|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC
|
Facility
IP
|
$25,617.00
|
|
|
Service Code
|
MS-DRG 442
|
| Min. Negotiated Rate |
$9,214.74 |
| Max. Negotiated Rate |
$25,617.00 |
| Rate for Payer: Aetna Managed Medicare |
$9,214.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,931.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,276.95
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,514.10
|
| Rate for Payer: Anthem Medicare Advantage |
$9,214.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,214.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,214.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,214.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16,111.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,214.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,554.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,214.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,214.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,214.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,214.74
|
| Rate for Payer: NAPHCARE Commercial |
$13,822.11
|
| Rate for Payer: Quartz Medicare Advantage |
$9,214.74
|
| Rate for Payer: The Alliance Commercial |
$25,617.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,214.74
|
| Rate for Payer: United Healthcare PPO |
$14,444.72
|
| Rate for Payer: Wellcare Medicare |
$9,214.74
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC
|
Facility
IP
|
$48,925.00
|
|
|
Service Code
|
MS-DRG 441
|
| Min. Negotiated Rate |
$17,598.88 |
| Max. Negotiated Rate |
$48,925.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,598.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38,393.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,428.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,958.74
|
| Rate for Payer: Anthem Medicare Advantage |
$17,598.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,598.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,598.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,598.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,036.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,598.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35,649.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,598.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,598.88
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,598.88
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,598.88
|
| Rate for Payer: NAPHCARE Commercial |
$26,398.32
|
| Rate for Payer: Quartz Medicare Advantage |
$17,598.88
|
| Rate for Payer: The Alliance Commercial |
$48,925.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,598.88
|
| Rate for Payer: United Healthcare PPO |
$27,753.90
|
| Rate for Payer: Wellcare Medicare |
$17,598.88
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC
|
Facility
IP
|
$19,321.00
|
|
|
Service Code
|
MS-DRG 443
|
| Min. Negotiated Rate |
$6,950.15 |
| Max. Negotiated Rate |
$19,321.00 |
| Rate for Payer: Aetna Managed Medicare |
$6,950.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,895.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,417.51
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,847.38
|
| Rate for Payer: Anthem Medicare Advantage |
$6,950.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,950.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,950.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,950.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,041.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,950.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,936.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,950.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,950.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,950.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,950.15
|
| Rate for Payer: NAPHCARE Commercial |
$10,425.22
|
| Rate for Payer: Quartz Medicare Advantage |
$6,950.15
|
| Rate for Payer: The Alliance Commercial |
$19,321.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,950.15
|
| Rate for Payer: United Healthcare PPO |
$10,849.86
|
| Rate for Payer: Wellcare Medicare |
$6,950.15
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC
|
Facility
IP
|
$23,057.00
|
|
|
Service Code
|
MS-DRG 439
|
| Min. Negotiated Rate |
$8,293.79 |
| Max. Negotiated Rate |
$23,057.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,293.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,042.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,829.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,139.08
|
| Rate for Payer: Anthem Medicare Advantage |
