|
CYSTIC FIBROSIS - PULMONARY DISEASE
|
Facility
|
IP
|
$20,780.89
|
|
|
Service Code
|
APR-DRG 1313
|
| Min. Negotiated Rate |
$18,458.89 |
| Max. Negotiated Rate |
$20,780.89 |
| Rate for Payer: Anthem Medicaid |
$19,898.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$19,898.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19,898.85
|
| Rate for Payer: Dean Health Medicaid |
$19,898.85
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18,458.89
|
| Rate for Payer: Managed Health Services Medicaid |
$20,780.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,898.85
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19,898.85
|
| Rate for Payer: United Healthcare Medicaid |
$19,898.85
|
|
|
CYSTIC FIBROSIS - PULMONARY DISEASE
|
Facility
|
IP
|
$9,469.77
|
|
|
Service Code
|
APR-DRG 1311
|
| Min. Negotiated Rate |
$8,411.64 |
| Max. Negotiated Rate |
$9,469.77 |
| Rate for Payer: Anthem Medicaid |
$9,067.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,067.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,067.83
|
| Rate for Payer: Dean Health Medicaid |
$9,067.83
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,411.64
|
| Rate for Payer: Managed Health Services Medicaid |
$9,469.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,067.83
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,067.83
|
| Rate for Payer: United Healthcare Medicaid |
$9,067.83
|
|
|
CYSTIC FIBROSIS - PULMONARY DISEASE
|
Facility
|
IP
|
$24,375.90
|
|
|
Service Code
|
APR-DRG 1314
|
| Min. Negotiated Rate |
$21,652.20 |
| Max. Negotiated Rate |
$24,375.90 |
| Rate for Payer: Anthem Medicaid |
$23,341.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$23,341.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$23,341.27
|
| Rate for Payer: Dean Health Medicaid |
$23,341.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21,652.20
|
| Rate for Payer: Managed Health Services Medicaid |
$24,375.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$23,341.27
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$23,341.27
|
| Rate for Payer: United Healthcare Medicaid |
$23,341.27
|
|
|
CYSTOGRAFIN diatrizoate 180mg/ml (18%) 300ml soln (MED)
|
Facility
|
IP
|
$236.00
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
6166129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$225.80 |
| Rate for Payer: Aetna Commercial |
$220.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$225.80
|
| Rate for Payer: Health EOS Commercial |
$218.44
|
| Rate for Payer: HFN Commercial |
$225.80
|
| Rate for Payer: Multiplan Commercial |
$196.35
|
| Rate for Payer: Preferred Network Access Commercial |
$225.80
|
| Rate for Payer: Quartz Beloit One Network |
$120.27
|
| Rate for Payer: Quartz Commercial |
$147.26
|
| Rate for Payer: WEA Trust Commercial |
$134.99
|
| Rate for Payer: WPS Commercial |
$181.79
|
|
|
CYSTOGRAFIN diatrizoate 180mg/ml (18%) 300ml soln (MED)
|
Facility
|
OP
|
$236.00
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
6166129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$225.80 |
| Rate for Payer: Aetna Commercial |
$220.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.08
|
| Rate for Payer: Aetna Managed Medicare |
$68.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$159.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$122.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$117.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$225.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.10
|
| Rate for Payer: Health EOS Commercial |
$218.44
|
| Rate for Payer: HFN Commercial |
$225.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$184.08
|
| Rate for Payer: Multiplan Commercial |
$196.35
|
| Rate for Payer: NAPHCARE Commercial |
$147.26
|
| Rate for Payer: Preferred Network Access Commercial |
$225.80
|
| Rate for Payer: Quartz Beloit One Network |
$120.27
|
| Rate for Payer: Quartz Commercial |
$159.54
|
| Rate for Payer: Quartz Medicare Advantage |
$147.26
|
| Rate for Payer: The Alliance Commercial |
$0.33
|
| Rate for Payer: WEA Trust Commercial |
$134.99
|
| Rate for Payer: WPS Commercial |
$0.19
|
|
|
CYSTOGRAM
|
Facility
|
OP
|
$720.00
|
|
| Hospital Charge Code |
2959978
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$209.66 |
| Max. Negotiated Rate |
$688.90 |
| Rate for Payer: Aetna Commercial |
