|
CONTRACEPTIVE MANAGEMENT
|
Facility
|
OP
|
$33.62
|
|
|
Service Code
|
EAPG 00875
|
| Min. Negotiated Rate |
$32.32 |
| Max. Negotiated Rate |
$33.62 |
| Rate for Payer: Anthem Medicaid |
$32.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$32.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.32
|
| Rate for Payer: Dean Health Medicaid |
$32.32
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$32.32
|
| Rate for Payer: Managed Health Services Medicaid |
$33.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$32.32
|
| Rate for Payer: United Healthcare Medicaid |
$32.32
|
|
|
CONTRAST LINE FAS4072
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
2972098
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.77 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
CONTRAST LINE FAS4072
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
2972098
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.30 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Aetna Managed Medicare |
$23.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.56
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: NAPHCARE Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$54.08
|
| Rate for Payer: Quartz Medicare Advantage |
$49.92
|
| Rate for Payer: The Alliance Commercial |
$41.60
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
CONTRAST X-RAY EXAM OF AORTA 7560526
|
Professional
|
Both
|
$752.00
|
|
|
Service Code
|
CPT 75605 26
|
| Hospital Charge Code |
3015289
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.82 |
| Max. Negotiated Rate |
$742.98 |
| Rate for Payer: Aetna Commercial |
$742.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$672.59
|
| Rate for Payer: Aetna Managed Medicare |
$50.82
|
| Rate for Payer: Anthem Medicare Advantage |
$50.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$50.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$50.82
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cigna Commercial |
$742.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$391.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.82
|
| Rate for Payer: Health EOS Commercial |
$711.69
|
| Rate for Payer: HFN Commercial |
$742.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$189.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$50.82
|
| Rate for Payer: Multiplan Commercial |
$625.66
|
| Rate for Payer: NAPHCARE Commercial |
$76.24
|
| Rate for Payer: Preferred Network Access Commercial |
$742.98
|
| Rate for Payer: Quartz Beloit One Network |
$344.12
|
| Rate for Payer: Quartz Commercial |
$445.79
|
| Rate for Payer: Quartz Medicare Advantage |
$50.82
|
| Rate for Payer: The Alliance Commercial |
$193.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.82
|
| Rate for Payer: WEA Trust Commercial |
$430.14
|
| Rate for Payer: WPS Commercial |
$254.12
|
|
|
Contrast X-RAY Exam of Aorta 7562526
|
Professional
|
Both
|
$364.00
|
|
|
Service Code
|
CPT 75625 26
|
| Hospital Charge Code |
3467522
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.86 |
| Max. Negotiated Rate |
$359.63 |
| Rate for Payer: Aetna Commercial |
$359.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.56
|
| Rate for Payer: Aetna Managed Medicare |
$62.86
|
| Rate for Payer: Anthem Medicare Advantage |
$62.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.86
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$359.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$189.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.86
|
| Rate for Payer: Health EOS Commercial |
$344.49
|
| Rate for Payer: HFN Commercial |
$359.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$235.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$235.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.86
|
| Rate for Payer: Multiplan Commercial |
$302.85
|
| Rate for Payer: NAPHCARE Commercial |
$94.29
|
| Rate for Payer: Preferred Network Access Commercial |
$359.63
|
| Rate for Payer: Quartz Beloit One Network |
$166.57
|
| Rate for Payer: Quartz Commercial |
$215.78
|
| Rate for Payer: Quartz Medicare Advantage |
$62.86
|
| Rate for Payer: The Alliance Commercial |
$238.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.86
|
| Rate for Payer: WEA Trust Commercial |
$208.21
|
