|
Clarient, M/PH Alys
|
Facility
|
OP
|
$602.00
|
|
|
Service Code
|
CPT 88374
|
| Hospital Charge Code |
4590609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$179.30 |
| Max. Negotiated Rate |
$717.18 |
| Rate for Payer: Aetna Commercial |
$563.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.43
|
| Rate for Payer: Aetna Managed Medicare |
$179.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$658.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$291.45
|
| Rate for Payer: Anthem Medicare Advantage |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$179.30
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$575.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$179.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$350.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$179.30
|
| Rate for Payer: Health EOS Commercial |
$557.21
|
| Rate for Payer: HFN Commercial |
$575.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$179.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$179.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$179.30
|
| Rate for Payer: Multiplan Commercial |
$500.86
|
| Rate for Payer: NAPHCARE Commercial |
$268.94
|
| Rate for Payer: Preferred Network Access Commercial |
$575.99
|
| Rate for Payer: Quartz Beloit One Network |
$306.78
|
| Rate for Payer: Quartz Commercial |
$406.95
|
| Rate for Payer: Quartz Medicare Advantage |
$179.30
|
| Rate for Payer: The Alliance Commercial |
$717.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$179.30
|
| Rate for Payer: United Healthcare PPO |
$469.56
|
| Rate for Payer: WEA Trust Commercial |
$344.34
|
| Rate for Payer: Wellcare Medicare |
$179.30
|
| Rate for Payer: WPS Commercial |
$463.72
|
|
|
Clarient, M/Phmtrc Alys
|
Facility
|
IP
|
$725.00
|
|
|
Service Code
|
CPT 88374
|
| Hospital Charge Code |
4856606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$369.46 |
| Max. Negotiated Rate |
$693.68 |
| Rate for Payer: Aetna Commercial |
$678.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$648.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$399.62
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$693.68
|
| Rate for Payer: Health EOS Commercial |
$671.06
|
| Rate for Payer: HFN Commercial |
$693.68
|
| Rate for Payer: Multiplan Commercial |
$603.20
|
| Rate for Payer: Preferred Network Access Commercial |
$693.68
|
| Rate for Payer: Quartz Beloit One Network |
$369.46
|
| Rate for Payer: Quartz Commercial |
$452.40
|
| Rate for Payer: WEA Trust Commercial |
$414.70
|
| Rate for Payer: WPS Commercial |
$558.47
|
|
|
Clarient, M/Phmtrc Alys
|
Facility
|
OP
|
$725.00
|
|
|
Service Code
|
CPT 88374
|
| Hospital Charge Code |
4856606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$179.30 |
| Max. Negotiated Rate |
$717.18 |
| Rate for Payer: Aetna Commercial |
$678.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$648.44
|
| Rate for Payer: Aetna Managed Medicare |
$179.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$658.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$291.45
|
| Rate for Payer: Anthem Medicare Advantage |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$399.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$179.30
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$693.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$179.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$421.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$179.30
|
| Rate for Payer: Health EOS Commercial |
$671.06
|
| Rate for Payer: HFN Commercial |
$693.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$179.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$179.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$179.30
|
| Rate for Payer: Multiplan Commercial |
$603.20
|
| Rate for Payer: NAPHCARE Commercial |
$268.94
|
| Rate for Payer: Preferred Network Access Commercial |
$693.68
|
| Rate for Payer: Quartz Beloit One Network |
$369.46
|
| Rate for Payer: Quartz Commercial |
$490.10
|
| Rate for Payer: Quartz Medicare Advantage |
$179.30
|
| Rate for Payer: The Alliance Commercial |
$717.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$179.30
|
| Rate for Payer: United Healthcare PPO |
$565.50
|
| Rate for Payer: WEA Trust Commercial |
$414.70
|
| Rate for Payer: Wellcare Medicare |
$179.30
|
| Rate for Payer: WPS Commercial |
$558.47
|
|
|
Clarient, Special Stains
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
4856607
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
Clarient, Special Stains
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
4856607
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$560.06 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.38
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$100.62
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
CLASS III PHARMACOTHERAPY
|
Facility
|
OP
|
$132.34
|
|
|
Service Code
|
EAPG 00437
|
| Min. Negotiated Rate |
$127.25 |
| Max. Negotiated Rate |
$132.34 |
| Rate for Payer: Anthem Medicaid |
$127.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$127.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$127.25
|
| Rate for Payer: Dean Health Medicaid |
$127.25
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$127.25
|