$673.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Aetna Managed Medicare |
$209.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$486.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$374.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$359.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.86
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$688.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$419.04
|
| Rate for Payer: Health EOS Commercial |
$666.43
|
| Rate for Payer: HFN Commercial |
$688.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$561.60
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: NAPHCARE Commercial |
$449.28
|
| Rate for Payer: Preferred Network Access Commercial |
$688.90
|
| Rate for Payer: Quartz Beloit One Network |
$366.91
|
| Rate for Payer: Quartz Commercial |
$486.72
|
| Rate for Payer: Quartz Medicare Advantage |
$449.28
|
| Rate for Payer: The Alliance Commercial |
$374.40
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
CYSTOGRAM
|
Facility
|
IP
|
$720.00
|
|
| Hospital Charge Code |
2959978
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$366.91 |
| Max. Negotiated Rate |
$688.90 |
| Rate for Payer: Aetna Commercial |
$673.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.86
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$688.90
|
| Rate for Payer: Health EOS Commercial |
$666.43
|
| Rate for Payer: HFN Commercial |
$688.90
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: Preferred Network Access Commercial |
$688.90
|
| Rate for Payer: Quartz Beloit One Network |
$366.91
|
| Rate for Payer: Quartz Commercial |
$449.28
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
CYSTOLITHOTOMY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2959980
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| 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: 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: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| 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 |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
CYSTOLITHOTOMY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2959980
|
|
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
|
|
|
CYSTO RECTOCELE REPAIR
|
Facility
|
IP
|
$4,721.00
|
|
| Hospital Charge Code |
2959981
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,405.82 |
| Max. Negotiated Rate |
$4,517.05 |
| Rate for Payer: Aetna Commercial |
$4,418.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,222.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,602.22
|
| Rate for Payer: Cash Price |
$1,416.30
|
| Rate for Payer: Cigna Commercial |
$4,517.05
|
| Rate for Payer: Health EOS Commercial |
$4,369.76
|
| Rate for Payer: HFN Commercial |
$4,517.05
|
| Rate for Payer: Multiplan Commercial |
$3,927.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,517.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,405.82
|
| Rate for Payer: Quartz Commercial |
$2,945.90
|
| Rate for Payer: WEA Trust Commercial |
$2,700.41
|
| Rate for Payer: WPS Commercial |
$3,636.59
|
|
|
CYSTO RECTOCELE REPAIR
|
Facility
|
OP
|
$4,721.00
|
|
| Hospital Charge Code |
2959981
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,374.76 |
| Max. Negotiated Rate |
$4,517.05 |
| Rate for Payer: Aetna Commercial |
$4,418.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,222.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,374.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,191.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,454.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,356.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,602.22
|
| Rate for Payer: Cash Price |
$1,416.30
|
| Rate for Payer: Cigna Commercial |
$4,517.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,747.62
|
| Rate for Payer: Health EOS Commercial |
$4,369.76
|
| Rate for Payer: HFN Commercial |
$4,517.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,682.38
|
| Rate for Payer: Multiplan Commercial |
$3,927.87
|
| Rate for Payer: NAPHCARE Commercial |
$2,945.90
|
| Rate for Payer: Preferred Network Access Commercial |
$4,517.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,405.82
|
| Rate for Payer: Quartz Commercial |
$3,191.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,945.90
|
