Quartz Beloit One Network |
$873.45
|
| Rate for Payer: Quartz Commercial |
$1,158.66
|
| Rate for Payer: Quartz Medicare Advantage |
$1,069.54
|
| Rate for Payer: The Alliance Commercial |
$891.28
|
| Rate for Payer: WEA Trust Commercial |
$980.41
|
| Rate for Payer: WPS Commercial |
$1,320.29
|
|
|
SPIDER PLATE LT 814100002
|
Facility
|
IP
|
$1,714.00
|
|
| Hospital Charge Code |
2965023
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$873.45 |
| Max. Negotiated Rate |
$1,639.96 |
| Rate for Payer: Aetna Commercial |
$1,604.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,533.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$944.76
|
| Rate for Payer: Cash Price |
$514.20
|
| Rate for Payer: Cigna Commercial |
$1,639.96
|
| Rate for Payer: Health EOS Commercial |
$1,586.48
|
| Rate for Payer: HFN Commercial |
$1,639.96
|
| Rate for Payer: Multiplan Commercial |
$1,426.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,639.96
|
| Rate for Payer: Quartz Beloit One Network |
$873.45
|
| Rate for Payer: Quartz Commercial |
$1,069.54
|
| Rate for Payer: WEA Trust Commercial |
$980.41
|
| Rate for Payer: WPS Commercial |
$1,320.29
|
|
|
SPINAL ANES - SET-UP CHARGE
|
Facility
|
IP
|
$1,160.00
|
|
| Hospital Charge Code |
4519579
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$591.14 |
| Max. Negotiated Rate |
$1,109.89 |
| Rate for Payer: Aetna Commercial |
$1,085.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,037.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$639.39
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,109.89
|
| Rate for Payer: Health EOS Commercial |
$1,073.70
|
| Rate for Payer: HFN Commercial |
$1,109.89
|
| Rate for Payer: Multiplan Commercial |
$965.12
|
| Rate for Payer: Preferred Network Access Commercial |
$1,109.89
|
| Rate for Payer: Quartz Beloit One Network |
$591.14
|
| Rate for Payer: Quartz Commercial |
$723.84
|
| Rate for Payer: WEA Trust Commercial |
$663.52
|
| Rate for Payer: WPS Commercial |
$893.55
|
|
|
SPINAL ANES - SET-UP CHARGE
|
Facility
|
OP
|
$1,160.00
|
|
| Hospital Charge Code |
4519579
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$337.79 |
| Max. Negotiated Rate |
$1,109.89 |
| Rate for Payer: Aetna Commercial |
$1,085.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,037.50
|
| Rate for Payer: Aetna Managed Medicare |
$337.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$784.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$603.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$579.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$639.39
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,109.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$675.12
|
| Rate for Payer: Health EOS Commercial |
$1,073.70
|
| Rate for Payer: HFN Commercial |
$1,109.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$904.80
|
| Rate for Payer: Multiplan Commercial |
$965.12
|
| Rate for Payer: NAPHCARE Commercial |
$723.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,109.89
|
| Rate for Payer: Quartz Beloit One Network |
$591.14
|
| Rate for Payer: Quartz Commercial |
$784.16
|
| Rate for Payer: Quartz Medicare Advantage |
$723.84
|
| Rate for Payer: The Alliance Commercial |
$603.20
|
| Rate for Payer: WEA Trust Commercial |
$663.52
|
| Rate for Payer: WPS Commercial |
$893.55
|
|
|
SPINAL DIAGNOSES AND INJURIES
|
Facility
|
OP
|
$102.20
|
|
|
Service Code
|
EAPG 00520
|
| Min. Negotiated Rate |
$98.27 |
| Max. Negotiated Rate |
$102.20 |
| Rate for Payer: Anthem Medicaid |
$98.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$98.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$98.27
|
| Rate for Payer: Dean Health Medicaid |
$98.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$98.27
|
| Rate for Payer: Managed Health Services Medicaid |
$102.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$98.27
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$98.27
|
| Rate for Payer: United Healthcare Medicaid |
$98.27
|
|
|
SPINAL DISORDERS AND INJURIES
|
Facility
|
IP
|
$17,799.67
|
|
|
Service Code
|
APR-DRG 0403
|
| Min. Negotiated Rate |
$15,810.78 |
| Max. Negotiated Rate |
$17,799.67 |
| Rate for Payer: Anthem Medicaid |
$17,044.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$17,044.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17,044.16
|
| Rate for Payer: Dean Health Medicaid |
$17,044.16
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15,810.78
|
| Rate for Payer: Managed Health Services Medicaid |
$17,799.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$17,044.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17,044.16
|
| Rate for Payer: United Healthcare Medicaid |
$17,044.16
|
|
|
SPINAL DISORDERS AND INJURIES
|
Facility
|
IP
|
$9,469.77
|
|
|
Service Code
|
APR-DRG 0401
|
| Min. Negotiated Rate |
$8,411.64 |
| Max. Negotiated Rate |
$9,469.77 |
| Rate for Payer: Anthem Medicaid |
$9,067.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,067.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,067.83
|
| Rate for Payer: Dean Health Medicaid |
$9,067.83
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,411.64
|
| Rate for Payer: Managed Health Services Medicaid |
$9,469.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,067.83
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,067.83
|
| Rate for Payer: United Healthcare Medicaid |
$9,067.83
|
|
|
SPINAL DISORDERS AND INJURIES
|
Facility
|
IP
|
$12,889.42
|
|
|
Service Code
|
APR-DRG 0402
|
| Min. Negotiated Rate |
$11,449.18 |
| Max. Negotiated Rate |
$12,889.42 |
| Rate for Payer: Anthem Medicaid |
$12,342.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12,342.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12,342.33
|
| Rate for Payer: Dean Health Medicaid |
$12,342.33
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11,449.18
|
| Rate for Payer: Managed Health Services Medicaid |
$12,889.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,342.33
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12,342.33
|
| Rate for Payer: United Healthcare Medicaid |
$12,342.33
|
|
|
SPINAL DISORDERS AND INJURIES
|
Facility
|
IP
|
$24,989.68
|
|
|
Service Code
|
APR-DRG 0404
|
| Min. Negotiated Rate |
$22,197.40 |
| Max. Negotiated Rate |
$24,989.68 |
| Rate for Payer: Anthem Medicaid |
$23,929.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$23,929.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$23,929.00
|
| Rate for Payer: Dean Health Medicaid |
$23,929.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$22,197.40
|
| Rate for Payer: Managed Health Services Medicaid |
$24,989.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$23,929.00
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$23,929.00
|
| Rate for Payer: United Healthcare Medicaid |
$23,929.00
|
|
|
SPINAL DISORDERS AND INJURIES WITH CC/MCC
|
Facility
|
IP
|
$54,097.68
|
|
|
Service Code
|
MSDRG 052
|
| Min. Negotiated Rate |
$14,801.17 |
| Max. Negotiated Rate |
$54,097.68 |
| Rate for Payer: Aetna Managed Medicare |
$14,801.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38,855.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,782.53
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,295.34
|
| Rate for Payer: Anthem Medicare Advantage |
$14,801.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,801.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,801.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,801.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,410.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,801.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39,434.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,801.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,801.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,801.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,801.17
|
| Rate for Payer: NAPHCARE Commercial |
$22,201.75
|
| Rate for Payer: Quartz Medicare Advantage |
$14,801.17
|
| Rate for Payer: The Alliance Commercial |
$54,097.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,801.17
|
| Rate for Payer: United Healthcare PPO |
$30,700.23
|
| Rate for Payer: Wellcare Medicare |
$14,801.17
|
|
