|
Dengue Virus RNA, Real-Time PCR
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
4392627
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$109.05 |
| Max. Negotiated Rate |
$204.76 |
| Rate for Payer: Aetna Commercial |
$200.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.96
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$204.76
|
| Rate for Payer: Health EOS Commercial |
$198.08
|
| Rate for Payer: HFN Commercial |
$204.76
|
| Rate for Payer: Multiplan Commercial |
$178.05
|
| Rate for Payer: Preferred Network Access Commercial |
$204.76
|
| Rate for Payer: Quartz Beloit One Network |
$109.05
|
| Rate for Payer: Quartz Commercial |
$133.54
|
| Rate for Payer: WEA Trust Commercial |
$122.41
|
| Rate for Payer: WPS Commercial |
$164.84
|
|
|
Dengue Virus RNA, Real-Time PCR
|
Professional
|
Both
|
$214.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
4392627
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.49 |
| Max. Negotiated Rate |
$211.43 |
| Rate for Payer: Aetna Commercial |
$211.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.40
|
| Rate for Payer: Aetna Managed Medicare |
$36.49
|
| Rate for Payer: Anthem Medicare Advantage |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.49
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$211.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$111.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.49
|
| Rate for Payer: Health EOS Commercial |
$202.53
|
| Rate for Payer: HFN Commercial |
$211.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$128.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.49
|
| Rate for Payer: Multiplan Commercial |
$178.05
|
| Rate for Payer: NAPHCARE Commercial |
$54.74
|
| Rate for Payer: Preferred Network Access Commercial |
$211.43
|
| Rate for Payer: Quartz Beloit One Network |
$97.93
|
| Rate for Payer: Quartz Commercial |
$126.86
|
| Rate for Payer: Quartz Medicare Advantage |
$36.49
|
| Rate for Payer: The Alliance Commercial |
$144.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.49
|
| Rate for Payer: WEA Trust Commercial |
$122.41
|
| Rate for Payer: WPS Commercial |
$160.57
|
|
|
DENTAL AND ORAL DIAGNOSES AND INJURIES
|
Facility
|
OP
|
$29.03
|
|
|
Service Code
|
EAPG 00563
|
| Min. Negotiated Rate |
$27.91 |
| Max. Negotiated Rate |
$29.03 |
| Rate for Payer: Anthem Medicaid |
$27.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$27.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.91
|
| Rate for Payer: Dean Health Medicaid |
$27.91
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$27.91
|
| Rate for Payer: Managed Health Services Medicaid |
$29.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.91
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$27.91
|
| Rate for Payer: United Healthcare Medicaid |
$27.91
|
|
|
DENTAL AND ORAL DISEASES WITH CC
|
Facility
|
IP
|
$26,281.84
|
|
|
Service Code
|
MSDRG 158
|
| Min. Negotiated Rate |
$7,474.22 |
| Max. Negotiated Rate |
$26,281.84 |
| Rate for Payer: Aetna Managed Medicare |
$7,474.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,851.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,215.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,455.92
|
| Rate for Payer: Anthem Medicare Advantage |
$7,474.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,474.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,474.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,474.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16,047.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,474.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,032.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,474.22
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,474.22
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,474.22
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,474.22
|
| Rate for Payer: NAPHCARE Commercial |
$11,211.33
|
| Rate for Payer: Quartz Medicare Advantage |
$7,474.22
|
| Rate for Payer: The Alliance Commercial |
$26,281.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,474.22
|
| Rate for Payer: United Healthcare PPO |
$14,817.26
|
| Rate for Payer: Wellcare Medicare |
$7,474.22
|
|
|
DENTAL AND ORAL DISEASES WITH MCC
|
Facility
|
IP
|
$47,531.12
|
|
|
Service Code
|
MSDRG 157
|
| Min. Negotiated Rate |
$13,654.38 |
| Max. Negotiated Rate |
$47,531.12 |
| Rate for Payer: Aetna Managed Medicare |
$13,654.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37,459.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28,712.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,278.44
|
| Rate for Payer: Anthem Medicare Advantage |
$13,654.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13,654.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13,654.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13,654.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30,281.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13,654.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,617.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13,654.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13,654.38
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13,654.38
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13,654.38
|
| Rate for Payer: NAPHCARE Commercial |
$20,481.57
|
| Rate for Payer: Quartz Medicare Advantage |
$13,654.38
|
| Rate for Payer: The Alliance Commercial |
$47,531.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13,654.38
|
| Rate for Payer: United Healthcare PPO |
$26,950.53
|
| Rate for Payer: Wellcare Medicare |
$13,654.38
|
|
|
DENTAL AND ORAL DISEASES WITHOUT CC/MCC
|
Facility
|
IP
|
