|
SWEA 99291 Critical care, evaluation and management of the critically ill or critically inj
|
Facility
|
IP
|
$1,568.00
|
|
|
Service Code
|
CPT 99291
|
| Hospital Charge Code |
3147612
|
|
Hospital Revenue Code
|
456
|
| Min. Negotiated Rate |
$799.05 |
| Max. Negotiated Rate |
$1,500.26 |
| Rate for Payer: Aetna Commercial |
$1,467.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,402.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$864.28
|
| Rate for Payer: Cash Price |
$470.40
|
| Rate for Payer: Cigna Commercial |
$1,500.26
|
| Rate for Payer: Health EOS Commercial |
$1,451.34
|
| Rate for Payer: HFN Commercial |
$1,500.26
|
| Rate for Payer: Multiplan Commercial |
$1,304.58
|
| Rate for Payer: Preferred Network Access Commercial |
$1,500.26
|
| Rate for Payer: Quartz Beloit One Network |
$799.05
|
| Rate for Payer: Quartz Commercial |
$978.43
|
| Rate for Payer: WEA Trust Commercial |
$896.90
|
| Rate for Payer: WPS Commercial |
$1,207.83
|
|
|
SWEA 99291 Critical care, evaluation and management of the critically ill or critically inj
|
Facility
|
OP
|
$1,568.00
|
|
|
Service Code
|
CPT 99291
|
| Hospital Charge Code |
3147612
|
|
Hospital Revenue Code
|
456
|
| Min. Negotiated Rate |
$108.49 |
| Max. Negotiated Rate |
$3,477.22 |
| Rate for Payer: Aetna Commercial |
$1,467.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,402.42
|
| Rate for Payer: Aetna Managed Medicare |
$869.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$606.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$447.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$426.40
|
| Rate for Payer: Anthem Medicare Advantage |
$869.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$864.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$869.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$869.30
|
| Rate for Payer: Cash Price |
$470.40
|
| Rate for Payer: Cash Price |
$470.40
|
| Rate for Payer: Cash Price |
$470.40
|
| Rate for Payer: Cigna Commercial |
$1,500.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$869.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$869.30
|
| Rate for Payer: Health EOS Commercial |
$1,451.34
|
| Rate for Payer: HFN Commercial |
$1,500.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,233.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$869.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$869.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$869.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$869.30
|
| Rate for Payer: Multiplan Commercial |
$1,304.58
|
| Rate for Payer: NAPHCARE Commercial |
$1,303.96
|
| Rate for Payer: Preferred Network Access Commercial |
$1,500.26
|
| Rate for Payer: Quartz Beloit One Network |
$799.05
|
| Rate for Payer: Quartz Commercial |
$1,059.97
|
| Rate for Payer: Quartz Medicare Advantage |
$869.30
|
| Rate for Payer: The Alliance Commercial |
$3,477.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$869.30
|
| Rate for Payer: United Healthcare PPO |
$1,223.04
|
| Rate for Payer: WEA Trust Commercial |
$896.90
|
| Rate for Payer: Wellcare Medicare |
$869.30
|
| Rate for Payer: WPS Commercial |
$1,207.83
|
|
|
SWEA 99292 Critical care, evaluation and management of the critically ill or critically inj
|
Facility
|
IP
|
$566.00
|
|
|
Service Code
|
CPT 99292
|
| Hospital Charge Code |
3147613
|
|
Hospital Revenue Code
|
456
|
| Min. Negotiated Rate |
$288.43 |
| Max. Negotiated Rate |
$541.55 |
| Rate for Payer: Aetna Commercial |
$529.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$506.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.98
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cigna Commercial |
$541.55
|
| Rate for Payer: Health EOS Commercial |
$523.89
|
| Rate for Payer: HFN Commercial |
$541.55
|
| Rate for Payer: Multiplan Commercial |
$470.91
|
| Rate for Payer: Preferred Network Access Commercial |
$541.55
|
| Rate for Payer: Quartz Beloit One Network |
$288.43
|
| Rate for Payer: Quartz Commercial |
$353.18
|
| Rate for Payer: WEA Trust Commercial |
$323.75
|
| Rate for Payer: WPS Commercial |
$435.99
|
|
|
SWEA 99292 Critical care, evaluation and management of the critically ill or critically inj
|
Facility
|
OP
|
$566.00
|
|
|
Service Code
|
CPT 99292
|
| Hospital Charge Code |
3147613
|
|
Hospital Revenue Code
|
456
|
| Min. Negotiated Rate |
$108.49 |
| Max. Negotiated Rate |
$606.32 |
| Rate for Payer: Aetna Commercial |
$529.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$506.23
|
| Rate for Payer: Aetna Managed Medicare |
$164.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$606.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$447.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$426.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.98
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cigna Commercial |
$541.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.49
|
| Rate for Payer: Health EOS Commercial |
$523.89
