|
DENTAL ANESTHESIA
|
Facility
|
OP
|
$740.32
|
|
|
Service Code
|
EAPG 00375
|
| Min. Negotiated Rate |
$711.84 |
| Max. Negotiated Rate |
$740.32 |
| Rate for Payer: Anthem Medicaid |
$711.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$711.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$711.84
|
| Rate for Payer: Dean Health Medicaid |
$711.84
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$711.84
|
| Rate for Payer: Managed Health Services Medicaid |
$740.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$711.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$711.84
|
| Rate for Payer: United Healthcare Medicaid |
$711.84
|
|
|
DENTAL DISEASES AND DISORDERS
|
Facility
|
IP
|
$23,586.75
|
|
|
Service Code
|
APR-DRG 1144
|
| Min. Negotiated Rate |
$20,951.23 |
| Max. Negotiated Rate |
$23,586.75 |
| Rate for Payer: Anthem Medicaid |
$22,585.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$22,585.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22,585.62
|
| Rate for Payer: Dean Health Medicaid |
$22,585.62
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$20,951.23
|
| Rate for Payer: Managed Health Services Medicaid |
$23,586.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$22,585.62
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$22,585.62
|
| Rate for Payer: United Healthcare Medicaid |
$22,585.62
|
|
|
DENTAL DISEASES AND DISORDERS
|
Facility
|
IP
|
$5,699.40
|
|
|
Service Code
|
APR-DRG 1142
|
| Min. Negotiated Rate |
$5,062.56 |
| Max. Negotiated Rate |
$5,699.40 |
| Rate for Payer: Anthem Medicaid |
$5,457.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,457.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,457.49
|
| Rate for Payer: Dean Health Medicaid |
$5,457.49
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,062.56
|
| Rate for Payer: Managed Health Services Medicaid |
$5,699.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,457.49
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,457.49
|
| Rate for Payer: United Healthcare Medicaid |
$5,457.49
|
|
|
DENTAL DISEASES AND DISORDERS
|
Facility
|
IP
|
$8,505.26
|
|
|
Service Code
|
APR-DRG 1143
|
| Min. Negotiated Rate |
$7,554.90 |
| Max. Negotiated Rate |
$8,505.26 |
| Rate for Payer: Anthem Medicaid |
$8,144.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,144.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,144.26
|
| Rate for Payer: Dean Health Medicaid |
$8,144.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,554.90
|
| Rate for Payer: Managed Health Services Medicaid |
$8,505.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,144.26
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,144.26
|
| Rate for Payer: United Healthcare Medicaid |
$8,144.26
|
|
|
DENTAL DISEASES AND DISORDERS
|
Facility
|
IP
|
$4,121.11
|
|
|
Service Code
|
APR-DRG 1141
|
| Min. Negotiated Rate |
$3,660.62 |
| Max. Negotiated Rate |
$4,121.11 |
| Rate for Payer: Anthem Medicaid |
$3,946.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$3,946.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,946.19
|
| Rate for Payer: Dean Health Medicaid |
$3,946.19
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,660.62
|
| Rate for Payer: Managed Health Services Medicaid |
$4,121.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,946.19
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3,946.19
|
| Rate for Payer: United Healthcare Medicaid |
$3,946.19
|
|
|
DENTAL RELATED PROCEDURE, EMERGENT CARE
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2950464
|
|
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
|
|
|
DENTAL RELATED PROCEDURE, EMERGENT CARE
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2950464
|
|
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
|
|
|
Dental Varnish
|
Professional
|
Both
|
$29.00
|
|
|
Service Code
|
CPT D1208
|
| Hospital Charge Code |
2572837
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.27 |
| Max. Negotiated Rate |
$36.05 |
| Rate for Payer: Aetna Commercial |
$28.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$28.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.10
|
| Rate for Payer: Health EOS Commercial |
$27.45
|
| Rate for Payer: HFN Commercial |
$28.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$36.05
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: Preferred Network Access Commercial |
$28.65
|
| Rate for Payer: Quartz Beloit One Network |
$13.27
|
| Rate for Payer: Quartz Commercial |
$17.19
|
| Rate for Payer: The Alliance Commercial |
$15.08
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$22.34
|
|
|
DENTISTRY, OPERATIVE
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960255
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
DENTISTRY, OPERATIVE
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960255
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
Deoxycorticosterone
|
Professional
|
Both
|
$452.00
|
|
|
Service Code
|
CPT 82633
|
| Hospital Charge Code |
977923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.22 |
| Max. Negotiated Rate |
$446.58 |
| Rate for Payer: Aetna Commercial |
$446.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.27
|
| Rate for Payer: Aetna Managed Medicare |
$32.22
|
| Rate for Payer: Anthem Medicare Advantage |