$8,293.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,293.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,293.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,293.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,585.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,293.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,676.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,293.79
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,293.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,293.79
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,293.79
|
| Rate for Payer: NAPHCARE Commercial |
$12,440.68
|
| Rate for Payer: Quartz Medicare Advantage |
$8,293.79
|
| Rate for Payer: The Alliance Commercial |
$23,057.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,293.79
|
| Rate for Payer: United Healthcare PPO |
$12,982.79
|
| Rate for Payer: Wellcare Medicare |
$8,293.79
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC
|
Facility
IP
|
$44,687.00
|
|
|
Service Code
|
MS-DRG 438
|
| Min. Negotiated Rate |
$16,074.49 |
| Max. Negotiated Rate |
$44,687.00 |
| Rate for Payer: Aetna Managed Medicare |
$16,074.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35,036.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,855.27
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,514.26
|
| Rate for Payer: Anthem Medicare Advantage |
$16,074.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,074.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,074.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,074.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28,323.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,074.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,541.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,074.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,074.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,074.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,074.49
|
| Rate for Payer: NAPHCARE Commercial |
$24,111.74
|
| Rate for Payer: Quartz Medicare Advantage |
$16,074.49
|
| Rate for Payer: The Alliance Commercial |
$44,687.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,074.49
|
| Rate for Payer: United Healthcare PPO |
$25,334.05
|
| Rate for Payer: Wellcare Medicare |
$16,074.49
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC
|
Facility
IP
|
$16,687.00
|
|
|
Service Code
|
MS-DRG 440
|
| Min. Negotiated Rate |
$6,002.43 |
| Max. Negotiated Rate |
$16,687.00 |
| Rate for Payer: Aetna Managed Medicare |
$6,002.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,007.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,970.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,472.36
|
| Rate for Payer: Anthem Medicare Advantage |
$6,002.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,002.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,002.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,002.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,515.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,002.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,004.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,002.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,002.43
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,002.43
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,002.43
|
| Rate for Payer: NAPHCARE Commercial |
$9,003.64
|
| Rate for Payer: Quartz Medicare Advantage |
$6,002.43
|
| Rate for Payer: The Alliance Commercial |
$16,687.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,002.43
|
| Rate for Payer: United Healthcare PPO |
$9,345.42
|
| Rate for Payer: Wellcare Medicare |
$6,002.43
|
|
|
DISORDERS OF PERSONALITY AND IMPULSE CONTROL
|
Facility
IP
|
$50,180.00
|
|
|
Service Code
|
MS-DRG 883
|
| Min. Negotiated Rate |
$18,050.26 |
| Max. Negotiated Rate |
$50,180.00 |
| Rate for Payer: Aetna Managed Medicare |
$18,050.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39,442.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30,232.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,722.64
|
| Rate for Payer: Anthem Medicare Advantage |
$18,050.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18,050.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18,050.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18,050.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,884.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18,050.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36,570.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18,050.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18,050.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18,050.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18,050.26
|
| Rate for Payer: NAPHCARE Commercial |
$27,075.39
|
| Rate for Payer: Quartz Medicare Advantage |
$18,050.26
|
| Rate for Payer: The Alliance Commercial |
$50,180.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18,050.26
|
| Rate for Payer: United Healthcare PPO |