| Rate for Payer: WPS Commercial |
$314.29
|
|
|
Control Nasal Hemorrahage 30901
|
Professional
|
Both
|
$841.00
|
|
|
Service Code
|
CPT 30901
|
| Hospital Charge Code |
1152805
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.04 |
| Max. Negotiated Rate |
$830.91 |
| Rate for Payer: Health EOS Commercial |
$795.92
|
| Rate for Payer: Aetna Commercial |
$830.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$752.19
|
| Rate for Payer: Aetna Managed Medicare |
$46.85
|
| Rate for Payer: Anthem Medicare Advantage |
$46.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.85
|
| Rate for Payer: Cash Price |
$252.30
|
| Rate for Payer: Cash Price |
$252.30
|
| Rate for Payer: Cash Price |
$252.30
|
| Rate for Payer: Cigna Commercial |
$830.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.85
|
| Rate for Payer: HFN Commercial |
$830.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$192.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$192.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.85
|
| Rate for Payer: Multiplan Commercial |
$699.71
|
| Rate for Payer: NAPHCARE Commercial |
$70.28
|
| Rate for Payer: Preferred Network Access Commercial |
$830.91
|
| Rate for Payer: Quartz Beloit One Network |
$384.84
|
| Rate for Payer: Quartz Commercial |
$498.54
|
| Rate for Payer: Quartz Medicare Advantage |
$46.85
|
| Rate for Payer: The Alliance Commercial |
$199.12
|
| Rate for Payer: United Healthcare Medicaid |
$35.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.85
|
| Rate for Payer: WEA Trust Commercial |
$481.05
|
| Rate for Payer: WPS Commercial |
$210.83
|
|
|
Control Nasal Hemorrahage; Anterior 3090150
|
Professional
|
Both
|
$1,474.00
|
|
|
Service Code
|
CPT 30901 50
|
| Hospital Charge Code |
5374713
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.04 |
| Max. Negotiated Rate |
$1,456.31 |
| Rate for Payer: Aetna Commercial |
$1,456.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,318.35
|
| Rate for Payer: Cash Price |
$442.20
|
| Rate for Payer: Cash Price |
$442.20
|
| Rate for Payer: Cash Price |
$442.20
|
| Rate for Payer: Cigna Commercial |
$1,456.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$919.78
|
| Rate for Payer: Health EOS Commercial |
$1,394.99
|
| Rate for Payer: HFN Commercial |
$1,456.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$192.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$192.00
|
| Rate for Payer: Multiplan Commercial |
$1,226.37
|
| Rate for Payer: Preferred Network Access Commercial |
$1,456.31
|
| Rate for Payer: Quartz Beloit One Network |
$674.50
|
| Rate for Payer: Quartz Commercial |
$873.79
|
| Rate for Payer: The Alliance Commercial |
$766.48
|
| Rate for Payer: United Healthcare Medicaid |
$35.04
|
| Rate for Payer: WEA Trust Commercial |
$843.13
|
| Rate for Payer: WPS Commercial |
$1,135.42
|
|
|
CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; INITIAL
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 30905
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$140.02 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| 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: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| 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: NAPHCARE Commercial |
$210.02
|
| 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 |
$2,347.28
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
|
|
CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 30906
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$249.26 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Managed Medicare |
$249.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Anthem Medicare Advantage |
$249.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$249.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$249.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$249.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$249.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$927.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$249.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$249.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$249.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$249.26
|
| Rate for Payer: NAPHCARE Commercial |
$373.89
|
| Rate for Payer: Quartz Medicare Advantage |