$32.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32.22
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$446.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$235.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.22
|
| Rate for Payer: Health EOS Commercial |
$427.77
|
| Rate for Payer: HFN Commercial |
$446.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$113.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32.22
|
| Rate for Payer: Multiplan Commercial |
$376.06
|
| Rate for Payer: NAPHCARE Commercial |
$48.33
|
| Rate for Payer: Preferred Network Access Commercial |
$446.58
|
| Rate for Payer: Quartz Beloit One Network |
$206.84
|
| Rate for Payer: Quartz Commercial |
$267.95
|
| Rate for Payer: Quartz Medicare Advantage |
$32.22
|
| Rate for Payer: The Alliance Commercial |
$127.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.22
|
| Rate for Payer: WEA Trust Commercial |
$258.54
|
| Rate for Payer: WPS Commercial |
$141.76
|
|
|
Deoxycorticosterone
|
Facility
|
IP
|
$452.00
|
|
|
Service Code
|
CPT 82633
|
| Hospital Charge Code |
977923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$230.34 |
| Max. Negotiated Rate |
$432.47 |
| Rate for Payer: Aetna Commercial |
$423.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.14
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$432.47
|
| Rate for Payer: Health EOS Commercial |
$418.37
|
| Rate for Payer: HFN Commercial |
$432.47
|
| Rate for Payer: Multiplan Commercial |
$376.06
|
| Rate for Payer: Preferred Network Access Commercial |
$432.47
|
| Rate for Payer: Quartz Beloit One Network |
$230.34
|
| Rate for Payer: Quartz Commercial |
$282.05
|
| Rate for Payer: WEA Trust Commercial |
$258.54
|
| Rate for Payer: WPS Commercial |
$348.18
|
|
|
Deoxycorticosterone
|
Facility
|
OP
|
$452.00
|
|
|
Service Code
|
CPT 82633
|
| Hospital Charge Code |
977923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.22 |
| Max. Negotiated Rate |
$432.47 |
| Rate for Payer: Aetna Commercial |
$423.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.27
|
| Rate for Payer: Aetna Managed Medicare |
$32.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$120.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.38
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.48
|
| Rate for Payer: Anthem Medicare Advantage |
$32.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32.22
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$432.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$32.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$263.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$32.22
|
| Rate for Payer: Health EOS Commercial |
$418.37
|
| Rate for Payer: HFN Commercial |
$432.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.22
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32.22
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$32.22
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$32.22
|
| Rate for Payer: Multiplan Commercial |
$376.06
|
| Rate for Payer: NAPHCARE Commercial |
$48.33
|
| Rate for Payer: Preferred Network Access Commercial |
$432.47
|
| Rate for Payer: Quartz Beloit One Network |
$230.34
|
| Rate for Payer: Quartz Commercial |
$305.55
|
| Rate for Payer: Quartz Medicare Advantage |
$32.22
|
| Rate for Payer: The Alliance Commercial |
$128.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.22
|
| Rate for Payer: United Healthcare PPO |
$352.56
|
| Rate for Payer: WEA Trust Commercial |
$258.54
|
| Rate for Payer: Wellcare Medicare |
$32.22
|
| Rate for Payer: WPS Commercial |
$348.18
|
|
|
Depo Suspension 3.75 mg Charge
|
Facility
|
IP
|
$2,412.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
2958934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,229.16 |
| Max. Negotiated Rate |
$2,307.80 |
| Rate for Payer: Aetna Commercial |
$2,257.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,157.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,329.49
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,307.80
|
| Rate for Payer: Health EOS Commercial |
$2,232.55
|
| Rate for Payer: HFN Commercial |
$2,307.80
|
| Rate for Payer: Multiplan Commercial |
$2,006.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,307.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,229.16
|
| Rate for Payer: Quartz Commercial |
$1,505.09
|
| Rate for Payer: WEA Trust Commercial |
$1,379.66
|
| Rate for Payer: WPS Commercial |
$1,857.96
|
|
|
Depo Suspension 3.75 mg Charge
|
Professional
|
Both
|
$2,412.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
2958934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,103.73 |
| Max. Negotiated Rate |
$5,044.67 |
| Rate for Payer: Aetna Commercial |
$2,383.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,157.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,834.42
|
| Rate for Payer: Anthem Medicare Advantage |
$1,834.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,834.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,834.42
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,383.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,834.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,639.16
|
| Rate for Payer: Health EOS Commercial |
$2,282.72
|
| Rate for Payer: HFN Commercial |