| Rate for Payer: The Alliance Commercial |
$2,454.92
|
| Rate for Payer: WEA Trust Commercial |
$2,700.41
|
| Rate for Payer: WPS Commercial |
$3,636.59
|
|
|
CYSTORRHAPHY
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2959983
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
CYSTORRHAPHY
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2959983
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
CYSTOSCOPY
|
Facility
|
IP
|
$1,566.00
|
|
| Hospital Charge Code |
2959977
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$798.03 |
| Max. Negotiated Rate |
$1,498.35 |
| Rate for Payer: Aetna Commercial |
$1,465.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,400.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$863.18
|
| Rate for Payer: Cash Price |
$469.80
|
| Rate for Payer: Cigna Commercial |
$1,498.35
|
| Rate for Payer: Health EOS Commercial |
$1,449.49
|
| Rate for Payer: HFN Commercial |
$1,498.35
|
| Rate for Payer: Multiplan Commercial |
$1,302.91
|
| Rate for Payer: Preferred Network Access Commercial |
$1,498.35
|
| Rate for Payer: Quartz Beloit One Network |
$798.03
|
| Rate for Payer: Quartz Commercial |
$977.18
|
| Rate for Payer: WEA Trust Commercial |
$895.75
|
| Rate for Payer: WPS Commercial |
$1,206.29
|
|
|
CYSTOSCOPY
|
Facility
|
OP
|
$1,566.00
|
|
| Hospital Charge Code |
2959977
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.02 |
| Max. Negotiated Rate |
$1,498.35 |
| Rate for Payer: Aetna Commercial |
$1,465.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,400.63
|
| Rate for Payer: Aetna Managed Medicare |
$456.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,058.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$814.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$781.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$863.18
|
| Rate for Payer: Cash Price |
$469.80
|
| Rate for Payer: Cigna Commercial |
$1,498.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$911.41
|
| Rate for Payer: Health EOS Commercial |
$1,449.49
|
| Rate for Payer: HFN Commercial |
$1,498.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,221.48
|
| Rate for Payer: Multiplan Commercial |
$1,302.91
|
| Rate for Payer: NAPHCARE Commercial |
$977.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,498.35
|
| Rate for Payer: Quartz Beloit One Network |
$798.03
|
| Rate for Payer: Quartz Commercial |
$1,058.62
|
| Rate for Payer: Quartz Medicare Advantage |
$977.18
|
| Rate for Payer: The Alliance Commercial |
$814.32
|
| Rate for Payer: WEA Trust Commercial |
$895.75
|
| Rate for Payer: WPS Commercial |
$1,206.29
|
|
|
Cystoscopy 5200022
|
Professional
|
Both
|
$1,075.00
|
|
|
Service Code
|
CPT 52000 22
|
| Hospital Charge Code |
5388760
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$147.17 |
| Max. Negotiated Rate |
$1,062.10 |
| Rate for Payer: Aetna Commercial |
$1,062.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$961.48
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cigna Commercial |
$1,062.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$147.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$670.80
|
| Rate for Payer: Health EOS Commercial |
$1,017.38
|
| Rate for Payer: HFN Commercial |
$1,062.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$278.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$278.46
|
| Rate for Payer: Multiplan Commercial |
$894.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,062.10
|
| Rate for Payer: Quartz Beloit One Network |
$491.92
|
| Rate for Payer: Quartz Commercial |
$637.26
|
| Rate for Payer: The Alliance Commercial |
$559.00
|
| Rate for Payer: United Healthcare Medicaid |
$147.17
|
| Rate for Payer: WEA Trust Commercial |
$614.90
|
| Rate for Payer: WPS Commercial |
$828.07
|
|
|
CYSTOSCOPY AND TREATMENT 52214
|
Professional
|
Both
|
$889.00
|
|
|
Service Code
|
CPT 52214
|
| Hospital Charge Code |
3014984
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$146.68 |
| Max. Negotiated Rate |
$878.33 |
| Rate for Payer: Aetna Commercial |
$878.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$795.12
|
| Rate for Payer: Aetna Managed Medicare |
$146.68
|
| Rate for Payer: Anthem Medicare Advantage |
$146.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$146.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$146.68
