|
Spinal Puncture Lumbar Diag
|
Facility
|
OP
|
$1,802.00
|
|
|
Service Code
|
CPT 62328
|
| Hospital Charge Code |
3072726
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$683.53 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$1,621.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,549.72
|
| Rate for Payer: Aetna Managed Medicare |
$683.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,171.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$901.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$864.96
|
| Rate for Payer: Anthem Medicare Advantage |
$683.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$955.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$683.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$683.53
|
| Rate for Payer: Cash Price |
$540.60
|
| Rate for Payer: Cash Price |
$540.60
|
| Rate for Payer: Cigna Commercial |
$1,657.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$683.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$683.53
|
| Rate for Payer: Health EOS Commercial |
$1,603.78
|
| Rate for Payer: HFN Commercial |
$1,657.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,542.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$683.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$683.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$683.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$683.53
|
| Rate for Payer: Multiplan Commercial |
$1,441.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,025.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,657.84
|
| Rate for Payer: Quartz Beloit One Network |
$882.98
|
| Rate for Payer: Quartz Commercial |
$1,171.30
|
| Rate for Payer: Quartz Medicare Advantage |
$683.53
|
| Rate for Payer: The Alliance Commercial |
$2,734.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$683.53
|
| Rate for Payer: WEA Trust Commercial |
$991.10
|
| Rate for Payer: Wellcare Medicare |
$683.53
|
| Rate for Payer: WPS Commercial |
$1,334.74
|
|
|
Spinal Puncture, Lumbar, Diagnostic 62270
|
Professional
|
Both
|
$508.00
|
|
|
Service Code
|
CPT 62270
|
| Hospital Charge Code |
1190835
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$59.29 |
| Max. Negotiated Rate |
$482.60 |
| Rate for Payer: Aetna Commercial |
$482.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.88
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$482.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$304.80
|
| Rate for Payer: Health EOS Commercial |
$462.28
|
| Rate for Payer: HFN Commercial |
$482.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$203.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$203.68
|
| Rate for Payer: Multiplan Commercial |
$406.40
|
| Rate for Payer: Preferred Network Access Commercial |
$482.60
|
| Rate for Payer: Quartz Beloit One Network |
$223.52
|
| Rate for Payer: Quartz Commercial |
$289.56
|
| Rate for Payer: The Alliance Commercial |
$254.00
|
| Rate for Payer: United Healthcare Medicaid |
$59.29
|
| Rate for Payer: WEA Trust Commercial |
$279.40
|
| Rate for Payer: WPS Commercial |
$376.28
|
|
|
SPINAL WITH GENERAL ANES - SET-UP CHARGE
|
Facility
|
IP
|
$1,668.00
|
|
| Hospital Charge Code |
4519588
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$817.32 |
| Max. Negotiated Rate |
$1,534.56 |
| Rate for Payer: Aetna Commercial |
$1,501.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,434.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$884.04
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cigna Commercial |
$1,534.56
|
| Rate for Payer: Health EOS Commercial |
$1,484.52
|
| Rate for Payer: HFN Commercial |
$1,534.56
|
| Rate for Payer: Multiplan Commercial |
$1,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,000.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,534.56
|
| Rate for Payer: Quartz Beloit One Network |
$817.32
|
| Rate for Payer: Quartz Commercial |
$1,000.80
|
| Rate for Payer: WEA Trust Commercial |
$917.40
|
| Rate for Payer: WPS Commercial |
$1,235.49
|
|
|
SPINAL WITH GENERAL ANES - SET-UP CHARGE
|
Facility
|
OP
|
$1,668.00
|
|
| Hospital Charge Code |
4519588
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$467.04 |
| Max. Negotiated Rate |
$6,672.00 |
| Rate for Payer: Aetna Commercial |
$1,501.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,434.48
|
| Rate for Payer: Aetna Managed Medicare |
$467.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,084.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$834.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$800.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$884.04
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cigna Commercial |
$1,534.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$933.41
|
| Rate for Payer: Health EOS Commercial |
$1,484.52
|
| Rate for Payer: HFN Commercial |
$1,534.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,251.00
|
| Rate for Payer: Multiplan Commercial |
$1,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,000.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,534.56
|
| Rate for Payer: Quartz Beloit One Network |
$817.32
|
| Rate for Payer: Quartz Commercial |
$1,084.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,000.80
|
| Rate for Payer: The Alliance Commercial |
