|
DIAPERS PREM 3-6 LB INFANT 04261
|
Facility
|
OP
|
$81.00
|
|
| Hospital Charge Code |
2963729
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.59 |
| Max. Negotiated Rate |
$77.50 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$23.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.14
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.18
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$50.54
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$54.76
|
| Rate for Payer: Quartz Medicare Advantage |
$50.54
|
| Rate for Payer: The Alliance Commercial |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$62.39
|
|
|
DIAPERS SIZE 3 STRETCH
|
Facility
|
OP
|
$135.00
|
|
| Hospital Charge Code |
2963801
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$129.17 |
| Rate for Payer: Aetna Commercial |
$126.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.74
|
| Rate for Payer: Aetna Managed Medicare |
$39.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$91.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$70.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$67.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.41
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$129.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.57
|
| Rate for Payer: Health EOS Commercial |
$124.96
|
| Rate for Payer: HFN Commercial |
$129.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.30
|
| Rate for Payer: Multiplan Commercial |
$112.32
|
| Rate for Payer: NAPHCARE Commercial |
$84.24
|
| Rate for Payer: Preferred Network Access Commercial |
$129.17
|
| Rate for Payer: Quartz Beloit One Network |
$68.80
|
| Rate for Payer: Quartz Commercial |
$91.26
|
| Rate for Payer: Quartz Medicare Advantage |
$84.24
|
| Rate for Payer: The Alliance Commercial |
$70.20
|
| Rate for Payer: WEA Trust Commercial |
$77.22
|
| Rate for Payer: WPS Commercial |
$103.99
|
|
|
DIAPERS SIZE 3 STRETCH
|
Facility
|
IP
|
$135.00
|
|
| Hospital Charge Code |
2963801
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$68.80 |
| Max. Negotiated Rate |
$129.17 |
| Rate for Payer: Aetna Commercial |
$126.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.41
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$129.17
|
| Rate for Payer: Health EOS Commercial |
$124.96
|
| Rate for Payer: HFN Commercial |
$129.17
|
| Rate for Payer: Multiplan Commercial |
$112.32
|
| Rate for Payer: Preferred Network Access Commercial |
$129.17
|
| Rate for Payer: Quartz Beloit One Network |
$68.80
|
| Rate for Payer: Quartz Commercial |
$84.24
|
| Rate for Payer: WEA Trust Commercial |
$77.22
|
| Rate for Payer: WPS Commercial |
$103.99
|
|
|
DIAPERS SIZE 4 STRETCH
|
Facility
|
IP
|
$92.00
|
|
| Hospital Charge Code |
2964012
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$57.41
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
DIAPERS SIZE 4 STRETCH
|
Facility
|
OP
|
$92.00
|
|
| Hospital Charge Code |
2964012
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.79 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Aetna Managed Medicare |
$26.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$47.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.54
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: NAPHCARE Commercial |
$57.41
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$62.19
|
| Rate for Payer: Quartz Medicare Advantage |
$57.41
|
| Rate for Payer: The Alliance Commercial |
$47.84
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
DIAPERS SML SZ 1 ULT DRY THIN
|
Facility
|
OP
|
$81.00
|
|
| Hospital Charge Code |
2963770
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.59 |
| Max. Negotiated Rate |
$77.50 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$23.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.14
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.18
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$50.54
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$54.76
|
| Rate for Payer: Quartz Medicare Advantage |
$50.54
|
| Rate for Payer: The Alliance Commercial |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$62.39
|
|
|
DIAPERS SML SZ 1 ULT DRY THIN
|
Facility
|
IP
|
$81.00
|
|
| Hospital Charge Code |
2963770
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$41.28 |
| Max. Negotiated Rate |
$77.50 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$50.54
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$62.39
|
|
|
DIAPHRAGMATIC PROCEDURES AND RELATED HERNIA REPAIR
|
Facility
|
OP
|
$1,428.67
|
|
|
Service Code
|
EAPG 00073
|
| Min. Negotiated Rate |
$1,373.71 |
| Max. Negotiated Rate |
$1,428.67 |
| Rate for Payer: Anthem Medicaid |
$1,373.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$1,373.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,373.71
|
| Rate for Payer: Dean Health Medicaid |
$1,373.71
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$1,373.71
|