|
| Rate for Payer: Cash Price |
$266.70
|
| Rate for Payer: Cash Price |
$266.70
|
| Rate for Payer: Cash Price |
$266.70
|
| Rate for Payer: Cigna Commercial |
$878.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$158.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.68
|
| Rate for Payer: Health EOS Commercial |
$841.35
|
| Rate for Payer: HFN Commercial |
$878.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$609.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$609.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$146.68
|
| Rate for Payer: Multiplan Commercial |
$739.65
|
| Rate for Payer: NAPHCARE Commercial |
$220.02
|
| Rate for Payer: Preferred Network Access Commercial |
$878.33
|
| Rate for Payer: Quartz Beloit One Network |
$406.81
|
| Rate for Payer: Quartz Commercial |
$527.00
|
| Rate for Payer: Quartz Medicare Advantage |
$146.68
|
| Rate for Payer: The Alliance Commercial |
$623.40
|
| Rate for Payer: United Healthcare Medicaid |
$158.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$146.68
|
| Rate for Payer: WEA Trust Commercial |
$508.51
|
| Rate for Payer: WPS Commercial |
$660.07
|
|
|
CYSTOSCOPY AND TREATMENT 52224
|
Professional
|
Both
|
$1,724.00
|
|
|
Service Code
|
CPT 52224
|
| Hospital Charge Code |
3014985
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$158.07 |
| Max. Negotiated Rate |
$1,703.31 |
| Rate for Payer: Aetna Commercial |
$1,703.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.95
|
| Rate for Payer: Aetna Managed Medicare |
$169.74
|
| Rate for Payer: Anthem Medicare Advantage |
$169.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$169.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$169.74
|
| Rate for Payer: Cash Price |
$517.20
|
| Rate for Payer: Cash Price |
$517.20
|
| Rate for Payer: Cash Price |
$517.20
|
| Rate for Payer: Cigna Commercial |
$1,703.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$158.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$169.74
|
| Rate for Payer: Health EOS Commercial |
$1,631.59
|
| Rate for Payer: HFN Commercial |
$1,703.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$703.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$703.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$169.74
|
| Rate for Payer: Multiplan Commercial |
$1,434.37
|
| Rate for Payer: NAPHCARE Commercial |
$254.61
|
| Rate for Payer: Preferred Network Access Commercial |
$1,703.31
|
| Rate for Payer: Quartz Beloit One Network |
$788.90
|
| Rate for Payer: Quartz Commercial |
$1,021.99
|
| Rate for Payer: Quartz Medicare Advantage |
$169.74
|
| Rate for Payer: The Alliance Commercial |
$721.39
|
| Rate for Payer: United Healthcare Medicaid |
$158.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$169.74
|
| Rate for Payer: WEA Trust Commercial |
$986.13
|
| Rate for Payer: WPS Commercial |
$763.82
|
|
|
Cystoscopy and Treatment 5231050
|
Professional
|
Both
|
$3,685.00
|
|
|
Service Code
|
CPT 52310 50
|
| Hospital Charge Code |
3898160
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$253.91 |
| Max. Negotiated Rate |
$3,640.78 |
| Rate for Payer: Aetna Commercial |
$3,640.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,295.86
|
| Rate for Payer: Cash Price |
$1,105.50
|
| Rate for Payer: Cash Price |
$1,105.50
|
| Rate for Payer: Cash Price |
$1,105.50
|
| Rate for Payer: Cigna Commercial |
$3,640.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$253.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,299.44
|
| Rate for Payer: Health EOS Commercial |
$3,487.48
|
| Rate for Payer: HFN Commercial |
$3,640.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$522.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$522.12
|
| Rate for Payer: Multiplan Commercial |
$3,065.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,640.78
|
| Rate for Payer: Quartz Beloit One Network |
$1,686.26
|
| Rate for Payer: Quartz Commercial |
$2,184.47
|
| Rate for Payer: The Alliance Commercial |
$1,916.20
|
| Rate for Payer: United Healthcare Medicaid |
$253.91
|
| Rate for Payer: WEA Trust Commercial |
$2,107.82
|
| Rate for Payer: WPS Commercial |
$2,838.56
|
|
|
CYSTOSCOPY AND TREATMENT 52332
|
Professional
|
Both
|
$2,455.00
|
|
|
Service Code
|
CPT 52332
|
| Hospital Charge Code |
3014994
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$134.98 |