$19,001.84
|
|
|
Service Code
|
MSDRG 159
|
| Min. Negotiated Rate |
$5,932.61 |
| Max. Negotiated Rate |
$19,001.84 |
| Rate for Payer: Aetna Managed Medicare |
$5,932.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,458.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,849.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,257.44
|
| Rate for Payer: Anthem Medicare Advantage |
$5,932.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,932.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,932.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,932.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,496.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,932.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,693.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,932.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,932.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,932.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,932.61
|
| Rate for Payer: NAPHCARE Commercial |
$8,898.91
|
| Rate for Payer: Quartz Medicare Advantage |
$5,932.61
|
| Rate for Payer: The Alliance Commercial |
$19,001.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,932.61
|
| Rate for Payer: United Healthcare PPO |
$10,660.22
|
| Rate for Payer: Wellcare Medicare |
$5,932.61
|
|
|
DENTAL ANESTHESIA
|
Facility
|
OP
|
$9.29
|
|
|
Service Code
|
EAPG 00375
|
| Min. Negotiated Rate |
$8.93 |
| Max. Negotiated Rate |
$9.29 |
| Rate for Payer: Anthem Medicaid |
$8.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.93
|
| Rate for Payer: Dean Health Medicaid |
$8.93
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.93
|
| Rate for Payer: Managed Health Services Medicaid |
$9.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.93
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.93
|
| Rate for Payer: United Healthcare Medicaid |
$8.93
|
|
|
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 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
|
$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: Molina Healthcare Medicaid |
$5,457.49
|
| 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: Quartz Badgercare/Employee Trust Funds/QHP |
$5,457.49
|
| Rate for Payer: United Healthcare Medicaid |
$5,457.49
|
|
|
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 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 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: HFN Commercial |
$28.65
|
| 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: 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
|
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
|
|
|
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
|
|
|
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 |
$5,266.00 |
| Rate for Payer: Aetna Commercial |
$2,383.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,157.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,914.91
|
| Rate for Payer: Anthem Medicare Advantage |
$1,914.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,914.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,914.91
|
| 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 |
$1,914.91
|
| Rate for Payer: Multiplan Commercial |
$2,006.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,872.37
|
| 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 |
$1,914.91
|
| Rate for Payer: The Alliance Commercial |
$5,266.00
|
| Rate for Payer: United Healthcare Medicaid |
$1,834.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,914.91
|
| 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 |
$7,659.64 |
| Rate for Payer: Aetna Commercial |
$2,257.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,157.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,914.91
|
| 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 |
$1,914.91
|
| 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 |
$1,914.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,914.91
|
| 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 |
$1,914.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,168.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,914.91
|
| 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 |
$7,123.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,914.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,914.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,914.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,914.91
|
| Rate for Payer: Multiplan Commercial |
$2,006.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,872.37
|
| 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 |
$1,914.91
|
| Rate for Payer: The Alliance Commercial |
$7,659.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,914.91
|
| Rate for Payer: WEA Trust Commercial |
$1,379.66
|
| Rate for Payer: Wellcare Medicare |
$1,914.91
|
| Rate for Payer: WPS Commercial |
$4,097.91
|
|
|
DEPRESSION EXCEPT MAJOR DEPRESSIVE DIAGNOSES
|
Facility
|
OP
|
$41.28
|
|
|
Service Code
|
EAPG 00824
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$41.28 |
| Rate for Payer: Anthem Medicaid |
$39.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$39.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.69
|
| Rate for Payer: Dean Health Medicaid |
$39.69
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$39.69
|
| Rate for Payer: Managed Health Services Medicaid |
$41.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.69
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$39.69
|
| Rate for Payer: United Healthcare Medicaid |
$39.69
|
|
|
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 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
|
|