| Rate for Payer: Managed Health Services Medicaid |
$132.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$127.25
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$127.25
|
| Rate for Payer: United Healthcare Medicaid |
$127.25
|
|
|
CLASS III THERAPEUTIC RADIOPHARMACEUTICALS
|
Facility
|
OP
|
$829.42
|
|
|
Service Code
|
EAPG 00245
|
| Min. Negotiated Rate |
$797.52 |
| Max. Negotiated Rate |
$829.42 |
| Rate for Payer: Anthem Medicaid |
$797.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$797.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$797.52
|
| Rate for Payer: Dean Health Medicaid |
$797.52
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$797.52
|
| Rate for Payer: Managed Health Services Medicaid |
$829.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$797.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$797.52
|
| Rate for Payer: United Healthcare Medicaid |
$797.52
|
|
|
CLASS II PHARMACOTHERAPY
|
Facility
|
OP
|
$73.38
|
|
|
Service Code
|
EAPG 00436
|
| Min. Negotiated Rate |
$70.55 |
| Max. Negotiated Rate |
$73.38 |
| Rate for Payer: Anthem Medicaid |
$70.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$70.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.55
|
| Rate for Payer: Dean Health Medicaid |
$70.55
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$70.55
|
| Rate for Payer: Managed Health Services Medicaid |
$73.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$70.55
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$70.55
|
| Rate for Payer: United Healthcare Medicaid |
$70.55
|
|
|
CLASS II THERAPEUTIC RADIOPHARMACEUTICALS
|
Facility
|
OP
|
$285.65
|
|
|
Service Code
|
EAPG 00244
|
| Min. Negotiated Rate |
$274.66 |
| Max. Negotiated Rate |
$285.65 |
| Rate for Payer: Anthem Medicaid |
$274.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$274.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$274.66
|
| Rate for Payer: Dean Health Medicaid |
$274.66
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$274.66
|
| Rate for Payer: Managed Health Services Medicaid |
$285.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$274.66
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$274.66
|
| Rate for Payer: United Healthcare Medicaid |
$274.66
|
|
|
CLASS I PHARMACOTHERAPY
|
Facility
|
OP
|
$24.90
|
|
|
Service Code
|
EAPG 00435
|
| Min. Negotiated Rate |
$23.94 |
| Max. Negotiated Rate |
$24.90 |
| Rate for Payer: Anthem Medicaid |
$23.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$23.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$23.94
|
| Rate for Payer: Dean Health Medicaid |
$23.94
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$23.94
|
| Rate for Payer: Managed Health Services Medicaid |
$24.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.94
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$23.94
|
| Rate for Payer: United Healthcare Medicaid |
$23.94
|
|
|
CLASS I THERAPEUTIC RADIOPHARMACEUTICALS
|
Facility
|
OP
|
$11.79
|
|
|
Service Code
|
EAPG 00243
|
| Min. Negotiated Rate |
$11.34 |
| Max. Negotiated Rate |
$11.79 |
| Rate for Payer: Anthem Medicaid |
$11.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$11.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.34
|
| Rate for Payer: Dean Health Medicaid |
$11.34
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.34
|
| Rate for Payer: Managed Health Services Medicaid |
$11.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.34
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.34
|
| Rate for Payer: United Healthcare Medicaid |
$11.34
|
|
|
CLASS IV PHARMACOTHERAPY
|
Facility
|
OP
|
$222.75
|
|
|
Service Code
|
EAPG 00438
|
| Min. Negotiated Rate |
$214.18 |
| Max. Negotiated Rate |
$222.75 |
| Rate for Payer: Anthem Medicaid |
$214.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$214.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$214.18
|
| Rate for Payer: Dean Health Medicaid |
$214.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$214.18
|
| Rate for Payer: Managed Health Services Medicaid |
$222.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$214.18
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$214.18
|
| Rate for Payer: United Healthcare Medicaid |
$214.18
|
|
|
CLASS IX COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
|
Facility
|
OP
|
$1,666.70
|
|
|
Service Code
|
EAPG 00461
|
| Min. Negotiated Rate |
$1,602.59 |
| Max. Negotiated Rate |
$1,666.70 |
| Rate for Payer: Anthem Medicaid |
$1,602.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$1,602.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,602.59
|
| Rate for Payer: Dean Health Medicaid |
$1,602.59
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$1,602.59
|
| Rate for Payer: Managed Health Services Medicaid |
$1,666.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,602.59
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$1,602.59
|
| Rate for Payer: United Healthcare Medicaid |
$1,602.59
|
|
|
CLASS VIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
|
Facility
|
OP
|
$1,208.10
|
|
|
Service Code
|
EAPG 00460
|
| Min. Negotiated Rate |
$1,161.63 |
| Max. Negotiated Rate |
$1,208.10 |
| Rate for Payer: Anthem Medicaid |
$1,161.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$1,161.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,161.63