$2,383.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,925.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,925.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,834.42
|
| Rate for Payer: Multiplan Commercial |
$2,006.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,751.64
|
| Rate for Payer: Preferred Network Access Commercial |
$2,383.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,103.73
|
| Rate for Payer: Quartz Commercial |
$1,429.83
|
| Rate for Payer: Quartz Medicare Advantage |
$1,834.42
|
| Rate for Payer: The Alliance Commercial |
$5,044.67
|
| Rate for Payer: United Healthcare Medicaid |
$1,834.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,834.42
|
| Rate for Payer: WEA Trust Commercial |
$1,379.66
|
| Rate for Payer: WPS Commercial |
$4,097.91
|
|
|
Depo Suspension 3.75 mg Charge
|
Facility
|
OP
|
$2,412.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
2958934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,204.07 |
| Max. Negotiated Rate |
$7,337.70 |
| Rate for Payer: Aetna Commercial |
$2,257.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,157.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,834.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,630.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,254.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,204.07
|
| Rate for Payer: Anthem Medicare Advantage |
$1,834.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,329.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,834.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,834.42
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,307.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,834.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,168.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,834.42
|
| Rate for Payer: Health EOS Commercial |
$2,232.55
|
| Rate for Payer: HFN Commercial |
$2,307.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,824.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,834.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,834.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,834.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,834.42
|
| Rate for Payer: Multiplan Commercial |
$2,006.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,751.64
|
| Rate for Payer: Preferred Network Access Commercial |
$2,307.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,229.16
|
| Rate for Payer: Quartz Commercial |
$1,630.51
|
| Rate for Payer: Quartz Medicare Advantage |
$1,834.42
|
| Rate for Payer: The Alliance Commercial |
$7,337.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,834.42
|
| Rate for Payer: WEA Trust Commercial |
$1,379.66
|
| Rate for Payer: Wellcare Medicare |
$1,834.42
|
| Rate for Payer: WPS Commercial |
$4,097.91
|
|
|
DEPRESSION EXCEPT MAJOR DEPRESSIVE DIAGNOSES
|
Facility
|
OP
|
$86.48
|
|
|
Service Code
|
EAPG 00824
|
| Min. Negotiated Rate |
$83.15 |
| Max. Negotiated Rate |
$86.48 |
| Rate for Payer: Anthem Medicaid |
$83.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$83.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$83.15
|
| Rate for Payer: Dean Health Medicaid |
$83.15
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$83.15
|
| Rate for Payer: Managed Health Services Medicaid |
$86.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$83.15
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$83.15
|
| Rate for Payer: United Healthcare Medicaid |
$83.15
|
|
|
DEPRESSIVE DISORDERS
|
Facility
|
IP
|
$3,244.27
|
|
|
Service Code
|
APR-DRG 7511
|
| Min. Negotiated Rate |
$2,881.77 |
| Max. Negotiated Rate |
$3,244.27 |
| Rate for Payer: Anthem Medicaid |
$3,106.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$3,106.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,106.57
|
| Rate for Payer: Dean Health Medicaid |
$3,106.57
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$2,881.77
|
| Rate for Payer: Managed Health Services Medicaid |
$3,244.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,106.57
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3,106.57
|
| Rate for Payer: United Healthcare Medicaid |
$3,106.57
|
|
|
DEPRESSIVE DISORDERS
|
Facility
|
IP
|
$4,384.15
|
|
|
Service Code
|
APR-DRG 7512
|
| Min. Negotiated Rate |
$3,894.28 |
| Max. Negotiated Rate |
$4,384.15 |
| Rate for Payer: Anthem Medicaid |
$4,198.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,198.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,198.07
|
| Rate for Payer: Dean Health Medicaid |
$4,198.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,894.28
|
| Rate for Payer: Managed Health Services Medicaid |
$4,384.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,198.07
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,198.07
|
| Rate for Payer: United Healthcare Medicaid |
$4,198.07
|
|
|
DEPRESSIVE DISORDERS
|
Facility
|
IP
|
$16,922.84
|
|
|
Service Code
|
APR-DRG 7514
|
| Min. Negotiated Rate |
$15,031.92 |
| Max. Negotiated Rate |
$16,922.84 |
| Rate for Payer: Anthem Medicaid |
$16,204.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$16,204.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16,204.55
|
| Rate for Payer: Dean Health Medicaid |
$16,204.55