$6,672.00
|
| Rate for Payer: WEA Trust Commercial |
$917.40
|
| Rate for Payer: WPS Commercial |
$1,235.49
|
|
|
SPIRAL BLADE 34MM TITANIUM
|
Facility
|
OP
|
$6,225.00
|
|
| Hospital Charge Code |
2966585
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,743.00 |
| Max. Negotiated Rate |
$24,900.00 |
| Rate for Payer: Aetna Commercial |
$5,602.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,353.50
|
| Rate for Payer: Aetna Managed Medicare |
$1,743.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,046.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,112.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,988.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,299.25
|
| Rate for Payer: Cash Price |
$1,867.50
|
| Rate for Payer: Cigna Commercial |
$5,727.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,483.51
|
| Rate for Payer: Health EOS Commercial |
$5,540.25
|
| Rate for Payer: HFN Commercial |
$5,727.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,668.75
|
| Rate for Payer: Multiplan Commercial |
$4,980.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,735.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,727.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,050.25
|
| Rate for Payer: Quartz Commercial |
$4,046.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,735.00
|
| Rate for Payer: The Alliance Commercial |
$24,900.00
|
| Rate for Payer: WEA Trust Commercial |
$3,423.75
|
| Rate for Payer: WPS Commercial |
$4,610.86
|
|
|
SPIRAL BLADE 34MM TITANIUM
|
Facility
|
IP
|
$6,225.00
|
|
| Hospital Charge Code |
2966585
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,050.25 |
| Max. Negotiated Rate |
$5,727.00 |
| Rate for Payer: Aetna Commercial |
$5,602.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,353.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,299.25
|
| Rate for Payer: Cash Price |
$1,867.50
|
| Rate for Payer: Cigna Commercial |
$5,727.00
|
| Rate for Payer: Health EOS Commercial |
$5,540.25
|
| Rate for Payer: HFN Commercial |
$5,727.00
|
| Rate for Payer: Multiplan Commercial |
$4,980.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,735.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,727.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,050.25
|
| Rate for Payer: Quartz Commercial |
$3,735.00
|
| Rate for Payer: WEA Trust Commercial |
$3,423.75
|
| Rate for Payer: WPS Commercial |
$4,610.86
|
|
|
Spirometry - AMB 94010
|
Professional
|
Both
|
$197.00
|
|
|
Service Code
|
CPT 94010
|
| Hospital Charge Code |
1152822
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.87 |
| Max. Negotiated Rate |
$187.15 |
| Rate for Payer: Aetna Commercial |
$187.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.42
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$187.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$118.20
|
| Rate for Payer: Health EOS Commercial |
$179.27
|
| Rate for Payer: HFN Commercial |
$187.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$99.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$99.40
|
| Rate for Payer: Multiplan Commercial |
$157.60
|
| Rate for Payer: Preferred Network Access Commercial |
$187.15
|
| Rate for Payer: Quartz Beloit One Network |
$86.68
|
| Rate for Payer: Quartz Commercial |
$112.29
|
| Rate for Payer: The Alliance Commercial |
$98.50
|
| Rate for Payer: United Healthcare Medicaid |
$41.87
|
| Rate for Payer: WEA Trust Commercial |
$108.35
|
| Rate for Payer: WPS Commercial |
$145.92
|
|
|
Spirometry - AMB 94010 (in office)
|
Professional
|
Both
|
$253.00
|
|
|
Service Code
|
CPT 94010
|
| Hospital Charge Code |
5494672
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.87 |
| Max. Negotiated Rate |
$240.35 |
| Rate for Payer: Aetna Commercial |
$240.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.58
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$240.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.80
|
| Rate for Payer: Health EOS Commercial |
$230.23
|
| Rate for Payer: HFN Commercial |
$240.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$99.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$99.40
|
| Rate for Payer: Multiplan Commercial |
$202.40
|
| Rate for Payer: Preferred Network Access Commercial |
$240.35
|
| Rate for Payer: Quartz Beloit One Network |
$111.32
|
| Rate for Payer: Quartz Commercial |
$144.21
|
| Rate for Payer: The Alliance Commercial |
$126.50
|
| Rate for Payer: United Healthcare Medicaid |
$41.87
|
| Rate for Payer: WEA Trust Commercial |
$139.15
|
| Rate for Payer: WPS Commercial |
$187.40
|
|
|
Spirometry-Bronchospasm Eval 94060
|
Professional
|
Both
|
$215.00
|
|
|
Service Code
|
CPT 94060
|
| Hospital Charge Code |
1152823
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$52.74 |
| Max. Negotiated Rate |
$204.25 |
| Rate for Payer: Aetna Commercial |
$204.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.90
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cigna Commercial |
$204.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.00
|
| Rate for Payer: Health EOS Commercial |
$195.65
|
| Rate for Payer: HFN Commercial |
$204.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$156.63
|
| Rate for Payer: Multiplan Commercial |