|
| Rate for Payer: HFN Commercial |
$541.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$441.48
|
| Rate for Payer: Multiplan Commercial |
$470.91
|
| Rate for Payer: NAPHCARE Commercial |
$353.18
|
| Rate for Payer: Preferred Network Access Commercial |
$541.55
|
| Rate for Payer: Quartz Beloit One Network |
$288.43
|
| Rate for Payer: Quartz Commercial |
$382.62
|
| Rate for Payer: Quartz Medicare Advantage |
$353.18
|
| Rate for Payer: The Alliance Commercial |
$391.71
|
| Rate for Payer: United Healthcare PPO |
$441.48
|
| Rate for Payer: WEA Trust Commercial |
$323.75
|
| Rate for Payer: WPS Commercial |
$435.99
|
|
|
SWELL SPOT DORSAL (SM) #SP-02-S
|
Facility
|
OP
|
$269.00
|
|
| Hospital Charge Code |
2970855
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.33 |
| Max. Negotiated Rate |
$257.38 |
| Rate for Payer: Aetna Commercial |
$251.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Aetna Managed Medicare |
$78.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$181.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$139.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$134.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.27
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$257.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$156.56
|
| Rate for Payer: Health EOS Commercial |
$248.99
|
| Rate for Payer: HFN Commercial |
$257.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$209.82
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: NAPHCARE Commercial |
$167.86
|
| Rate for Payer: Preferred Network Access Commercial |
$257.38
|
| Rate for Payer: Quartz Beloit One Network |
$137.08
|
| Rate for Payer: Quartz Commercial |
$181.84
|
| Rate for Payer: Quartz Medicare Advantage |
$167.86
|
| Rate for Payer: The Alliance Commercial |
$139.88
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: WPS Commercial |
$207.21
|
|
|
SWELL SPOT DORSAL (SM) #SP-02-S
|
Facility
|
IP
|
$269.00
|
|
| Hospital Charge Code |
2970855
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$137.08 |
| Max. Negotiated Rate |
$257.38 |
| Rate for Payer: Aetna Commercial |
$251.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.27
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$257.38
|
| Rate for Payer: Health EOS Commercial |
$248.99
|
| Rate for Payer: HFN Commercial |
$257.38
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: Preferred Network Access Commercial |
$257.38
|
| Rate for Payer: Quartz Beloit One Network |
$137.08
|
| Rate for Payer: Quartz Commercial |
$167.86
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: WPS Commercial |
$207.21
|
|
|
SWELL SPOTS CURVED #5609-18-03
|
Facility
|
OP
|
$430.00
|
|
| Hospital Charge Code |
2971122
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$125.22 |
| Max. Negotiated Rate |
$411.42 |
| Rate for Payer: Aetna Commercial |
$402.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.59
|
| Rate for Payer: Aetna Managed Medicare |
$125.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$290.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$223.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$214.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.02
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$411.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.26
|
| Rate for Payer: Health EOS Commercial |
$398.01
|
| Rate for Payer: HFN Commercial |
$411.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$335.40
|
| Rate for Payer: Multiplan Commercial |
$357.76
|
| Rate for Payer: NAPHCARE Commercial |
$268.32
|
| Rate for Payer: Preferred Network Access Commercial |
$411.42
|
| Rate for Payer: Quartz Beloit One Network |
$219.13
|
| Rate for Payer: Quartz Commercial |
$290.68
|
| Rate for Payer: Quartz Medicare Advantage |
$268.32
|
| Rate for Payer: The Alliance Commercial |
$223.60
|
| Rate for Payer: WEA Trust Commercial |
$245.96
|
| Rate for Payer: WPS Commercial |
$331.23
|
|
|
SWELL SPOTS CURVED #5609-18-03
|
Facility
|
IP
|
$430.00
|
|
| Hospital Charge Code |
2971122
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$219.13 |
| Max. Negotiated Rate |
$411.42 |
| Rate for Payer: Aetna Commercial |
$402.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.02
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$411.42
|
| Rate for Payer: Health EOS Commercial |
$398.01
|
| Rate for Payer: HFN Commercial |
$411.42
|
| Rate for Payer: Multiplan Commercial |
$357.76
|
| Rate for Payer: Preferred Network Access Commercial |
$411.42
|
| Rate for Payer: Quartz Beloit One Network |
$219.13
|
| Rate for Payer: Quartz Commercial |
$268.32
|
| Rate for Payer: WEA Trust Commercial |
$245.96
|
| Rate for Payer: WPS Commercial |
$331.23
|
|
|
SWELL SPOTS DORSAL (SMALL) #5609-18-01
|
Facility
|
IP
|
$430.00
|
|
| Hospital Charge Code |
2971121
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$219.13 |
| Max. Negotiated Rate |
$411.42 |
