|
TRACH BLUE RHINO G2 W/JACKSON SZ 6 SHILEY FLEX TRACH TUBE G57716
|
Facility
|
IP
|
$3,659.00
|
|
| Hospital Charge Code |
5617788
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,864.63 |
| Max. Negotiated Rate |
$3,500.93 |
| Rate for Payer: Aetna Commercial |
$3,424.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,272.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,016.84
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,500.93
|
| Rate for Payer: Health EOS Commercial |
$3,386.77
|
| Rate for Payer: HFN Commercial |
$3,500.93
|
| Rate for Payer: Multiplan Commercial |
$3,044.29
|
| Rate for Payer: Preferred Network Access Commercial |
$3,500.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,864.63
|
| Rate for Payer: Quartz Commercial |
$2,283.22
|
| Rate for Payer: WEA Trust Commercial |
$2,092.95
|
| Rate for Payer: WPS Commercial |
$2,818.53
|
|
|
TRACH BLUE RHINO G2 W/JACKSON SZ 6 SHILEY FLEX TRACH TUBE G57716
|
Facility
|
OP
|
$3,659.00
|
|
| Hospital Charge Code |
5617788
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,065.50 |
| Max. Negotiated Rate |
$3,500.93 |
| Rate for Payer: Aetna Commercial |
$3,424.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,272.61
|
| Rate for Payer: Aetna Managed Medicare |
$1,065.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,473.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,902.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,826.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,016.84
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,500.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,129.54
|
| Rate for Payer: Health EOS Commercial |
$3,386.77
|
| Rate for Payer: HFN Commercial |
$3,500.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,854.02
|
| Rate for Payer: Multiplan Commercial |
$3,044.29
|
| Rate for Payer: NAPHCARE Commercial |
$2,283.22
|
| Rate for Payer: Preferred Network Access Commercial |
$3,500.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,864.63
|
| Rate for Payer: Quartz Commercial |
$2,473.48
|
| Rate for Payer: Quartz Medicare Advantage |
$2,283.22
|
| Rate for Payer: The Alliance Commercial |
$1,902.68
|
| Rate for Payer: WEA Trust Commercial |
$2,092.95
|
| Rate for Payer: WPS Commercial |
$2,818.53
|
|
|
TRACH BLUE RHINO G2 W/JACKSON SZ 8 SHILEY FLEX TRACH TUBE G57717
|
Facility
|
IP
|
$3,659.00
|
|
| Hospital Charge Code |
5617789
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,864.63 |
| Max. Negotiated Rate |
$3,500.93 |
| Rate for Payer: Aetna Commercial |
$3,424.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,272.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,016.84
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,500.93
|
| Rate for Payer: Health EOS Commercial |
$3,386.77
|
| Rate for Payer: HFN Commercial |
$3,500.93
|
| Rate for Payer: Multiplan Commercial |
$3,044.29
|
| Rate for Payer: Preferred Network Access Commercial |
$3,500.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,864.63
|
| Rate for Payer: Quartz Commercial |
$2,283.22
|
| Rate for Payer: WEA Trust Commercial |
$2,092.95
|
| Rate for Payer: WPS Commercial |
$2,818.53
|
|
|
TRACH BLUE RHINO G2 W/JACKSON SZ 8 SHILEY FLEX TRACH TUBE G57717
|
Facility
|
OP
|
$3,659.00
|
|
| Hospital Charge Code |
5617789
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,065.50 |
| Max. Negotiated Rate |
$3,500.93 |
| Rate for Payer: Aetna Commercial |
$3,424.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,272.61
|
| Rate for Payer: Aetna Managed Medicare |
$1,065.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,473.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,902.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,826.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,016.84
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,500.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,129.54
|
| Rate for Payer: Health EOS Commercial |
$3,386.77
|
| Rate for Payer: HFN Commercial |
$3,500.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,854.02
|
| Rate for Payer: Multiplan Commercial |
$3,044.29
|
| Rate for Payer: NAPHCARE Commercial |
$2,283.22
|
| Rate for Payer: Preferred Network Access Commercial |
$3,500.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,864.63
|
| Rate for Payer: Quartz Commercial |
$2,473.48
|
| Rate for Payer: Quartz Medicare Advantage |
$2,283.22
|
| Rate for Payer: The Alliance Commercial |
$1,902.68
|
| Rate for Payer: WEA Trust Commercial |
$2,092.95
|
| Rate for Payer: WPS Commercial |
$2,818.53
|
|
|
TRACH CUFF FLEX SHILEY 8CN85H
|
Facility
|
OP
|
$2,086.00
|
|
| Hospital Charge Code |
5415936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$607.44 |
| Max. Negotiated Rate |
$1,995.88 |
| Rate for Payer: Aetna Commercial |
$1,952.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,865.72
|
| Rate for Payer: Aetna Managed Medicare |