$28,470.45
|
| Rate for Payer: Wellcare Medicare |
$18,050.26
|
|
|
DISORDERS OF THE BILIARY TRACT WITH CC
|
Facility
IP
|
$29,214.00
|
|
|
Service Code
|
MS-DRG 445
|
| Min. Negotiated Rate |
$10,508.65 |
| Max. Negotiated Rate |
$29,214.00 |
| Rate for Payer: Aetna Managed Medicare |
$10,508.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,868.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,528.29
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,653.02
|
| Rate for Payer: Anthem Medicare Advantage |
$10,508.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,508.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,508.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,508.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,486.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,508.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,192.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,508.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,508.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,508.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,508.65
|
| Rate for Payer: NAPHCARE Commercial |
$15,762.98
|
| Rate for Payer: Quartz Medicare Advantage |
$10,508.65
|
| Rate for Payer: The Alliance Commercial |
$29,214.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,508.65
|
| Rate for Payer: United Healthcare PPO |
$16,498.71
|
| Rate for Payer: Wellcare Medicare |
$10,508.65
|
|
|
DISORDERS OF THE BILIARY TRACT WITH MCC
|
Facility
IP
|
$43,741.00
|
|
|
Service Code
|
MS-DRG 444
|
| Min. Negotiated Rate |
$15,734.03 |
| Max. Negotiated Rate |
$43,741.00 |
| Rate for Payer: Aetna Managed Medicare |
$15,734.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34,197.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,212.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,903.14
|
| Rate for Payer: Anthem Medicare Advantage |
$15,734.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,734.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,734.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,734.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,644.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,734.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,847.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,734.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,734.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,734.03
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,734.03
|
| Rate for Payer: NAPHCARE Commercial |
$23,601.04
|
| Rate for Payer: Quartz Medicare Advantage |
$15,734.03
|
| Rate for Payer: The Alliance Commercial |
$43,741.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,734.03
|
| Rate for Payer: United Healthcare PPO |
$24,793.61
|
| Rate for Payer: Wellcare Medicare |
$15,734.03
|
|
|
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC
|
Facility
IP
|
$21,629.00
|
|
|
Service Code
|
MS-DRG 446
|
| Min. Negotiated Rate |
$7,780.24 |
| Max. Negotiated Rate |
$21,629.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,780.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,784.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,864.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,222.40
|
| Rate for Payer: Anthem Medicare Advantage |
$7,780.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,780.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,780.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,780.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,567.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,780.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,629.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,780.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,780.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,780.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,780.24
|
| Rate for Payer: NAPHCARE Commercial |
$11,670.36
|
| Rate for Payer: Quartz Medicare Advantage |
$7,780.24
|
| Rate for Payer: The Alliance Commercial |
$21,629.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,780.24
|
| Rate for Payer: United Healthcare PPO |
$12,167.57
|
| Rate for Payer: Wellcare Medicare |
$7,780.24
|
|
|
Dispensing Fee Bicros
|
Facility
OP
|
$1,924.00
|
|
|
Service Code
|
HCPCS V5240
|
| Hospital Charge Code |
3243591
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$538.72 |
| Max. Negotiated Rate |
$7,696.00 |
| Rate for Payer: Aetna Commercial |
$1,731.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,654.64
|
| Rate for Payer: Aetna Managed Medicare |
$538.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,250.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$962.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$923.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,019.72
|