| Max. Negotiated Rate |
$2,425.54 |
| Rate for Payer: Aetna Commercial |
$2,425.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,195.75
|
| Rate for Payer: Aetna Managed Medicare |
$134.98
|
| Rate for Payer: Anthem Medicare Advantage |
$134.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$134.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$134.98
|
| Rate for Payer: Cash Price |
$736.50
|
| Rate for Payer: Cash Price |
$736.50
|
| Rate for Payer: Cash Price |
$736.50
|
| Rate for Payer: Cigna Commercial |
$2,425.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$313.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.98
|
| Rate for Payer: Health EOS Commercial |
$2,323.41
|
| Rate for Payer: HFN Commercial |
$2,425.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$536.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$536.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$134.98
|
| Rate for Payer: Multiplan Commercial |
$2,042.56
|
| Rate for Payer: NAPHCARE Commercial |
$202.47
|
| Rate for Payer: Preferred Network Access Commercial |
$2,425.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,123.41
|
| Rate for Payer: Quartz Commercial |
$1,455.32
|
| Rate for Payer: Quartz Medicare Advantage |
$134.98
|
| Rate for Payer: The Alliance Commercial |
$573.67
|
| Rate for Payer: United Healthcare Medicaid |
$313.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$134.98
|
| Rate for Payer: WEA Trust Commercial |
$1,404.26
|
| Rate for Payer: WPS Commercial |
$607.42
|
|
|
Cystoscopy and Treatment 5233222
|
Professional
|
Both
|
$2,886.00
|
|
|
Service Code
|
CPT 52332 22
|
| Hospital Charge Code |
3975037
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$313.36 |
| Max. Negotiated Rate |
$2,851.37 |
| Rate for Payer: Aetna Commercial |
$2,851.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,581.24
|
| Rate for Payer: Cash Price |
$865.80
|
| Rate for Payer: Cash Price |
$865.80
|
| Rate for Payer: Cash Price |
$865.80
|
| Rate for Payer: Cigna Commercial |
$2,851.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$313.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,800.86
|
| Rate for Payer: Health EOS Commercial |
$2,731.31
|
| Rate for Payer: HFN Commercial |
$2,851.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$536.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$536.66
|
| Rate for Payer: Multiplan Commercial |
$2,401.15
|
| Rate for Payer: Preferred Network Access Commercial |
$2,851.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,320.63
|
| Rate for Payer: Quartz Commercial |
$1,710.82
|
| Rate for Payer: The Alliance Commercial |
$1,500.72
|
| Rate for Payer: United Healthcare Medicaid |
$313.36
|
| Rate for Payer: WEA Trust Commercial |
$1,650.79
|
| Rate for Payer: WPS Commercial |
$2,223.09
|
|
|
Cystoscopy and Treatment 5233250
|
Professional
|
Both
|
$4,911.00
|
|
|
Service Code
|
CPT 52332 50
|
| Hospital Charge Code |
3493548
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$313.36 |
| Max. Negotiated Rate |
$4,852.07 |
| Rate for Payer: Aetna Commercial |
$4,852.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,392.40
|
| Rate for Payer: Cash Price |
$1,473.30
|
| Rate for Payer: Cash Price |
$1,473.30
|
| Rate for Payer: Cash Price |
$1,473.30
|
| Rate for Payer: Cigna Commercial |
$4,852.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$313.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,064.46
|
| Rate for Payer: Health EOS Commercial |
$4,647.77
|
| Rate for Payer: HFN Commercial |
$4,852.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$536.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$536.66
|
| Rate for Payer: Multiplan Commercial |
$4,085.95
|
| Rate for Payer: Preferred Network Access Commercial |
$4,852.07
|
| Rate for Payer: Quartz Beloit One Network |
$2,247.27
|
| Rate for Payer: Quartz Commercial |
$2,911.24
|
| Rate for Payer: The Alliance Commercial |
$2,553.72
|
| Rate for Payer: United Healthcare Medicaid |
$313.36
|
| Rate for Payer: WEA Trust Commercial |
$2,809.09
|
| Rate for Payer: WPS Commercial |
$3,782.94
|
|
|
CYSTOSCOPY, REMOVAL OF CLOTS 52001
|
Professional
|
Both
|
$1,425.00
|
|
|
Service Code
|
CPT 52001
|
| Hospital Charge Code |
3014981
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$135.92 |