|
| Rate for Payer: Dean Health Medicaid |
$1,161.63
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$1,161.63
|
| Rate for Payer: Managed Health Services Medicaid |
$1,208.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,161.63
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$1,161.63
|
| Rate for Payer: United Healthcare Medicaid |
$1,161.63
|
|
|
CLASS VII PHARMACOTHERAPY
|
Facility
|
OP
|
$839.90
|
|
|
Service Code
|
EAPG 00444
|
| Min. Negotiated Rate |
$807.60 |
| Max. Negotiated Rate |
$839.90 |
| Rate for Payer: Anthem Medicaid |
$807.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$807.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$807.60
|
| Rate for Payer: Dean Health Medicaid |
$807.60
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$807.60
|
| Rate for Payer: Managed Health Services Medicaid |
$839.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$807.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$807.60
|
| Rate for Payer: United Healthcare Medicaid |
$807.60
|
|
|
CLASS VI PHARMACOTHERAPY
|
Facility
|
OP
|
$560.81
|
|
|
Service Code
|
EAPG 00440
|
| Min. Negotiated Rate |
$539.24 |
| Max. Negotiated Rate |
$560.81 |
| Rate for Payer: Anthem Medicaid |
$539.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$539.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$539.24
|
| Rate for Payer: Dean Health Medicaid |
$539.24
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$539.24
|
| Rate for Payer: Managed Health Services Medicaid |
$560.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$539.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$539.24
|
| Rate for Payer: United Healthcare Medicaid |
$539.24
|
|
|
CLASS V PHARMACOTHERAPY
|
Facility
|
OP
|
$360.33
|
|
|
Service Code
|
EAPG 00439
|
| Min. Negotiated Rate |
$346.47 |
| Max. Negotiated Rate |
$360.33 |
| Rate for Payer: Anthem Medicaid |
$346.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$346.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$346.47
|
| Rate for Payer: Dean Health Medicaid |
$346.47
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$346.47
|
| Rate for Payer: Managed Health Services Medicaid |
$360.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$346.47
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$346.47
|
| Rate for Payer: United Healthcare Medicaid |
$346.47
|
|
|
CLASS X COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
|
Facility
|
OP
|
$2,646.81
|
|
|
Service Code
|
EAPG 00462
|
| Min. Negotiated Rate |
$2,545.00 |
| Max. Negotiated Rate |
$2,646.81 |
| Rate for Payer: Anthem Medicaid |
$2,545.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$2,545.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,545.00
|
| Rate for Payer: Dean Health Medicaid |
$2,545.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$2,545.00
|
| Rate for Payer: Managed Health Services Medicaid |
$2,646.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,545.00
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$2,545.00
|
| Rate for Payer: United Healthcare Medicaid |
$2,545.00
|
|
|
CLASS XI COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
|
Facility
|
OP
|
$4,268.96
|
|
|
Service Code
|
EAPG 00463
|
| Min. Negotiated Rate |
$4,104.75 |
| Max. Negotiated Rate |
$4,268.96 |
| Rate for Payer: Anthem Medicaid |
$4,104.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,104.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,104.75
|
| Rate for Payer: Dean Health Medicaid |
$4,104.75
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4,104.75
|
| Rate for Payer: Managed Health Services Medicaid |
$4,268.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,104.75
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,104.75
|
| Rate for Payer: United Healthcare Medicaid |
$4,104.75
|
|
|
CLASS XII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
|
Facility
|
OP
|
$6,552.81
|
|
|
Service Code
|
EAPG 00464
|
| Min. Negotiated Rate |
$6,300.76 |
| Max. Negotiated Rate |
$6,552.81 |
| Rate for Payer: Anthem Medicaid |
$6,300.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,300.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,300.76
|
| Rate for Payer: Dean Health Medicaid |
$6,300.76
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6,300.76
|
| Rate for Payer: Managed Health Services Medicaid |
$6,552.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,300.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,300.76
|
| Rate for Payer: United Healthcare Medicaid |
$6,300.76
|
|
|
CLAVICLE BRIDGE PLATE VARIAX SUPERIOR MIDSHAFT - INCREASED CURVATURE 6HL RT 628166
|
Facility
|
OP
|
$5,528.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6207056
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,609.75 |
| Max. Negotiated Rate |
$5,289.19 |
| Rate for Payer: Aetna Commercial |
$5,174.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,944.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,609.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,736.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,874.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,759.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,047.03
|
| Rate for Payer: Cash Price |
$1,658.40
|