| Rate for Payer: Managed Health Services Medicaid |
$1,428.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,373.71
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$1,373.71
|
| Rate for Payer: United Healthcare Medicaid |
$1,373.71
|
|
|
Diazepam 10mg/2ml syringe [MED]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
2983116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.82 |
| Max. Negotiated Rate |
$31.57 |
| Rate for Payer: Aetna Commercial |
$30.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.19
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$31.57
|
| Rate for Payer: Health EOS Commercial |
$30.54
|
| Rate for Payer: HFN Commercial |
$31.57
|
| Rate for Payer: Multiplan Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$31.57
|
| Rate for Payer: Quartz Beloit One Network |
$16.82
|
| Rate for Payer: Quartz Commercial |
$20.59
|
| Rate for Payer: WEA Trust Commercial |
$18.88
|
| Rate for Payer: WPS Commercial |
$25.42
|
|
|
Diazepam 10mg/2ml syringe [MED]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
2983116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$31.57 |
| Rate for Payer: Aetna Commercial |
$30.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.52
|
| Rate for Payer: Aetna Managed Medicare |
$9.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.19
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$31.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.00
|
| Rate for Payer: Health EOS Commercial |
$30.54
|
| Rate for Payer: HFN Commercial |
$31.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.74
|
| Rate for Payer: Multiplan Commercial |
$27.46
|
| Rate for Payer: NAPHCARE Commercial |
$20.59
|
| Rate for Payer: Preferred Network Access Commercial |
$31.57
|
| Rate for Payer: Quartz Beloit One Network |
$16.82
|
| Rate for Payer: Quartz Commercial |
$22.31
|
| Rate for Payer: Quartz Medicare Advantage |
$20.59
|
| Rate for Payer: The Alliance Commercial |
$28.50
|
| Rate for Payer: WEA Trust Commercial |
$18.88
|
| Rate for Payer: WPS Commercial |
$17.00
|
|
|
Diazepam JW Waste Charge per 0.5 mg
|
Professional
|
Both
|
$56.00
|
|
|
Service Code
|
HCPCS J3360 JW
|
| Hospital Charge Code |
5266697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$55.33 |
| Rate for Payer: Aetna Commercial |
$55.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$55.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.80
|
| Rate for Payer: Health EOS Commercial |
$53.00
|
| Rate for Payer: HFN Commercial |
$55.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.75
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$55.33
|
| Rate for Payer: Quartz Beloit One Network |
$25.63
|
| Rate for Payer: Quartz Commercial |
$33.20
|
| Rate for Payer: The Alliance Commercial |
$29.12
|
| Rate for Payer: United Healthcare Medicaid |
$6.96
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$17.00
|
|
|
Diazepam JW Waste Charge per 0.5 mg
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
HCPCS J3360 JW
|
| Hospital Charge Code |
5266697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$34.94
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
Diazepam JW Waste Charge per 0.5 mg
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
HCPCS J3360 JW
|
| Hospital Charge Code |
5266697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$16.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.00
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.68
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$37.86
|
| Rate for Payer: Quartz Medicare Advantage |
$34.94
|
| Rate for Payer: The Alliance Commercial |
$29.12
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$17.00
|
|
|
Different Drug Addíl IV Push 96375 - Admin Each Add'l IV Push Charge
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
3023768
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$95.30 |
| Max. Negotiated Rate |
$178.92 |
| Rate for Payer: Aetna Commercial |
$175.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.07
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$178.92
|
| Rate for Payer: Health EOS Commercial |
$173.09
|
| Rate for Payer: HFN Commercial |
$178.92
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: Preferred Network Access Commercial |
$178.92
|
| Rate for Payer: Quartz Beloit One Network |
$95.30
|
| Rate for Payer: Quartz Commercial |
$116.69
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
Different Drug Addíl IV Push 96375 - Admin Each Add'l IV Push Charge
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
3023768
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$49.28 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$175.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.35
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.28
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$178.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$173.09
|
| Rate for Payer: HFN Commercial |