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15,031.92
|
| Rate for Payer: Managed Health Services Medicaid |
$16,922.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,204.55
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16,204.55
|
| Rate for Payer: United Healthcare Medicaid |
$16,204.55
|
|
|
DEPRESSIVE DISORDERS
|
Facility
|
IP
|
$8,855.99
|
|
|
Service Code
|
APR-DRG 7513
|
| Min. Negotiated Rate |
$7,866.45 |
| Max. Negotiated Rate |
$8,855.99 |
| Rate for Payer: Anthem Medicaid |
$8,480.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,480.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,480.10
|
| Rate for Payer: Dean Health Medicaid |
$8,480.10
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,866.45
|
| Rate for Payer: Managed Health Services Medicaid |
$8,855.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,480.10
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,480.10
|
| Rate for Payer: United Healthcare Medicaid |
$8,480.10
|
|
|
DEPRESSIVE NEUROSES
|
Facility
|
IP
|
$25,397.84
|
|
|
Service Code
|
MSDRG 881
|
| Min. Negotiated Rate |
$7,712.38 |
| Max. Negotiated Rate |
$25,397.84 |
| Rate for Payer: Aetna Managed Medicare |
$7,712.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20,529.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,735.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,950.07
|
| Rate for Payer: Anthem Medicare Advantage |
$7,712.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,712.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,712.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,712.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16,595.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,712.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,712.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,712.38
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,712.38
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,712.38
|
| Rate for Payer: NAPHCARE Commercial |
$11,568.57
|
| Rate for Payer: Quartz Medicare Advantage |
$7,712.38
|
| Rate for Payer: The Alliance Commercial |
$25,397.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,712.38
|
| Rate for Payer: United Healthcare PPO |
$14,312.04
|
| Rate for Payer: Wellcare Medicare |
$7,712.38
|
|
|
DEPTH GAUGE/COUNTER SINK 3.0MM IS1104
|
Facility
|
IP
|
$4,846.00
|
|
| Hospital Charge Code |
5831690
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,469.52 |
| Max. Negotiated Rate |
$4,636.65 |
| Rate for Payer: Aetna Commercial |
$4,535.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,334.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.12
|
| Rate for Payer: Cash Price |
$1,453.80
|
| Rate for Payer: Cigna Commercial |
$4,636.65
|
| Rate for Payer: Health EOS Commercial |
$4,485.46
|
| Rate for Payer: HFN Commercial |
$4,636.65
|
| Rate for Payer: Multiplan Commercial |
$4,031.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,636.65
|
| Rate for Payer: Quartz Beloit One Network |
$2,469.52
|
| Rate for Payer: Quartz Commercial |
$3,023.90
|
| Rate for Payer: WEA Trust Commercial |
$2,771.91
|
| Rate for Payer: WPS Commercial |
$3,732.87
|
|
|
DEPTH GAUGE/COUNTER SINK 3.0MM IS1104
|
Facility
|
OP
|
$4,846.00
|
|
| Hospital Charge Code |
5831690
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,411.16 |
| Max. Negotiated Rate |
$4,636.65 |
| Rate for Payer: Aetna Commercial |
$4,535.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,334.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,275.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,519.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.12
|
| Rate for Payer: Cash Price |
$1,453.80
|
| Rate for Payer: Cigna Commercial |
$4,636.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.37
|
| Rate for Payer: Health EOS Commercial |
$4,485.46
|
| Rate for Payer: HFN Commercial |
$4,636.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,779.88
|
| Rate for Payer: Multiplan Commercial |
$4,031.87
|
| Rate for Payer: NAPHCARE Commercial |
$3,023.90
|
| Rate for Payer: Preferred Network Access Commercial |
$4,636.65
|
| Rate for Payer: Quartz Beloit One Network |
$2,469.52
|
| Rate for Payer: Quartz Commercial |
$3,275.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,023.90
|
| Rate for Payer: The Alliance Commercial |
$2,519.92
|
| Rate for Payer: WEA Trust Commercial |
$2,771.91
|
| Rate for Payer: WPS Commercial |
$3,732.87
|
|
|
DE QUERVAIN'S RELEASE
|
Facility
|
IP
|
$1,337.00
|
|
| Hospital Charge Code |
2959994
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$681.34 |
| Max. Negotiated Rate |
$1,279.24 |
| Rate for Payer: Aetna Commercial |
$1,251.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,195.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$736.95
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,279.24
|
| Rate for Payer: Health EOS Commercial |
$1,237.53
|
| Rate for Payer: HFN Commercial |
$1,279.24
|
| Rate for Payer: Multiplan Commercial |
$1,112.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,279.24
|
| Rate for Payer: Quartz Beloit One Network |
$681.34
|
| Rate for Payer: Quartz Commercial |
$834.29
|
| Rate for Payer: WEA Trust Commercial |
$764.76
|
| Rate for Payer: WPS Commercial |
$1,029.89
|
|