$249.26
|
| Rate for Payer: The Alliance Commercial |
$997.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$249.26
|
| Rate for Payer: United Healthcare PPO |
$2,347.28
|
| Rate for Payer: Wellcare Medicare |
$249.26
|
|
|
CONTROL OF NOSEBLEED 30903
|
Professional
|
Both
|
$905.00
|
|
|
Service Code
|
CPT 30903
|
| Hospital Charge Code |
3014364
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$63.06 |
| Max. Negotiated Rate |
$894.14 |
| Rate for Payer: Aetna Commercial |
$894.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$809.43
|
| Rate for Payer: Aetna Managed Medicare |
$65.42
|
| Rate for Payer: Anthem Medicare Advantage |
$65.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$65.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$65.42
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$894.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$63.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.42
|
| Rate for Payer: Health EOS Commercial |
$856.49
|
| Rate for Payer: HFN Commercial |
$894.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$263.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$263.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$65.42
|
| Rate for Payer: Multiplan Commercial |
$752.96
|
| Rate for Payer: NAPHCARE Commercial |
$98.12
|
| Rate for Payer: Preferred Network Access Commercial |
$894.14
|
| Rate for Payer: Quartz Beloit One Network |
$414.13
|
| Rate for Payer: Quartz Commercial |
$536.48
|
| Rate for Payer: Quartz Medicare Advantage |
$65.42
|
| Rate for Payer: The Alliance Commercial |
$278.02
|
| Rate for Payer: United Healthcare Medicaid |
$63.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$65.42
|
| Rate for Payer: WEA Trust Commercial |
$517.66
|
| Rate for Payer: WPS Commercial |
$294.37
|
|
|
Control of Nosebleed 3090350
|
Professional
|
Both
|
$1,574.00
|
|
|
Service Code
|
CPT 30903 50
|
| Hospital Charge Code |
4294580
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$63.06 |
| Max. Negotiated Rate |
$1,555.11 |
| Rate for Payer: Aetna Commercial |
$1,555.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,407.79
|
| Rate for Payer: Cash Price |
$472.20
|
| Rate for Payer: Cash Price |
$472.20
|
| Rate for Payer: Cash Price |
$472.20
|
| Rate for Payer: Cigna Commercial |
$1,555.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$63.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$982.18
|
| Rate for Payer: Health EOS Commercial |
$1,489.63
|
| Rate for Payer: HFN Commercial |
$1,555.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$263.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$263.85
|
| Rate for Payer: Multiplan Commercial |
$1,309.57
|
| Rate for Payer: Preferred Network Access Commercial |
$1,555.11
|
| Rate for Payer: Quartz Beloit One Network |
$720.26
|
| Rate for Payer: Quartz Commercial |
$933.07
|
| Rate for Payer: The Alliance Commercial |
$818.48
|
| Rate for Payer: United Healthcare Medicaid |
$63.06
|
| Rate for Payer: WEA Trust Commercial |
$900.33
|
| Rate for Payer: WPS Commercial |
$1,212.45
|
|
|
CONTROL PUMP WITH IZ AMS 800 72404127
|
Facility
|
OP
|
$34,254.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5385020
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,974.76 |
| Max. Negotiated Rate |
$32,774.23 |
| Rate for Payer: Aetna Commercial |
$32,061.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30,636.78
|
| Rate for Payer: Aetna Managed Medicare |
$9,974.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,155.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,812.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,099.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,880.80
|
| Rate for Payer: Cash Price |
$10,276.20
|
| Rate for Payer: Cigna Commercial |
$32,774.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,935.83
|
| Rate for Payer: Health EOS Commercial |
$31,705.50
|
| Rate for Payer: HFN Commercial |
$32,774.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,718.12
|
| Rate for Payer: Multiplan Commercial |
$28,499.33
|
| Rate for Payer: NAPHCARE Commercial |
$21,374.50
|
| Rate for Payer: Preferred Network Access Commercial |
$32,774.23
|
| Rate for Payer: Quartz Beloit One Network |
$17,455.84
|