$172.00
|
| Rate for Payer: Preferred Network Access Commercial |
$204.25
|
| Rate for Payer: Quartz Beloit One Network |
$94.60
|
| Rate for Payer: Quartz Commercial |
$122.55
|
| Rate for Payer: The Alliance Commercial |
$107.50
|
| Rate for Payer: United Healthcare Medicaid |
$52.74
|
| Rate for Payer: WEA Trust Commercial |
$118.25
|
| Rate for Payer: WPS Commercial |
$159.25
|
|
|
SPLENECTOMYSPLENORRHAPHY
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960385
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,248.80 |
| Max. Negotiated Rate |
$17,840.00 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,248.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,899.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,230.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,140.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,495.82
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,899.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,676.00
|
| Rate for Payer: The Alliance Commercial |
$17,840.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
SPLENECTOMYSPLENORRHAPHY
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960385
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,185.40 |
| Max. Negotiated Rate |
$4,103.20 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,676.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
SPLENIC PROCEDURES WITH CC
|
Facility
|
IP
|
$75,232.00
|
|
|
Service Code
|
MSDRG 800
|
| Min. Negotiated Rate |
$27,061.76 |
| Max. Negotiated Rate |
$75,232.00 |
| Rate for Payer: Aetna Managed Medicare |
$27,061.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59,163.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45,348.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43,083.96
|
| Rate for Payer: Anthem Medicare Advantage |
$27,061.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27,061.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27,061.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$27,061.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47,827.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$27,061.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54,945.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27,061.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27,061.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$27,061.76
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$27,061.76
|
| Rate for Payer: NAPHCARE Commercial |
$40,592.64
|
| Rate for Payer: Quartz Medicare Advantage |
$27,061.76
|
| Rate for Payer: The Alliance Commercial |
$75,232.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27,061.76
|
| Rate for Payer: United Healthcare PPO |
$42,775.50
|
| Rate for Payer: Wellcare Medicare |
$27,061.76
|
|
|
SPLENIC PROCEDURES WITH MCC
|
Facility
|
IP
|
$132,043.00
|
|
|
Service Code
|
MSDRG 799
|
| Min. Negotiated Rate |
$47,497.57 |
| Max. Negotiated Rate |
$132,043.00 |
| Rate for Payer: Aetna Managed Medicare |
$47,497.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103,851.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79,600.95
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75,626.10
|
| Rate for Payer: Anthem Medicare Advantage |
$47,497.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47,497.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47,497.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$47,497.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83,951.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$47,497.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96,614.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47,497.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47,497.57
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$47,497.57
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$47,497.57
|
| Rate for Payer: NAPHCARE Commercial |
$71,246.36
|
| Rate for Payer: Quartz Medicare Advantage |
$47,497.57
|
| Rate for Payer: The Alliance Commercial |
$132,043.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47,497.57
|
| Rate for Payer: United Healthcare PPO |
$75,215.78
|
| Rate for Payer: Wellcare Medicare |
$47,497.57
|
|
|
SPLENIC PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$47,901.00
|
|
|
Service Code
|
MSDRG 801
|
| Min. Negotiated Rate |
$17,230.70 |
| Max. Negotiated Rate |
$47,901.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,230.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37,554.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28,784.99
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,347.62
|
| Rate for Payer: Anthem Medicare Advantage |
$17,230.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,230.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,230.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,230.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30,358.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,230.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,899.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,230.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,230.70
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,230.70
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,230.70
