|
CLASS IV PHARMACOTHERAPY
|
Facility
|
OP
|
$41.20
|
|
|
Service Code
|
EAPG 00438
|
| Min. Negotiated Rate |
$39.61 |
| Max. Negotiated Rate |
$41.20 |
| Rate for Payer: Anthem Medicaid |
$39.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$39.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.61
|
| Rate for Payer: Dean Health Medicaid |
$39.61
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$39.61
|
| Rate for Payer: Managed Health Services Medicaid |
$41.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.61
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$39.61
|
| Rate for Payer: United Healthcare Medicaid |
$39.61
|
|
|
CLASS IX COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
|
Facility
|
OP
|
$375.25
|
|
|
Service Code
|
EAPG 00461
|
| Min. Negotiated Rate |
$360.82 |
| Max. Negotiated Rate |
$375.25 |
| Rate for Payer: Anthem Medicaid |
$360.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$360.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$360.82
|
| Rate for Payer: Dean Health Medicaid |
$360.82
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$360.82
|
| Rate for Payer: Managed Health Services Medicaid |
$375.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$360.82
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$360.82
|
| Rate for Payer: United Healthcare Medicaid |
$360.82
|
|
|
CLASS VIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
|
Facility
|
OP
|
$268.15
|
|
|
Service Code
|
EAPG 00460
|
| Min. Negotiated Rate |
$257.84 |
| Max. Negotiated Rate |
$268.15 |
| Rate for Payer: Anthem Medicaid |
$257.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$257.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$257.84
|
| Rate for Payer: Dean Health Medicaid |
$257.84
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$257.84
|
| Rate for Payer: Managed Health Services Medicaid |
$268.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$257.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$257.84
|
| Rate for Payer: United Healthcare Medicaid |
$257.84
|
|
|
CLASS VII PHARMACOTHERAPY
|
Facility
|
OP
|
$206.31
|
|
|
Service Code
|
EAPG 00444
|
| Min. Negotiated Rate |
$198.38 |
| Max. Negotiated Rate |
$206.31 |
| Rate for Payer: Anthem Medicaid |
$198.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$198.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$198.38
|
| Rate for Payer: Dean Health Medicaid |
$198.38
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$198.38
|
| Rate for Payer: Managed Health Services Medicaid |
$206.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$198.38
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$198.38
|
| Rate for Payer: United Healthcare Medicaid |
$198.38
|
|
|
CLASS VI PHARMACOTHERAPY
|
Facility
|
OP
|
$108.24
|
|
|
Service Code
|
EAPG 00440
|
| Min. Negotiated Rate |
$104.07 |
| Max. Negotiated Rate |
$108.24 |
| Rate for Payer: Anthem Medicaid |
$104.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$104.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.07
|
| Rate for Payer: Dean Health Medicaid |
$104.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$104.07
|
| Rate for Payer: Managed Health Services Medicaid |
$108.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$104.07
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$104.07
|
| Rate for Payer: United Healthcare Medicaid |
$104.07
|
|
|
CLASS V PHARMACOTHERAPY
|
Facility
|
OP
|
$103.66
|
|
|
Service Code
|
EAPG 00439
|
| Min. Negotiated Rate |
$99.67 |
| Max. Negotiated Rate |
$103.66 |
| Rate for Payer: Anthem Medicaid |
$99.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$99.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$99.67
|
| Rate for Payer: Dean Health Medicaid |
$99.67
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$99.67
|
| Rate for Payer: Managed Health Services Medicaid |
$103.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$99.67
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$99.67
|
| Rate for Payer: United Healthcare Medicaid |
$99.67
|
|
|
CLASS X COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
|
Facility
|
OP
|
$927.18
|
|
|
Service Code
|
EAPG 00462
|
| Min. Negotiated Rate |
$891.52 |
| Max. Negotiated Rate |
$927.18 |
| Rate for Payer: Anthem Medicaid |
$891.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$891.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$891.52
|
| Rate for Payer: Dean Health Medicaid |
$891.52
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$891.52
|
| Rate for Payer: Managed Health Services Medicaid |
$927.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$891.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$891.52
|
| Rate for Payer: United Healthcare Medicaid |
$891.52
|
|
|
CLASS XI COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
|
Facility
|
OP
|
$1,033.36
|
|
|
Service Code
|
EAPG 00463
|
| Min. Negotiated Rate |
$993.62 |
| Max. Negotiated Rate |
$1,033.36 |
| Rate for Payer: Anthem Medicaid |
$993.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$993.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$993.62
|
| Rate for Payer: Dean Health Medicaid |
$993.62
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$993.62
|
| Rate for Payer: Managed Health Services Medicaid |
$1,033.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$993.62
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$993.62
|
| Rate for Payer: United Healthcare Medicaid |
$993.62
|
|
|
CLASS XII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
|
Facility
|
OP
|
$1,643.01
|
|
|
Service Code
|
EAPG 00464
|
| Min. Negotiated Rate |
$1,579.81 |
| Max. Negotiated Rate |
$1,643.01 |
| Rate for Payer: Anthem Medicaid |
$1,579.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$1,579.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,579.81
|
| Rate for Payer: Dean Health Medicaid |
$1,579.81
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$1,579.81
|
| Rate for Payer: Managed Health Services Medicaid |