| Rate for Payer: Quartz Commercial |
$23,155.70
|
| Rate for Payer: Quartz Medicare Advantage |
$21,374.50
|
| Rate for Payer: The Alliance Commercial |
$17,812.08
|
| Rate for Payer: WEA Trust Commercial |
$19,593.29
|
| Rate for Payer: WPS Commercial |
$26,385.86
|
|
|
CONTROL PUMP WITH IZ AMS 800 72404127
|
Facility
|
IP
|
$34,254.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5385020
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17,455.84 |
| Max. Negotiated Rate |
$32,774.23 |
| Rate for Payer: Aetna Commercial |
$32,061.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30,636.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,880.80
|
| Rate for Payer: Cash Price |
$10,276.20
|
| Rate for Payer: Cigna Commercial |
$32,774.23
|
| Rate for Payer: Health EOS Commercial |
$31,705.50
|
| Rate for Payer: HFN Commercial |
$32,774.23
|
| Rate for Payer: Multiplan Commercial |
$28,499.33
|
| Rate for Payer: Preferred Network Access Commercial |
$32,774.23
|
| Rate for Payer: Quartz Beloit One Network |
$17,455.84
|
| Rate for Payer: Quartz Commercial |
$21,374.50
|
| Rate for Payer: WEA Trust Commercial |
$19,593.29
|
| Rate for Payer: WPS Commercial |
$26,385.86
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
|
IP
|
$6,225.50
|
|
|
Service Code
|
APR-DRG 3841
|
| Min. Negotiated Rate |
$5,529.88 |
| Max. Negotiated Rate |
$6,225.50 |
| Rate for Payer: Anthem Medicaid |
$5,961.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,961.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,961.26
|
| Rate for Payer: Dean Health Medicaid |
$5,961.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,529.88
|
| Rate for Payer: Managed Health Services Medicaid |
$6,225.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,961.26
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,961.26
|
| Rate for Payer: United Healthcare Medicaid |
$5,961.26
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
|
IP
|
$17,448.94
|
|
|
Service Code
|
APR-DRG 3844
|
| Min. Negotiated Rate |
$15,499.23 |
| Max. Negotiated Rate |
$17,448.94 |
| Rate for Payer: Anthem Medicaid |
$16,708.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$16,708.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16,708.32
|
| Rate for Payer: Dean Health Medicaid |
$16,708.32
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15,499.23
|
| Rate for Payer: Managed Health Services Medicaid |
$17,448.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,708.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16,708.32
|
| Rate for Payer: United Healthcare Medicaid |
$16,708.32
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
|
IP
|
$10,872.70
|
|
|
Service Code
|
APR-DRG 3843
|
| Min. Negotiated Rate |
$9,657.81 |
| Max. Negotiated Rate |
$10,872.70 |
| Rate for Payer: Anthem Medicaid |
$10,411.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$10,411.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,411.21
|
| Rate for Payer: Dean Health Medicaid |
$10,411.21
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9,657.81
|
| Rate for Payer: Managed Health Services Medicaid |
$10,872.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,411.21
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$10,411.21
|
| Rate for Payer: United Healthcare Medicaid |
$10,411.21
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
|
IP
|
$7,628.43
|
|
|
Service Code
|
APR-DRG 3842
|
| Min. Negotiated Rate |
$6,776.05 |
| Max. Negotiated Rate |
$7,628.43 |
| Rate for Payer: United Healthcare Medicaid |
$7,304.64
|
| Rate for Payer: Anthem Medicaid |
$7,304.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$7,304.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,304.64
|
| Rate for Payer: Dean Health Medicaid |
$7,304.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6,776.05
|
| Rate for Payer: Managed Health Services Medicaid |
$7,628.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,304.64
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7,304.64
|
|
|
CONTUSIONS TO EXTERNAL ORGANS OTHER THAN HEAD TRAUMA
|
Facility
|
OP
|
$55.28
|
|
|
Service Code
|
EAPG 00610
|
| Min. Negotiated Rate |
$53.16 |
| Max. Negotiated Rate |
$55.28 |
| Rate for Payer: Anthem Medicaid |