| Rate for Payer: Aetna Commercial |
$402.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.02
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$411.42
|
| Rate for Payer: Health EOS Commercial |
$398.01
|
| Rate for Payer: HFN Commercial |
$411.42
|
| Rate for Payer: Multiplan Commercial |
$357.76
|
| Rate for Payer: Preferred Network Access Commercial |
$411.42
|
| Rate for Payer: Quartz Beloit One Network |
$219.13
|
| Rate for Payer: Quartz Commercial |
$268.32
|
| Rate for Payer: WEA Trust Commercial |
$245.96
|
| Rate for Payer: WPS Commercial |
$331.23
|
|
|
SWELL SPOTS DORSAL (SMALL) #5609-18-01
|
Facility
|
OP
|
$430.00
|
|
| Hospital Charge Code |
2971121
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$125.22 |
| Max. Negotiated Rate |
$411.42 |
| Rate for Payer: Aetna Commercial |
$402.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.59
|
| Rate for Payer: Aetna Managed Medicare |
$125.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$290.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$223.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$214.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.02
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$411.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.26
|
| Rate for Payer: Health EOS Commercial |
$398.01
|
| Rate for Payer: HFN Commercial |
$411.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$335.40
|
| Rate for Payer: Multiplan Commercial |
$357.76
|
| Rate for Payer: NAPHCARE Commercial |
$268.32
|
| Rate for Payer: Preferred Network Access Commercial |
$411.42
|
| Rate for Payer: Quartz Beloit One Network |
$219.13
|
| Rate for Payer: Quartz Commercial |
$290.68
|
| Rate for Payer: Quartz Medicare Advantage |
$268.32
|
| Rate for Payer: The Alliance Commercial |
$223.60
|
| Rate for Payer: WEA Trust Commercial |
$245.96
|
| Rate for Payer: WPS Commercial |
$331.23
|
|
|
SWELL SPOTS KATINA (SMALL) #5609-18-04
|
Facility
|
IP
|
$476.00
|
|
| Hospital Charge Code |
2971283
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$242.57 |
| Max. Negotiated Rate |
$455.44 |
| Rate for Payer: Aetna Commercial |
$445.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.37
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cigna Commercial |
$455.44
|
| Rate for Payer: Health EOS Commercial |
$440.59
|
| Rate for Payer: HFN Commercial |
$455.44
|
| Rate for Payer: Multiplan Commercial |
$396.03
|
| Rate for Payer: Preferred Network Access Commercial |
$455.44
|
| Rate for Payer: Quartz Beloit One Network |
$242.57
|
| Rate for Payer: Quartz Commercial |
$297.02
|
| Rate for Payer: WEA Trust Commercial |
$272.27
|
| Rate for Payer: WPS Commercial |
$366.66
|
|
|
SWELL SPOTS KATINA (SMALL) #5609-18-04
|
Facility
|
OP
|
$476.00
|
|
| Hospital Charge Code |
2971283
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$138.61 |
| Max. Negotiated Rate |
$455.44 |
| Rate for Payer: Aetna Commercial |
$445.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.73
|
| Rate for Payer: Aetna Managed Medicare |
$138.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$321.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$247.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$237.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.37
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cigna Commercial |
$455.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$277.03
|
| Rate for Payer: Health EOS Commercial |
$440.59
|
| Rate for Payer: HFN Commercial |
$455.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$371.28
|
| Rate for Payer: Multiplan Commercial |
$396.03
|
| Rate for Payer: NAPHCARE Commercial |
$297.02
|
| Rate for Payer: Preferred Network Access Commercial |
$455.44
|
| Rate for Payer: Quartz Beloit One Network |
$242.57
|
| Rate for Payer: Quartz Commercial |
$321.78
|
| Rate for Payer: Quartz Medicare Advantage |
$297.02
|
| Rate for Payer: The Alliance Commercial |
$247.52
|
| Rate for Payer: WEA Trust Commercial |
$272.27
|
| Rate for Payer: WPS Commercial |
$366.66
|
|
|
SWELL SPOTS PALMER (SM) #SP-03-S
|
Facility
|
IP
|
$269.00
|
|
| Hospital Charge Code |
2971025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$137.08 |
| Max. Negotiated Rate |
$257.38 |
| Rate for Payer: Aetna Commercial |
$251.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.27
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$257.38
|
| Rate for Payer: Health EOS Commercial |
$248.99
|
| Rate for Payer: HFN Commercial |
$257.38
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: Preferred Network Access Commercial |
$257.38
|
| Rate for Payer: Quartz Beloit One Network |
$137.08
|
| Rate for Payer: Quartz Commercial |
$167.86
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: WPS Commercial |
$207.21
|
|
|
SWELL SPOTS PALMER (SM) #SP-03-S
|
Facility
|
OP
|
$269.00
|
|
| Hospital Charge Code |
2971025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.33 |
| Max. Negotiated Rate |