|
| Rate for Payer: NAPHCARE Commercial |
$25,846.05
|
| Rate for Payer: Quartz Medicare Advantage |
$17,230.70
|
| Rate for Payer: The Alliance Commercial |
$47,901.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,230.70
|
| Rate for Payer: United Healthcare PPO |
$27,169.44
|
| Rate for Payer: Wellcare Medicare |
$17,230.70
|
|
|
SPLINT 1 1/4 DIGITAL 11
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
2969019
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
SPLINT 1 1/4 DIGITAL 11
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
2969019
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$516.00 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$36.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.75
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$77.40
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
SPLINT 3 1/4 DIGITAL 13
|
Facility
|
IP
|
$121.00
|
|
| Hospital Charge Code |
2969021
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$59.29 |
| Max. Negotiated Rate |
$111.32 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$72.60
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$72.60
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$89.62
|
|
|
SPLINT 3 1/4 DIGITAL 13
|
Facility
|
OP
|
$121.00
|
|
| Hospital Charge Code |
2969021
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$33.88 |
| Max. Negotiated Rate |
$484.00 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Aetna Managed Medicare |
$33.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.71
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.75
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$72.60
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$78.65
|
| Rate for Payer: Quartz Medicare Advantage |
$72.60
|
| Rate for Payer: The Alliance Commercial |
$484.00
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$89.62
|
|
|
SPLINT 3 1/4 DIGITAL/BULB 15
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
2969023
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
SPLINT 3 1/4 DIGITAL/BULB 15
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
2969023
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$516.00 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$36.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.75
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$77.40
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
SPLINT 4 1/4 DIGITAL 14
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
2969022
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
SPLINT 4 1/4 DIGITAL 14
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
2969022
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$516.00 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$36.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.75
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$77.40
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
SPLINT 4 1/4 DIGITAL/BULB 16
|
Facility
|
IP
|
$134.00
|
|
| Hospital Charge Code |
2969024
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.66 |
| Max. Negotiated Rate |
$123.28 |
| Rate for Payer: Aetna Commercial |
$120.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.02
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$123.28
|
| Rate for Payer: Health EOS Commercial |
$119.26
|
| Rate for Payer: HFN Commercial |
$123.28
|
| Rate for Payer: Multiplan Commercial |
$107.20
|
| Rate for Payer: NAPHCARE Commercial |
$80.40
|
| Rate for Payer: Preferred Network Access Commercial |
$123.28
|
| Rate for Payer: Quartz Beloit One Network |
$65.66
|
| Rate for Payer: Quartz Commercial |
$80.40
|
| Rate for Payer: WEA Trust Commercial |
$73.70
|
| Rate for Payer: WPS Commercial |
$99.25
|
|
|
SPLINT 4 1/4 DIGITAL/BULB 16
|
Facility
|
OP
|
$134.00
|
|
| Hospital Charge Code |
2969024
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.52 |
| Max. Negotiated Rate |
$536.00 |
| Rate for Payer: Aetna Commercial |
$120.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.24
|
| Rate for Payer: Aetna Managed Medicare |
$37.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.02
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$123.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.99
|
| Rate for Payer: Health EOS Commercial |
$119.26
|
| Rate for Payer: HFN Commercial |
$123.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.50
|
| Rate for Payer: Multiplan Commercial |
$107.20
|
| Rate for Payer: NAPHCARE Commercial |
$80.40
|
| Rate for Payer: Preferred Network Access Commercial |
$123.28
|
| Rate for Payer: Quartz Beloit One Network |
$65.66
|
| Rate for Payer: Quartz Commercial |
$87.10
|
| Rate for Payer: Quartz Medicare Advantage |
$80.40
|
| Rate for Payer: The Alliance Commercial |
$536.00
|
| Rate for Payer: WEA Trust Commercial |
$73.70
|
| Rate for Payer: WPS Commercial |
$99.25
|
|
|
SPLINT 5 1/4 DIGITAL/BULB 17 9119-07
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
2969025
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$516.00 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$36.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.75
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$77.40
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