$53.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$53.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.16
|
| Rate for Payer: Dean Health Medicaid |
$53.16
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$53.16
|
| Rate for Payer: Managed Health Services Medicaid |
$55.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$53.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$53.16
|
| Rate for Payer: United Healthcare Medicaid |
$53.16
|
|
|
CONVERT NEPHROSTOMY CATHETER TO NEPHROURETERAL CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, VIA PRE-EXISTING NEPHROSTOMY TRACT
|
Facility
|
OP
|
$8,799.61
|
|
|
Service Code
|
CPT 50434
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,199.90 |
| Max. Negotiated Rate |
$8,799.61 |
| Rate for Payer: Aetna Managed Medicare |
$2,199.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$2,199.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,199.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,199.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,199.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,199.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,183.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,199.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,199.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,199.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,199.90
|
| Rate for Payer: NAPHCARE Commercial |
$3,299.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,199.90
|
| Rate for Payer: The Alliance Commercial |
$8,799.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,199.90
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$2,199.90
|
|
|
Copper Level
|
Facility
|
OP
|
$208.00
|
|
|
Service Code
|
CPT 82525
|
| Hospital Charge Code |
977909
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$199.01 |
| Rate for Payer: Aetna Commercial |
$194.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.04
|
| Rate for Payer: Aetna Managed Medicare |
$12.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.42
|
| Rate for Payer: Anthem Medicare Advantage |
$12.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.91
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$199.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.91
|
| Rate for Payer: Health EOS Commercial |
$192.52
|
| Rate for Payer: HFN Commercial |
$199.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.91
|
| Rate for Payer: Multiplan Commercial |
$173.06
|
| Rate for Payer: NAPHCARE Commercial |
$19.36
|
| Rate for Payer: Preferred Network Access Commercial |
$199.01
|
| Rate for Payer: Quartz Beloit One Network |
$106.00
|
| Rate for Payer: Quartz Commercial |
$140.61
|
| Rate for Payer: Quartz Medicare Advantage |
$12.91
|
| Rate for Payer: The Alliance Commercial |
$51.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.91
|
| Rate for Payer: United Healthcare PPO |
$162.24
|
| Rate for Payer: WEA Trust Commercial |
$118.98
|
| Rate for Payer: Wellcare Medicare |
$12.91
|
| Rate for Payer: WPS Commercial |
$160.22
|
|
|
Copper Level
|
Professional
|
Both
|
$208.00
|
|
|
Service Code
|
CPT 82525
|
| Hospital Charge Code |
977909
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$205.50 |
| Rate for Payer: Aetna Commercial |
$205.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.04
|
| Rate for Payer: Aetna Managed Medicare |
$12.91
|
| Rate for Payer: Anthem Medicare Advantage |
$12.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.91
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$205.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$108.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.91
|
| Rate for Payer: Health EOS Commercial |
$196.85
|
| Rate for Payer: HFN Commercial |
$205.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.91
|
| Rate for Payer: Multiplan Commercial |
$173.06
|
| Rate for Payer: NAPHCARE Commercial |
$19.36
|
| Rate for Payer: Preferred Network Access Commercial |
$205.50
|
| Rate for Payer: Quartz Beloit One Network |
$95.18
|
| Rate for Payer: Quartz Commercial |
$123.30
|
| Rate for Payer: Quartz Medicare Advantage |
$12.91
|
| Rate for Payer: The Alliance Commercial |
$50.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.91
|
| Rate for Payer: WEA Trust Commercial |
$118.98
|
| Rate for Payer: WPS Commercial |