$257.38 |
| Rate for Payer: Aetna Commercial |
$251.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Aetna Managed Medicare |
$78.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$181.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$139.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$134.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.27
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$257.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$156.56
|
| Rate for Payer: Health EOS Commercial |
$248.99
|
| Rate for Payer: HFN Commercial |
$257.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$209.82
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: NAPHCARE Commercial |
$167.86
|
| Rate for Payer: Preferred Network Access Commercial |
$257.38
|
| Rate for Payer: Quartz Beloit One Network |
$137.08
|
| Rate for Payer: Quartz Commercial |
$181.84
|
| Rate for Payer: Quartz Medicare Advantage |
$167.86
|
| Rate for Payer: The Alliance Commercial |
$139.88
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: WPS Commercial |
$207.21
|
|
|
Syfovre (pegcetacoplan) Ophthalmic 15mg/0.1 mL
|
Professional
|
Both
|
$354.00
|
|
|
Service Code
|
HCPCS C9151
|
| Hospital Charge Code |
6219274
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$161.99 |
| Max. Negotiated Rate |
$349.75 |
| Rate for Payer: Aetna Commercial |
$349.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$349.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$184.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$220.90
|
| Rate for Payer: Health EOS Commercial |
$335.03
|
| Rate for Payer: HFN Commercial |
$349.75
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: Preferred Network Access Commercial |
$349.75
|
| Rate for Payer: Quartz Beloit One Network |
$161.99
|
| Rate for Payer: Quartz Commercial |
$209.85
|
| Rate for Payer: The Alliance Commercial |
$184.08
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
Syfovre (pegcetacoplan) Ophthalmic 15mg/0.1 mL
|
Facility
|
OP
|
$354.00
|
|
|
Service Code
|
HCPCS C9151
|
| Hospital Charge Code |
6219274
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$103.08 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Aetna Managed Medicare |
$103.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.03
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.12
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: NAPHCARE Commercial |
$220.90
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$239.30
|
| Rate for Payer: Quartz Medicare Advantage |
$220.90
|
| Rate for Payer: The Alliance Commercial |
$184.08
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
Syfovre (pegcetacoplan) Ophthalmic 15mg/0.1 mL
|
Facility
|
IP
|
$354.00
|
|
|
Service Code
|
HCPCS C9151
|
| Hospital Charge Code |
6219274
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$180.40 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$220.90
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$5,874.77
|
|
|
Service Code
|
APR-DRG 2041
|
| Min. Negotiated Rate |
$5,218.34 |
| Max. Negotiated Rate |
$5,874.77 |
| Rate for Payer: Anthem Medicaid |
$5,625.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,625.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,625.41
|
| Rate for Payer: Dean Health Medicaid |
$5,625.41
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,218.34
|
| Rate for Payer: Managed Health Services Medicaid |
$5,874.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,625.41
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,625.41
|
| Rate for Payer: United Healthcare Medicaid |
$5,625.41
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$24,208.08
|
|
|
Service Code
|
MSDRG 312
|
| Min. Negotiated Rate |
$7,181.66 |
| Max. Negotiated Rate |
$24,208.08 |
| Rate for Payer: Aetna Managed Medicare |
$7,181.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,017.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,576.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,848.96
|
| Rate for Payer: Anthem Medicare Advantage |
$7,181.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,181.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,181.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,181.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,373.61
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,181.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,511.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,181.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,181.66
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,181.66
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,181.66
|
| Rate for Payer: NAPHCARE Commercial |
$10,772.49
|
| Rate for Payer: Quartz Medicare Advantage |
$7,181.66
|
| Rate for Payer: The Alliance Commercial |
$24,208.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,181.66
|
| Rate for Payer: United Healthcare PPO |
$13,633.14