| Max. Negotiated Rate |
$1,407.90 |
| Rate for Payer: Aetna Commercial |
$1,407.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Aetna Managed Medicare |
$244.30
|
| Rate for Payer: Anthem Medicare Advantage |
$244.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$244.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$244.30
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,407.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$135.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$244.30
|
| Rate for Payer: Health EOS Commercial |
$1,348.62
|
| Rate for Payer: HFN Commercial |
$1,407.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$991.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$991.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$244.30
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$366.44
|
| Rate for Payer: Preferred Network Access Commercial |
$1,407.90
|
| Rate for Payer: Quartz Beloit One Network |
$652.08
|
| Rate for Payer: Quartz Commercial |
$844.74
|
| Rate for Payer: Quartz Medicare Advantage |
$244.30
|
| Rate for Payer: The Alliance Commercial |
$1,038.26
|
| Rate for Payer: United Healthcare Medicaid |
$135.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$244.30
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,099.33
|
|
|
CYSTOSCOPY & TREATMENT-BILATERAL 523322250
|
Professional
|
Both
|
$5,772.00
|
|
|
Service Code
|
CPT 52332 23,50
|
| Hospital Charge Code |
6172222
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$313.36 |
| Max. Negotiated Rate |
$5,702.74 |
| Rate for Payer: Aetna Commercial |
$5,702.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,162.48
|
| Rate for Payer: Cash Price |
$1,731.60
|
| Rate for Payer: Cash Price |
$1,731.60
|
| Rate for Payer: Cash Price |
$1,731.60
|
| Rate for Payer: Cigna Commercial |
$5,702.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$313.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,601.73
|
| Rate for Payer: Health EOS Commercial |
$5,462.62
|
| Rate for Payer: HFN Commercial |
$5,702.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$536.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$536.66
|
| Rate for Payer: Multiplan Commercial |
$4,802.30
|
| Rate for Payer: Preferred Network Access Commercial |
$5,702.74
|
| Rate for Payer: Quartz Beloit One Network |
$2,641.27
|
| Rate for Payer: Quartz Commercial |
$3,421.64
|
| Rate for Payer: The Alliance Commercial |
$3,001.44
|
| Rate for Payer: United Healthcare Medicaid |
$313.36
|
| Rate for Payer: WEA Trust Commercial |
$3,301.58
|
| Rate for Payer: WPS Commercial |
$4,446.17
|
|
|
CYSTOSCOPY & URETER CATHETER 52005
|
Professional
|
Both
|
$1,406.00
|
|
|
Service Code
|
CPT 52005
|
| Hospital Charge Code |
3014982
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$115.96 |
| Max. Negotiated Rate |
$1,389.13 |
| Rate for Payer: Aetna Commercial |
$1,389.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,257.53
|
| Rate for Payer: Aetna Managed Medicare |
$115.96
|
| Rate for Payer: Anthem Medicare Advantage |
$115.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$115.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$115.96
|
| Rate for Payer: Cash Price |
$421.80
|
| Rate for Payer: Cash Price |
$421.80
|
| Rate for Payer: Cash Price |
$421.80
|
| Rate for Payer: Cigna Commercial |
$1,389.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$203.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.96
|
| Rate for Payer: Health EOS Commercial |
$1,330.64
|
| Rate for Payer: HFN Commercial |
$1,389.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$458.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$458.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$115.96
|
| Rate for Payer: Multiplan Commercial |
$1,169.79
|
| Rate for Payer: NAPHCARE Commercial |
$173.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,389.13
|
| Rate for Payer: Quartz Beloit One Network |
$643.39
|
| Rate for Payer: Quartz Commercial |
$833.48
|
| Rate for Payer: Quartz Medicare Advantage |
$115.96
|
| Rate for Payer: The Alliance Commercial |
$492.83
|
| Rate for Payer: United Healthcare Medicaid |
$203.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$115.96
|
| Rate for Payer: WEA Trust Commercial |
$804.23
|
| Rate for Payer: WPS Commercial |
$521.82
|
|