$1,643.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,579.81
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$1,579.81
|
| Rate for Payer: United Healthcare Medicaid |
$1,579.81
|
|
|
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
|
|
|
CLAVICLE RESECTION, DISTAL
|
Facility
|
IP
|
$4,657.00
|
|
| Hospital Charge Code |
2959932
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,373.21 |
| 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: 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: Health EOS Commercial |
$4,310.52
|
| Rate for Payer: HFN Commercial |
$4,455.82
|
| Rate for Payer: Multiplan Commercial |
$3,874.62
|
| 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 |
$2,905.97
|
| Rate for Payer: WEA Trust Commercial |
$2,663.80
|
| Rate for Payer: WPS Commercial |
$3,587.29
|
|
|
CLAVICULECTOMY; PARTIAL
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 23120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,673.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
|
Clean Out Mastoid Cavity 6922050
|
Professional
|
Both
|
$363.00
|
|
|
Service Code
|
CPT 69220 50
|
| Hospital Charge Code |
3798676
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$45.34 |
| Max. Negotiated Rate |
$358.64 |
| Rate for Payer: Aetna Commercial |
$358.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$324.67
|
| Rate for Payer: Cash Price |
$108.90
|
| Rate for Payer: Cash Price |
$108.90
|
| Rate for Payer: Cash Price |
$108.90
|
| Rate for Payer: Cigna Commercial |
$358.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.51
|
| Rate for Payer: Health EOS Commercial |
$343.54
|
| Rate for Payer: HFN Commercial |
$358.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$175.19
|
| Rate for Payer: Multiplan Commercial |
$302.02
|
| Rate for Payer: Preferred Network Access Commercial |
$358.64
|
| Rate for Payer: Quartz Beloit One Network |
$166.11
|
| Rate for Payer: Quartz Commercial |
$215.19
|
| Rate for Payer: The Alliance Commercial |
$188.76
|
| Rate for Payer: United Healthcare Medicaid |
$45.34
|
| Rate for Payer: WEA Trust Commercial |
$207.64
|
| Rate for Payer: WPS Commercial |
$279.62
|
|
|
CLEFT LIP AND PALATE REPAIR
|
Facility
|
IP
|
$8,329.89
|
|
|
Service Code
|
APR-DRG 0951
|
| Min. Negotiated Rate |
$7,399.13 |
| Max. Negotiated Rate |
$8,329.89 |
| Rate for Payer: Anthem Medicaid |
$7,976.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$7,976.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,976.33
|
| Rate for Payer: Dean Health Medicaid |
$7,976.33
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,399.13
|
| Rate for Payer: Managed Health Services Medicaid |
$8,329.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,976.33
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7,976.33
|
| Rate for Payer: United Healthcare Medicaid |
$7,976.33
|
|
|
CLEFT LIP AND PALATE REPAIR
|
Facility
|
IP
|
$14,116.98
|
|
|
Service Code
|
APR-DRG 0953
|
| Min. Negotiated Rate |
$12,539.58 |
| Max. Negotiated Rate |
$14,116.98 |
| Rate for Payer: Anthem Medicaid |
$13,517.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$13,517.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13,517.79
|
| Rate for Payer: Dean Health Medicaid |
$13,517.79
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12,539.58
|
| Rate for Payer: Managed Health Services Medicaid |
$14,116.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,517.79
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13,517.79
|
| Rate for Payer: United Healthcare Medicaid |
$13,517.79
|
|
|
CLEFT LIP AND PALATE REPAIR
|
Facility
|
IP
|
$8,855.99
|
|
|
Service Code
|
APR-DRG 0952
|
| Min. Negotiated Rate |
$7,866.45 |
| Max. Negotiated Rate |
$8,855.99 |
| Rate for Payer: Anthem Medicaid |
$8,480.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,480.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,480.10
|
| Rate for Payer: Dean Health Medicaid |
$8,480.10
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,866.45
|
| Rate for Payer: Managed Health Services Medicaid |
$8,855.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,480.10
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,480.10
|
| Rate for Payer: United Healthcare Medicaid |
$8,480.10
|
|
|
CLEFT LIP AND PALATE REPAIR
|
Facility
|
IP
|
$29,286.16
|
|
|
Service Code
|
APR-DRG 0954
|
| Min. Negotiated Rate |
$26,013.79 |
| Max. Negotiated Rate |
$29,286.16 |
| Rate for Payer: Anthem Medicaid |
$28,043.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$28,043.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28,043.11
|
| Rate for Payer: Dean Health Medicaid |
$28,043.11
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26,013.79
|
| Rate for Payer: Managed Health Services Medicaid |
$29,286.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$28,043.11
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$28,043.11
|
| Rate for Payer: United Healthcare Medicaid |
$28,043.11
|
|
|
CLEFT LIP AND PALATE REPAIR
|
Facility
|
OP
|
$579.64
|
|
|
Service Code
|
EAPG 00262
|
| Min. Negotiated Rate |
$557.34 |
| Max. Negotiated Rate |
$579.64 |
| Rate for Payer: Anthem Medicaid |
$557.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$557.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$557.34
|
| Rate for Payer: Dean Health Medicaid |
$557.34
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$557.34
|
| Rate for Payer: Managed Health Services Medicaid |
$579.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$557.34
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$557.34
|
| Rate for Payer: United Healthcare Medicaid |
$557.34
|
|
|
CLEFT LIP & PALATE REPAIR
|
Facility
|
IP
|
$4,324.00
|
|
| Hospital Charge Code |
2959934
|
|
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
|
|
|
CLEFT LIP & PALATE REPAIR
|
Facility
|
OP
|
$4,324.00
|
|
| Hospital Charge Code |
2959934
|
|
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
|
|
|
CLEFT LIP REVISION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2959933
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