| Rate for Payer: Cigna Commercial |
$5,289.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,217.30
|
| Rate for Payer: Health EOS Commercial |
$5,116.72
|
| Rate for Payer: HFN Commercial |
$5,289.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,311.84
|
| Rate for Payer: Multiplan Commercial |
$4,599.30
|
| Rate for Payer: NAPHCARE Commercial |
$3,449.47
|
| Rate for Payer: Preferred Network Access Commercial |
$5,289.19
|
| Rate for Payer: Quartz Beloit One Network |
$2,817.07
|
| Rate for Payer: Quartz Commercial |
$3,736.93
|
| Rate for Payer: Quartz Medicare Advantage |
$3,449.47
|
| Rate for Payer: The Alliance Commercial |
$2,874.56
|
| Rate for Payer: WEA Trust Commercial |
$3,162.02
|
| Rate for Payer: WPS Commercial |
$4,258.22
|
|
|
CLAVICLE BRIDGE PLATE VARIAX SUPERIOR MIDSHAFT - INCREASED CURVATURE 6HL RT 628166
|
Facility
|
IP
|
$5,528.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6207056
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.07 |
| Max. Negotiated Rate |
$5,289.19 |
| Rate for Payer: Aetna Commercial |
$5,174.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,944.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,047.03
|
| Rate for Payer: Cash Price |
$1,658.40
|
| Rate for Payer: Cigna Commercial |
$5,289.19
|
| Rate for Payer: Health EOS Commercial |
$5,116.72
|
| Rate for Payer: HFN Commercial |
$5,289.19
|
| Rate for Payer: Multiplan Commercial |
$4,599.30
|
| Rate for Payer: Preferred Network Access Commercial |
$5,289.19
|
| Rate for Payer: Quartz Beloit One Network |
$2,817.07
|
| Rate for Payer: Quartz Commercial |
$3,449.47
|
| Rate for Payer: WEA Trust Commercial |
$3,162.02
|
| Rate for Payer: WPS Commercial |
$4,258.22
|
|
|
CLAVICLE RESECTION
|
Facility
|
OP
|
$4,324.00
|
|
| Hospital Charge Code |
2960345
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,259.15 |
| Max. Negotiated Rate |
$4,137.20 |
| Rate for Payer: Aetna Commercial |
$4,047.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,867.39
|
| Rate for Payer: Aetna Managed Medicare |
$1,259.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,923.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,248.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,158.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.39
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$4,137.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,516.57
|
| Rate for Payer: Health EOS Commercial |
$4,002.29
|
| Rate for Payer: HFN Commercial |
$4,137.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,372.72
|
| Rate for Payer: Multiplan Commercial |
$3,597.57
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.18
|
| Rate for Payer: Preferred Network Access Commercial |
$4,137.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,203.51
|
| Rate for Payer: Quartz Commercial |
$2,923.02
|
| Rate for Payer: Quartz Medicare Advantage |
$2,698.18
|
| Rate for Payer: The Alliance Commercial |
$2,248.48
|
| Rate for Payer: WEA Trust Commercial |
$2,473.33
|
| Rate for Payer: WPS Commercial |
$3,330.78
|
|
|
CLAVICLE RESECTION
|
Facility
|
IP
|
$4,324.00
|
|
| Hospital Charge Code |
2960345
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,203.51 |
| Max. Negotiated Rate |
$4,137.20 |
| Rate for Payer: Aetna Commercial |
$4,047.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,867.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.39
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$4,137.20
|
| Rate for Payer: Health EOS Commercial |
$4,002.29
|
| Rate for Payer: HFN Commercial |
$4,137.20
|
| Rate for Payer: Multiplan Commercial |
$3,597.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,137.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,203.51
|
| Rate for Payer: Quartz Commercial |
$2,698.18
|
| Rate for Payer: WEA Trust Commercial |
$2,473.33
|
| Rate for Payer: WPS Commercial |
$3,330.78
|
|
|
CLAVICLE RESECTION, DISTAL
|
Facility
|
OP
|
$4,657.00
|
|
| Hospital Charge Code |
2959932
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,356.12 |
| Max. Negotiated Rate |
$4,455.82 |
| Rate for Payer: Aetna Commercial |
$4,358.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,165.22
|
| Rate for Payer: Aetna Managed Medicare |
$1,356.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,148.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,421.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,324.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,566.94
|
| Rate for Payer: Cash Price |
$1,397.10
|
| Rate for Payer: Cigna Commercial |
$4,455.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,710.37
|
| Rate for Payer: Health EOS Commercial |
$4,310.52
|
| Rate for Payer: HFN Commercial |
$4,455.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,632.46
|
| Rate for Payer: Multiplan Commercial |
$3,874.62
|
| Rate for Payer: NAPHCARE Commercial |
$2,905.97
|
| Rate for Payer: Preferred Network Access Commercial |
$4,455.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,373.21
|
| Rate for Payer: Quartz Commercial |
$3,148.13
|
| Rate for Payer: Quartz Medicare Advantage |
$2,905.97
|
| Rate for Payer: The Alliance Commercial |
$2,421.64
|
| Rate for Payer: WEA Trust Commercial |
$2,663.80
|
| Rate for Payer: WPS Commercial |
$3,587.29
|
|