|
| Rate for Payer: Wellcare Medicare |
$7,181.66
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$13,678.56
|
|
|
Service Code
|
APR-DRG 2044
|
| Min. Negotiated Rate |
$12,150.15 |
| Max. Negotiated Rate |
$13,678.56 |
| Rate for Payer: Anthem Medicaid |
$13,097.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$13,097.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13,097.98
|
| Rate for Payer: Dean Health Medicaid |
$13,097.98
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12,150.15
|
| Rate for Payer: Managed Health Services Medicaid |
$13,678.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,097.98
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13,097.98
|
| Rate for Payer: United Healthcare Medicaid |
$13,097.98
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$8,505.26
|
|
|
Service Code
|
APR-DRG 2043
|
| Min. Negotiated Rate |
$7,554.90 |
| Max. Negotiated Rate |
$8,505.26 |
| Rate for Payer: Anthem Medicaid |
$8,144.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,144.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,144.26
|
| Rate for Payer: Dean Health Medicaid |
$8,144.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,554.90
|
| Rate for Payer: Managed Health Services Medicaid |
$8,505.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,144.26
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,144.26
|
| Rate for Payer: United Healthcare Medicaid |
$8,144.26
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
OP
|
$107.44
|
|
|
Service Code
|
EAPG 00605
|
| Min. Negotiated Rate |
$103.31 |
| Max. Negotiated Rate |
$107.44 |
| Rate for Payer: Anthem Medicaid |
$103.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$103.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$103.31
|
| Rate for Payer: Dean Health Medicaid |
$103.31
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$103.31
|
| Rate for Payer: Managed Health Services Medicaid |
$107.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$103.31
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$103.31
|
| Rate for Payer: United Healthcare Medicaid |
$103.31
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$6,663.92
|
|
|
Service Code
|
APR-DRG 2042
|
| Min. Negotiated Rate |
$5,919.31 |
| Max. Negotiated Rate |
$6,663.92 |
| Rate for Payer: Anthem Medicaid |
$6,381.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,381.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,381.07
|
| Rate for Payer: Dean Health Medicaid |
$6,381.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,919.31
|
| Rate for Payer: Managed Health Services Medicaid |
$6,663.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,381.07
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,381.07
|
| Rate for Payer: United Healthcare Medicaid |
$6,381.07
|
|
|
SYNDACTYLY
|
Facility
|
OP
|
$1,242.00
|
|
| Hospital Charge Code |
2960400
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$361.67 |
| Max. Negotiated Rate |
$1,188.35 |
| Rate for Payer: Aetna Commercial |
$1,162.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,110.84
|
| Rate for Payer: Aetna Managed Medicare |
$361.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$839.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$645.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$620.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$684.59
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$1,188.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$722.84
|
| Rate for Payer: Health EOS Commercial |
$1,149.60
|
| Rate for Payer: HFN Commercial |
$1,188.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$968.76
|
| Rate for Payer: Multiplan Commercial |
$1,033.34
|
| Rate for Payer: NAPHCARE Commercial |
$775.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,188.35
|
| Rate for Payer: Quartz Beloit One Network |
$632.92
|
| Rate for Payer: Quartz Commercial |
$839.59
|
| Rate for Payer: Quartz Medicare Advantage |
$775.01
|
| Rate for Payer: The Alliance Commercial |
$645.84
|
| Rate for Payer: WEA Trust Commercial |
$710.42
|
| Rate for Payer: WPS Commercial |
$956.71
|
|
|
SYNDACTYLY
|
Facility
|
IP
|
$1,242.00
|
|
| Hospital Charge Code |
2960400
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$632.92 |
| Max. Negotiated Rate |
$1,188.35 |
| Rate for Payer: Aetna Commercial |
$1,162.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,110.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$684.59
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$1,188.35
|
| Rate for Payer: Health EOS Commercial |
$1,149.60
|
| Rate for Payer: HFN Commercial |
$1,188.35
|
| Rate for Payer: Multiplan Commercial |
$1,033.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,188.35
|
| Rate for Payer: Quartz Beloit One Network |
$632.92
|
| Rate for Payer: Quartz Commercial |
$775.01
|
| Rate for Payer: WEA Trust Commercial |
$710.42
|
| Rate for Payer: WPS Commercial |
$956.71
|
|