$607.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,410.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,084.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,041.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,149.80
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,995.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,214.05
|
| Rate for Payer: Health EOS Commercial |
$1,930.80
|
| Rate for Payer: HFN Commercial |
$1,995.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,627.08
|
| Rate for Payer: Multiplan Commercial |
$1,735.55
|
| Rate for Payer: NAPHCARE Commercial |
$1,301.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,995.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,063.03
|
| Rate for Payer: Quartz Commercial |
$1,410.14
|
| Rate for Payer: Quartz Medicare Advantage |
$1,301.66
|
| Rate for Payer: The Alliance Commercial |
$1,084.72
|
| Rate for Payer: WEA Trust Commercial |
$1,193.19
|
| Rate for Payer: WPS Commercial |
$1,606.85
|
|
|
TRACH CUFF FLEX SHILEY 8CN85H
|
Facility
|
IP
|
$2,086.00
|
|
| Hospital Charge Code |
5415936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,063.03 |
| Max. Negotiated Rate |
$1,995.88 |
| Rate for Payer: Aetna Commercial |
$1,952.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,865.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,149.80
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,995.88
|
| Rate for Payer: Health EOS Commercial |
$1,930.80
|
| Rate for Payer: HFN Commercial |
$1,995.88
|
| Rate for Payer: Multiplan Commercial |
$1,735.55
|
| Rate for Payer: Preferred Network Access Commercial |
$1,995.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,063.03
|
| Rate for Payer: Quartz Commercial |
$1,301.66
|
| Rate for Payer: WEA Trust Commercial |
$1,193.19
|
| Rate for Payer: WPS Commercial |
$1,606.85
|
|
|
TRACHEAL TUBE 8.0MM UNCUFFED 504080
|
Facility
|
IP
|
$514.00
|
|
| Hospital Charge Code |
2963739
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.93 |
| Max. Negotiated Rate |
$491.80 |
| Rate for Payer: Aetna Commercial |
$481.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$459.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.32
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$491.80
|
| Rate for Payer: Health EOS Commercial |
$475.76
|
| Rate for Payer: HFN Commercial |
$491.80
|
| Rate for Payer: Multiplan Commercial |
$427.65
|
| Rate for Payer: Preferred Network Access Commercial |
$491.80
|
| Rate for Payer: Quartz Beloit One Network |
$261.93
|
| Rate for Payer: Quartz Commercial |
$320.74
|
| Rate for Payer: WEA Trust Commercial |
$294.01
|
| Rate for Payer: WPS Commercial |
$395.93
|
|
|
TRACHEAL TUBE 8.0MM UNCUFFED 504080
|
Facility
|
OP
|
$514.00
|
|
| Hospital Charge Code |
2963739
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.68 |
| Max. Negotiated Rate |
$491.80 |
| Rate for Payer: Aetna Commercial |
$481.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$459.72
|
| Rate for Payer: Aetna Managed Medicare |
$149.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$347.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$267.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$256.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.32
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$491.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$299.15
|
| Rate for Payer: Health EOS Commercial |
$475.76
|
| Rate for Payer: HFN Commercial |
$491.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$400.92
|
| Rate for Payer: Multiplan Commercial |
$427.65
|
| Rate for Payer: NAPHCARE Commercial |
$320.74
|
| Rate for Payer: Preferred Network Access Commercial |
$491.80
|
| Rate for Payer: Quartz Beloit One Network |
$261.93
|
| Rate for Payer: Quartz Commercial |
$347.46
|
| Rate for Payer: Quartz Medicare Advantage |
$320.74
|
| Rate for Payer: The Alliance Commercial |
$267.28
|
| Rate for Payer: WEA Trust Commercial |
$294.01
|
| Rate for Payer: WPS Commercial |
$395.93
|
|
|
TRACHEOSTOMY
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960448
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
TRACHEOSTOMY
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960448
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
TRACHEOSTOMY AND RELATED TRACHEAL PROCEDURES
|
Facility
|
OP
|
$1,426.92
|
|
|
Service Code
|
EAPG 00072
|
| Min. Negotiated Rate |
$1,372.03 |
| Max. Negotiated Rate |
$1,426.92 |
| Rate for Payer: Anthem Medicaid |
$1,372.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$1,372.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,372.03
|
| Rate for Payer: Dean Health Medicaid |
$1,372.03
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$1,372.03
|
| Rate for Payer: Managed Health Services Medicaid |
$1,426.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,372.03
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$1,372.03