$56.79
|
|
|
Copper Level
|
Facility
|
IP
|
$208.00
|
|
|
Service Code
|
CPT 82525
|
| Hospital Charge Code |
977909
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$106.00 |
| Max. Negotiated Rate |
$199.01 |
| Rate for Payer: Aetna Commercial |
$194.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.65
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$199.01
|
| Rate for Payer: Health EOS Commercial |
$192.52
|
| Rate for Payer: HFN Commercial |
$199.01
|
| Rate for Payer: Multiplan Commercial |
$173.06
|
| Rate for Payer: Preferred Network Access Commercial |
$199.01
|
| Rate for Payer: Quartz Beloit One Network |
$106.00
|
| Rate for Payer: Quartz Commercial |
$129.79
|
| Rate for Payer: WEA Trust Commercial |
$118.98
|
| Rate for Payer: WPS Commercial |
$160.22
|
|
|
Copper Level 24 Hour Urine
|
Professional
|
Both
|
$208.00
|
|
|
Service Code
|
CPT 82525
|
| Hospital Charge Code |
980587
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$205.50 |
| Rate for Payer: Aetna Commercial |
$205.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.04
|
| Rate for Payer: Aetna Managed Medicare |
$12.91
|
| Rate for Payer: Anthem Medicare Advantage |
$12.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.91
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$205.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$108.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.91
|
| Rate for Payer: Health EOS Commercial |
$196.85
|
| Rate for Payer: HFN Commercial |
$205.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.91
|
| Rate for Payer: Multiplan Commercial |
$173.06
|
| Rate for Payer: NAPHCARE Commercial |
$19.36
|
| Rate for Payer: Preferred Network Access Commercial |
$205.50
|
| Rate for Payer: Quartz Beloit One Network |
$95.18
|
| Rate for Payer: Quartz Commercial |
$123.30
|
| Rate for Payer: Quartz Medicare Advantage |
$12.91
|
| Rate for Payer: The Alliance Commercial |
$50.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.91
|
| Rate for Payer: WEA Trust Commercial |
$118.98
|
| Rate for Payer: WPS Commercial |
$56.79
|
|
|
Copper Level 24 Hour Urine
|
Facility
|
IP
|
$208.00
|
|
|
Service Code
|
CPT 82525
|
| Hospital Charge Code |
980587
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$106.00 |
| Max. Negotiated Rate |
$199.01 |
| Rate for Payer: Aetna Commercial |
$194.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.65
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$199.01
|
| Rate for Payer: Health EOS Commercial |
$192.52
|
| Rate for Payer: HFN Commercial |
$199.01
|
| Rate for Payer: Multiplan Commercial |
$173.06
|
| Rate for Payer: Preferred Network Access Commercial |
$199.01
|
| Rate for Payer: Quartz Beloit One Network |
$106.00
|
| Rate for Payer: Quartz Commercial |
$129.79
|
| Rate for Payer: WEA Trust Commercial |
$118.98
|
| Rate for Payer: WPS Commercial |
$160.22
|
|
|
Copper Level 24 Hour Urine
|
Facility
|
OP
|
$208.00
|
|
|
Service Code
|
CPT 82525
|
| Hospital Charge Code |
980587
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$199.01 |
| Rate for Payer: Aetna Commercial |
$194.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.04
|
| Rate for Payer: Aetna Managed Medicare |
$12.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.42
|
| Rate for Payer: Anthem Medicare Advantage |
$12.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.91
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$199.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.91
|
| Rate for Payer: Health EOS Commercial |
$192.52
|
| Rate for Payer: HFN Commercial |
$199.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.91
|
| Rate for Payer: Multiplan Commercial |
$173.06
|
| Rate for Payer: NAPHCARE Commercial |
$19.36
|
| Rate for Payer: Preferred Network Access Commercial |
$199.01
|
| Rate for Payer: Quartz Beloit One Network |
$106.00
|
| Rate for Payer: Quartz Commercial |
$140.61
|
| Rate for Payer: Quartz Medicare Advantage |
$12.91
|
| Rate for Payer: The Alliance Commercial |
$51.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.91
|
| Rate for Payer: United Healthcare PPO |
$162.24
|
| Rate for Payer: WEA Trust Commercial |
$118.98
|
| Rate for Payer: Wellcare Medicare |
$12.91
|
| Rate for Payer: WPS Commercial |
$160.22
|
|