| Rate for Payer: Cash Price |
$577.20
|
| Rate for Payer: Cigna Commercial |
$1,770.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,076.67
|
| Rate for Payer: Health EOS Commercial |
$1,712.36
|
| Rate for Payer: HFN Commercial |
$1,770.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,443.00
|
| Rate for Payer: Multiplan Commercial |
$1,539.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,154.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,770.08
|
| Rate for Payer: Quartz Beloit One Network |
$942.76
|
| Rate for Payer: Quartz Commercial |
$1,250.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,154.40
|
| Rate for Payer: The Alliance Commercial |
$7,696.00
|
| Rate for Payer: United Healthcare PPO |
$1,443.00
|
| Rate for Payer: WEA Trust Commercial |
$1,058.20
|
| Rate for Payer: WPS Commercial |
$1,425.11
|
|
|
Dispensing Fee Bicros
|
Professional
|
$1,924.00
|
|
|
Service Code
|
HCPCS V5240
|
| Hospital Charge Code |
3243591
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$846.56 |
| Max. Negotiated Rate |
$1,827.80 |
| Rate for Payer: Aetna Commercial |
$1,827.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,654.64
|
| Rate for Payer: Cash Price |
$577.20
|
| Rate for Payer: Cash Price |
$577.20
|
| Rate for Payer: Cigna Commercial |
$1,827.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$962.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,154.40
|
| Rate for Payer: Health EOS Commercial |
$1,750.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$906.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$906.19
|
| Rate for Payer: Multiplan Commercial |
$1,539.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,827.80
|
| Rate for Payer: Quartz Beloit One Network |
$846.56
|
| Rate for Payer: Quartz Commercial |
$1,096.68
|
| Rate for Payer: The Alliance Commercial |
$962.00
|
| Rate for Payer: WEA Trust Commercial |
$1,058.20
|
| Rate for Payer: WPS Commercial |
$1,425.11
|
|
|
Dispensing Fee Bicros
|
Facility
IP
|
$1,924.00
|
|
|
Service Code
|
HCPCS V5240
|
| Hospital Charge Code |
3243591
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$942.76 |
| Max. Negotiated Rate |
$1,770.08 |
| Rate for Payer: Aetna Commercial |
$1,731.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,019.72
|
| Rate for Payer: Cash Price |
$577.20
|
| Rate for Payer: Cigna Commercial |
$1,770.08
|
| Rate for Payer: Health EOS Commercial |
$1,712.36
|
| Rate for Payer: HFN Commercial |
$1,770.08
|
| Rate for Payer: Multiplan Commercial |
$1,539.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,154.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,770.08
|
| Rate for Payer: Quartz Beloit One Network |
$942.76
|
| Rate for Payer: Quartz Commercial |
$1,154.40
|
| Rate for Payer: WEA Trust Commercial |
$1,058.20
|
| Rate for Payer: WPS Commercial |
$1,425.11
|
|
|
Dispensing Fee Binaural
|
Professional
|
$2,428.00
|
|
|
Service Code
|
HCPCS V5160
|
| Hospital Charge Code |
3243567
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$1,057.02 |
| Max. Negotiated Rate |
$2,306.60 |
| Rate for Payer: Aetna Commercial |
$2,306.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,088.08
|
| Rate for Payer: Cash Price |
$728.40
|
| Rate for Payer: Cash Price |
$728.40
|
| Rate for Payer: Cigna Commercial |
$2,306.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,214.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,456.80
|
| Rate for Payer: Health EOS Commercial |
$2,209.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,057.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,057.02
|
| Rate for Payer: Multiplan Commercial |
$1,942.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,306.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,068.32
|
| Rate for Payer: Quartz Commercial |
$1,383.96
|
| Rate for Payer: The Alliance Commercial |
$1,214.00
|
| Rate for Payer: WEA Trust Commercial |
$1,335.40
|
| Rate for Payer: WPS Commercial |
$1,798.42
|
|
|
Dispensing Fee Binaural
|
Facility
IP
|
$2,428.00
|
|
|
Service Code
|
HCPCS V5160
|
| Hospital Charge Code |
3243567
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$1,189.72 |
| Max. Negotiated Rate |
$2,233.76 |
| Rate for Payer: Aetna Commercial |
$2,185.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,286.84
|
| Rate for Payer: Cash Price |
$728.40
|
| Rate for Payer: Cigna Commercial |
$2,233.76
|
| Rate for Payer: Health EOS Commercial |
$2,160.92
|
| Rate for Payer: HFN Commercial |
$2,233.76
|
| Rate for Payer: Multiplan Commercial |
$1,942.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,456.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,233.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,189.72
|
| Rate for Payer: Quartz Commercial |
$1,456.80
|
| Rate for Payer: WEA Trust Commercial |
$1,335.40
|
| Rate for Payer: WPS Commercial |