|
| Rate for Payer: United Healthcare Medicaid |
$1,372.03
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC
|
Facility
|
IP
|
$111,066.80
|
|
|
Service Code
|
MSDRG 012
|
| Min. Negotiated Rate |
$32,793.74 |
| Max. Negotiated Rate |
$111,066.80 |
| Rate for Payer: Aetna Managed Medicare |
$32,793.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$91,989.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$70,509.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66,988.53
|
| Rate for Payer: Anthem Medicare Advantage |
$32,793.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32,793.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32,793.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$32,793.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74,363.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$32,793.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81,219.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32,793.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32,793.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$32,793.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$32,793.74
|
| Rate for Payer: NAPHCARE Commercial |
$49,190.61
|
| Rate for Payer: Quartz Medicare Advantage |
$32,793.74
|
| Rate for Payer: The Alliance Commercial |
$111,066.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32,793.74
|
| Rate for Payer: United Healthcare PPO |
$63,230.33
|
| Rate for Payer: Wellcare Medicare |
$32,793.74
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC
|
Facility
|
IP
|
$142,902.24
|
|
|
Service Code
|
MSDRG 011
|
| Min. Negotiated Rate |
$42,275.34 |
| Max. Negotiated Rate |
$142,902.24 |
| Rate for Payer: Aetna Managed Medicare |
$42,275.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$119,004.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91,215.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$86,660.85
|
| Rate for Payer: Anthem Medicare Advantage |
$42,275.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$42,275.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$42,275.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$42,275.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96,201.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$42,275.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$104,569.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42,275.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$42,275.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$42,275.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$42,275.34
|
| Rate for Payer: NAPHCARE Commercial |
$63,413.02
|
| Rate for Payer: Quartz Medicare Advantage |
$42,275.34
|
| Rate for Payer: The Alliance Commercial |
$142,902.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42,275.34
|
| Rate for Payer: United Healthcare PPO |
$81,408.90
|
| Rate for Payer: Wellcare Medicare |
$42,275.34
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC
|
Facility
|
IP
|
$74,590.88
|
|
|
Service Code
|
MSDRG 013
|
| Min. Negotiated Rate |
$22,576.17 |
| Max. Negotiated Rate |
$74,590.88 |
| Rate for Payer: Aetna Managed Medicare |
$22,576.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62,878.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48,195.91
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45,789.27
|
| Rate for Payer: Anthem Medicare Advantage |
$22,576.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22,576.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22,576.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$22,576.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50,830.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$22,576.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54,466.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22,576.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22,576.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$22,576.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$22,576.17
|
| Rate for Payer: NAPHCARE Commercial |
$33,864.26
|
| Rate for Payer: Quartz Medicare Advantage |
$22,576.17
|
| Rate for Payer: The Alliance Commercial |
$74,590.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22,576.17
|
| Rate for Payer: United Healthcare PPO |
$42,402.47
|
| Rate for Payer: Wellcare Medicare |
$22,576.17
|
|
|
Tracheostomy speaking valve - Equipment/Device Used
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS L8501
|
| Hospital Charge Code |
3008019
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$113.32 |
| Max. Negotiated Rate |
$1,090.75 |
| Rate for Payer: Aetna Commercial |
$1,067.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,019.62
|
| Rate for Payer: Aetna Managed Medicare |
$331.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$113.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$113.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$113.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$628.37