$1,798.42
|
|
|
Dispensing Fee Binaural
|
Facility
OP
|
$2,428.00
|
|
|
Service Code
|
HCPCS V5160
|
| Hospital Charge Code |
3243567
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$679.84 |
| Max. Negotiated Rate |
$9,712.00 |
| Rate for Payer: Aetna Commercial |
$2,185.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,088.08
|
| Rate for Payer: Aetna Managed Medicare |
$679.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,578.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,214.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,165.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,286.84
|
| Rate for Payer: Cash Price |
$728.40
|
| Rate for Payer: Cigna Commercial |
$2,233.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,358.71
|
| Rate for Payer: Health EOS Commercial |
$2,160.92
|
| Rate for Payer: HFN Commercial |
$2,233.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,821.00
|
| Rate for Payer: Multiplan Commercial |
$1,942.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,456.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,233.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,189.72
|
| Rate for Payer: Quartz Commercial |
$1,578.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,456.80
|
| Rate for Payer: The Alliance Commercial |
$9,712.00
|
| Rate for Payer: United Healthcare PPO |
$1,821.00
|
| Rate for Payer: WEA Trust Commercial |
$1,335.40
|
| Rate for Payer: WPS Commercial |
$1,798.42
|
|
|
Dispensing Fee, Monaural
|
Professional
|
$997.00
|
|
|
Service Code
|
HCPCS V5241
|
| Hospital Charge Code |
3243597
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$438.68 |
| Max. Negotiated Rate |
$947.15 |
| Rate for Payer: Aetna Commercial |
$947.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$857.42
|
| Rate for Payer: Cash Price |
$299.10
|
| Rate for Payer: Cigna Commercial |
$947.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$498.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$598.20
|
| Rate for Payer: Health EOS Commercial |
$907.27
|
| Rate for Payer: Multiplan Commercial |
$797.60
|
| Rate for Payer: Preferred Network Access Commercial |
$947.15
|
| Rate for Payer: Quartz Beloit One Network |
$438.68
|
| Rate for Payer: Quartz Commercial |
$568.29
|
| Rate for Payer: The Alliance Commercial |
$498.50
|
| Rate for Payer: WEA Trust Commercial |
$548.35
|
| Rate for Payer: WPS Commercial |
$738.48
|
|
|
Dispensing Fee, Monaural
|
Facility
OP
|
$997.00
|
|
|
Service Code
|
HCPCS V5241
|
| Hospital Charge Code |
3243597
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$279.16 |
| Max. Negotiated Rate |
$3,988.00 |
| Rate for Payer: Aetna Commercial |
$897.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$857.42
|
| Rate for Payer: Aetna Managed Medicare |
$279.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$648.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$498.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$478.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$528.41
|
| Rate for Payer: Cash Price |
$299.10
|
| Rate for Payer: Cigna Commercial |
$917.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$557.92
|
| Rate for Payer: Health EOS Commercial |
$887.33
|
| Rate for Payer: HFN Commercial |
$917.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$747.75
|
| Rate for Payer: Multiplan Commercial |
$797.60
|
| Rate for Payer: NAPHCARE Commercial |
$598.20
|
| Rate for Payer: Preferred Network Access Commercial |
$917.24
|
| Rate for Payer: Quartz Beloit One Network |
$488.53
|
| Rate for Payer: Quartz Commercial |
$648.05
|
| Rate for Payer: Quartz Medicare Advantage |
$598.20
|
| Rate for Payer: The Alliance Commercial |
$3,988.00
|
| Rate for Payer: United Healthcare PPO |
$747.75
|
| Rate for Payer: WEA Trust Commercial |
$548.35
|
| Rate for Payer: WPS Commercial |
$738.48
|
|
|
Dispensing Fee, Monaural
|
Facility
IP
|
$997.00
|
|
|
Service Code
|
HCPCS V5241
|
| Hospital Charge Code |
3243597
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$488.53 |
| Max. Negotiated Rate |
$917.24 |
| Rate for Payer: Aetna Commercial |
$897.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$528.41
|
| Rate for Payer: Cash Price |
$299.10
|
| Rate for Payer: Cigna Commercial |
$917.24
|
| Rate for Payer: Health EOS Commercial |
$887.33
|
| Rate for Payer: HFN Commercial |
$917.24
|
| Rate for Payer: Multiplan Commercial |
$797.60
|
| Rate for Payer: NAPHCARE Commercial |
$598.20
|
| Rate for Payer: Preferred Network Access Commercial |
$917.24
|
| Rate for Payer: Quartz Beloit One Network |
$488.53
|
| Rate for Payer: Quartz Commercial |
$598.20
|
| Rate for Payer: WEA Trust Commercial |
$548.35
|
| Rate for Payer: WPS Commercial |
$738.48
|
|
|
Disposable adhesive
|
Facility
OP
|
$272.00
|
|
| Hospital Charge Code |
3025935