|
| Rate for Payer: Cash Price |
$342.00
|
| Rate for Payer: Cash Price |
$342.00
|
| Rate for Payer: Cigna Commercial |
$1,090.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$663.48
|
| Rate for Payer: Health EOS Commercial |
$1,055.18
|
| Rate for Payer: HFN Commercial |
$1,090.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$889.20
|
| Rate for Payer: Multiplan Commercial |
$948.48
|
| Rate for Payer: NAPHCARE Commercial |
$711.36
|
| Rate for Payer: Preferred Network Access Commercial |
$1,090.75
|
| Rate for Payer: Quartz Beloit One Network |
$580.94
|
| Rate for Payer: Quartz Commercial |
$770.64
|
| Rate for Payer: Quartz Medicare Advantage |
$711.36
|
| Rate for Payer: The Alliance Commercial |
$615.18
|
| Rate for Payer: WEA Trust Commercial |
$652.08
|
| Rate for Payer: WPS Commercial |
$878.14
|
|
|
Tracheostomy speaking valve - Equipment/Device Used
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS L8501
|
| Hospital Charge Code |
3008019
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$580.94 |
| Max. Negotiated Rate |
$1,090.75 |
| Rate for Payer: Aetna Commercial |
$1,067.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,019.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$628.37
|
| Rate for Payer: Cash Price |
$342.00
|
| Rate for Payer: Cigna Commercial |
$1,090.75
|
| Rate for Payer: Health EOS Commercial |
$1,055.18
|
| Rate for Payer: HFN Commercial |
$1,090.75
|
| Rate for Payer: Multiplan Commercial |
$948.48
|
| Rate for Payer: Preferred Network Access Commercial |
$1,090.75
|
| Rate for Payer: Quartz Beloit One Network |
$580.94
|
| Rate for Payer: Quartz Commercial |
$711.36
|
| Rate for Payer: WEA Trust Commercial |
$652.08
|
| Rate for Payer: WPS Commercial |
$878.14
|
|
|
TRACHEOSTOMY TUBE SHILEY SZ 8
|
Facility
|
OP
|
$1,135.00
|
|
| Hospital Charge Code |
2965406
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.51 |
| Max. Negotiated Rate |
$1,085.97 |
| Rate for Payer: Aetna Commercial |
$1,062.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,015.14
|
| Rate for Payer: Aetna Managed Medicare |
$330.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$767.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$590.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$566.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.61
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cigna Commercial |
$1,085.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$660.57
|
| Rate for Payer: Health EOS Commercial |
$1,050.56
|
| Rate for Payer: HFN Commercial |
$1,085.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$885.30
|
| Rate for Payer: Multiplan Commercial |
$944.32
|
| Rate for Payer: NAPHCARE Commercial |
$708.24
|
| Rate for Payer: Preferred Network Access Commercial |
$1,085.97
|
| Rate for Payer: Quartz Beloit One Network |
$578.40
|
| Rate for Payer: Quartz Commercial |
$767.26
|
| Rate for Payer: Quartz Medicare Advantage |
$708.24
|
| Rate for Payer: The Alliance Commercial |
$590.20
|
| Rate for Payer: WEA Trust Commercial |
$649.22
|
| Rate for Payer: WPS Commercial |
$874.29
|
|
|
TRACHEOSTOMY TUBE SHILEY SZ 8
|
Facility
|
IP
|
$1,135.00
|
|
| Hospital Charge Code |
2965406
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$578.40 |
| Max. Negotiated Rate |
$1,085.97 |
| Rate for Payer: Aetna Commercial |
$1,062.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,015.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.61
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cigna Commercial |
$1,085.97
|
| Rate for Payer: Health EOS Commercial |
$1,050.56
|
| Rate for Payer: HFN Commercial |
$1,085.97
|
| Rate for Payer: Multiplan Commercial |
$944.32
|
| Rate for Payer: Preferred Network Access Commercial |
$1,085.97
|
| Rate for Payer: Quartz Beloit One Network |
$578.40
|
| Rate for Payer: Quartz Commercial |
$708.24
|
| Rate for Payer: WEA Trust Commercial |
$649.22
|
| Rate for Payer: WPS Commercial |
$874.29
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES
|
Facility
|
IP
|
$406,779.36
|
|
|
Service Code
|
MSDRG 004
|
| Min. Negotiated Rate |
$106,583.52 |
| Max. Negotiated Rate |
$406,779.36 |
| Rate for Payer: Aetna Managed Medicare |
$106,583.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$302,226.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$231,654.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$220,086.56
|
| Rate for Payer: Anthem Medicare Advantage |
$106,583.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$106,583.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$106,583.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$106,583.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$244,316.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$106,583.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$298,116.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$106,583.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$106,583.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$106,583.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$106,583.52
|
| Rate for Payer: NAPHCARE Commercial |
$159,875.27
|
| Rate for Payer: Quartz Medicare Advantage |
$106,583.52
|
| Rate for Payer: The Alliance Commercial |
$406,779.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$106,583.52
|
| Rate for Payer: United Healthcare PPO |
$232,087.13
|
| Rate for Payer: Wellcare Medicare |
$106,583.52
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$155,900.55
|
|
|
Service Code
|
APR-DRG 0044
|
| Min. Negotiated Rate |
$138,480.60 |
| Max. Negotiated Rate |
$155,900.55 |
| Rate for Payer: Anthem Medicaid |
$149,283.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$149,283.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$149,283.37
|
| Rate for Payer: Dean Health Medicaid |
$149,283.37
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$138,480.60
|
| Rate for Payer: Managed Health Services Medicaid |
$155,900.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$149,283.37
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$149,283.37
|
| Rate for Payer: United Healthcare Medicaid |
$149,283.37
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$107,499.48
|
|
|
Service Code
|
APR-DRG 0043
|
| Min. Negotiated Rate |
$95,487.75 |
| Max. Negotiated Rate |
$107,499.48 |
| Rate for Payer: Anthem Medicaid |
$102,936.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$102,936.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$102,936.68
|
| Rate for Payer: Dean Health Medicaid |
$102,936.68
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$95,487.75
|
| Rate for Payer: Managed Health Services Medicaid |
$107,499.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$102,936.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$102,936.68
|
| Rate for Payer: United Healthcare Medicaid |
$102,936.68
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$47,524.24
|
|
|
Service Code
|
APR-DRG 0041
|
| Min. Negotiated Rate |
$42,214.00 |
| Max. Negotiated Rate |
$47,524.24 |
| Rate for Payer: Anthem Medicaid |
$45,507.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$45,507.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45,507.08
|
| Rate for Payer: Dean Health Medicaid |
$45,507.08
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$42,214.00
|
| Rate for Payer: Managed Health Services Medicaid |
$47,524.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$45,507.08
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$45,507.08
|
| Rate for Payer: United Healthcare Medicaid |
$45,507.08
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$68,655.87
|
|
|
Service Code
|
APR-DRG 0042
|
| Min. Negotiated Rate |
$60,984.42 |
| Max. Negotiated Rate |
$68,655.87 |
| Rate for Payer: Anthem Medicaid |
$65,741.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$65,741.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$65,741.78
|
| Rate for Payer: Dean Health Medicaid |
$65,741.78
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$60,984.42
|
| Rate for Payer: Managed Health Services Medicaid |
$68,655.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$65,741.78
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$65,741.78
|
| Rate for Payer: United Healthcare Medicaid |
$65,741.78
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$27,620.18
|
|
|
Service Code
|
APR-DRG 0051
|
| Min. Negotiated Rate |
$24,533.96 |
| Max. Negotiated Rate |
$27,620.18 |
| Rate for Payer: Anthem Medicaid |
$26,447.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$26,447.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26,447.84
|
| Rate for Payer: Dean Health Medicaid |
$26,447.84
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$24,533.96
|
| Rate for Payer: Managed Health Services Medicaid |
$27,620.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,447.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26,447.84
|
| Rate for Payer: United Healthcare Medicaid |
$26,447.84
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$108,551.68
|
|
|
Service Code
|
APR-DRG 0054
|
| Min. Negotiated Rate |
$96,422.37 |
| Max. Negotiated Rate |
$108,551.68 |
| Rate for Payer: Anthem Medicaid |
$103,944.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$103,944.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$103,944.21
|
| Rate for Payer: Dean Health Medicaid |
$103,944.21
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$96,422.37
|
| Rate for Payer: Managed Health Services Medicaid |
$108,551.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$103,944.21
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$103,944.21
|
| Rate for Payer: United Healthcare Medicaid |
$103,944.21
|
|