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$76.16 |
| Max. Negotiated Rate |
$1,088.00 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Aetna Managed Medicare |
$76.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$136.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.21
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.00
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$176.80
|
| Rate for Payer: Quartz Medicare Advantage |
$163.20
|
| Rate for Payer: The Alliance Commercial |
$1,088.00
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Disposable adhesive
|
Facility
IP
|
$272.00
|
|
| Hospital Charge Code |
3025935
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$133.28 |
| Max. Negotiated Rate |
$250.24 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$163.20
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
DISPOSABLE BONE MILL STRYKER MEDIUM 5400-701-000
|
Facility
IP
|
$4,690.00
|
|
| Hospital Charge Code |
4447693
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,298.10 |
| Max. Negotiated Rate |
$4,314.80 |
| Rate for Payer: Aetna Commercial |
$4,221.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,485.70
|
| Rate for Payer: Cash Price |
$1,407.00
|
| Rate for Payer: Cigna Commercial |
$4,314.80
|
| Rate for Payer: Health EOS Commercial |
$4,174.10
|
| Rate for Payer: HFN Commercial |
$4,314.80
|
| Rate for Payer: Multiplan Commercial |
$3,752.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,814.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,314.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,298.10
|
| Rate for Payer: Quartz Commercial |
$2,814.00
|
| Rate for Payer: WEA Trust Commercial |
$2,579.50
|
| Rate for Payer: WPS Commercial |
$3,473.88
|
|
|
DISPOSABLE BONE MILL STRYKER MEDIUM 5400-701-000
|
Facility
OP
|
$4,690.00
|
|
| Hospital Charge Code |
4447693
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,313.20 |
| Max. Negotiated Rate |
$18,760.00 |
| Rate for Payer: Aetna Commercial |
$4,221.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,033.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,313.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,048.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,345.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,251.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,485.70
|
| Rate for Payer: Cash Price |
$1,407.00
|
| Rate for Payer: Cigna Commercial |
$4,314.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,624.52
|
| Rate for Payer: Health EOS Commercial |
$4,174.10
|
| Rate for Payer: HFN Commercial |
$4,314.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,517.50
|
| Rate for Payer: Multiplan Commercial |
$3,752.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,814.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,314.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,298.10
|
| Rate for Payer: Quartz Commercial |
$3,048.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,814.00
|
| Rate for Payer: The Alliance Commercial |
$18,760.00
|
| Rate for Payer: WEA Trust Commercial |
$2,579.50
|
| Rate for Payer: WPS Commercial |
$3,473.88
|
|
|
Disposable Bvm - Adult
|
Facility
OP
|
$19.00
|
|
| Hospital Charge Code |
3040344
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.32 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.34
|
| Rate for Payer: Aetna Managed Medicare |
$5.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.07
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$17.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.63
|
| Rate for Payer: Health EOS Commercial |
$16.91
|
| Rate for Payer: HFN Commercial |
$17.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.25
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: NAPHCARE Commercial |
$11.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17.48
|
| Rate for Payer: Quartz Beloit One Network |
$9.31
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: Quartz Medicare Advantage |
$11.40
|
| Rate for Payer: The Alliance Commercial |
$76.00
|
| Rate for Payer: WEA Trust Commercial |
$10.45
|
| Rate for Payer: WPS Commercial |
$14.07
|
|
|
Disposable Bvm - Adult
|
Facility
IP
|
$19.00
|
|
| Hospital Charge Code |
3040344
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$17.48 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.07
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$17.48
|
| Rate for Payer: Health EOS Commercial |
$16.91
|
| Rate for Payer: HFN Commercial |
$17.48
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: NAPHCARE Commercial |
$11.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17.48
|
| Rate for Payer: Quartz Beloit One Network |
$9.31
|
| Rate for Payer: Quartz Commercial |
$11.40
|
| Rate for Payer: WEA Trust Commercial |
$10.45
|
| Rate for Payer: WPS Commercial |
$14.07
|
|