$178.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49.28
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$178.92
|
| Rate for Payer: Quartz Beloit One Network |
$95.30
|
| Rate for Payer: Quartz Commercial |
$126.41
|
| Rate for Payer: Quartz Medicare Advantage |
$49.28
|
| Rate for Payer: The Alliance Commercial |
$197.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.28
|
| Rate for Payer: United Healthcare PPO |
$145.86
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
Diffusion Capacity - Pulmonary Function Test Charge
|
Facility
|
IP
|
$675.00
|
|
|
Service Code
|
CPT 94729
|
| Hospital Charge Code |
3006997
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$343.98 |
| Max. Negotiated Rate |
$645.84 |
| Rate for Payer: Aetna Commercial |
$631.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$603.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$372.06
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$645.84
|
| Rate for Payer: Health EOS Commercial |
$624.78
|
| Rate for Payer: HFN Commercial |
$645.84
|
| Rate for Payer: Multiplan Commercial |
$561.60
|
| Rate for Payer: Preferred Network Access Commercial |
$645.84
|
| Rate for Payer: Quartz Beloit One Network |
$343.98
|
| Rate for Payer: Quartz Commercial |
$421.20
|
| Rate for Payer: WEA Trust Commercial |
$386.10
|
| Rate for Payer: WPS Commercial |
$519.95
|
|
|
Diffusion Capacity - Pulmonary Function Test Charge
|
Facility
|
OP
|
$675.00
|
|
|
Service Code
|
CPT 94729
|
| Hospital Charge Code |
3006997
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$196.56 |
| Max. Negotiated Rate |
$645.84 |
| Rate for Payer: Aetna Commercial |
$631.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$603.72
|
| Rate for Payer: Aetna Managed Medicare |
$196.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$456.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$351.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$336.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$372.06
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$645.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$392.85
|
| Rate for Payer: Health EOS Commercial |
$624.78
|
| Rate for Payer: HFN Commercial |
$645.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$526.50
|
| Rate for Payer: Multiplan Commercial |
$561.60
|
| Rate for Payer: NAPHCARE Commercial |
$421.20
|
| Rate for Payer: Preferred Network Access Commercial |
$645.84
|
| Rate for Payer: Quartz Beloit One Network |
$343.98
|
| Rate for Payer: Quartz Commercial |
$456.30
|
| Rate for Payer: Quartz Medicare Advantage |
$421.20
|
| Rate for Payer: The Alliance Commercial |
$252.22
|
| Rate for Payer: United Healthcare PPO |
$526.50
|
| Rate for Payer: WEA Trust Commercial |
$386.10
|
| Rate for Payer: WPS Commercial |
$519.95
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$20,254.80
|
|
|
Service Code
|
APR-DRG 2404
|
| Min. Negotiated Rate |
$17,991.57 |
| Max. Negotiated Rate |
$20,254.80 |
| Rate for Payer: Anthem Medicaid |
$19,395.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$19,395.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19,395.08
|
| Rate for Payer: Dean Health Medicaid |
$19,395.08
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17,991.57
|
| Rate for Payer: Managed Health Services Medicaid |
$20,254.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,395.08
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19,395.08
|
| Rate for Payer: United Healthcare Medicaid |
$19,395.08
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$7,014.65
|
|
|
Service Code
|
APR-DRG 2401
|
| Min. Negotiated Rate |
$6,230.85 |
| Max. Negotiated Rate |
$7,014.65 |
| Rate for Payer: Anthem Medicaid |
$6,716.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,716.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,716.91
|
| Rate for Payer: Dean Health Medicaid |
$6,716.91
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6,230.85
|
| Rate for Payer: Managed Health Services Medicaid |
$7,014.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,716.91
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,716.91
|
| Rate for Payer: United Healthcare Medicaid |
$6,716.91
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
OP
|
$38.50
|
|
|
Service Code
|
EAPG 00620
|
| Min. Negotiated Rate |
$37.02 |
| Max. Negotiated Rate |
$38.50 |
| Rate for Payer: Anthem Medicaid |
$37.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$37.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.02
|
| Rate for Payer: Dean Health Medicaid |
$37.02
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$37.02
|
| Rate for Payer: Managed Health Services Medicaid |
$38.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.02
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$37.02
|
| Rate for Payer: United Healthcare Medicaid |
$37.02
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$8,680.63
|
|
|
Service Code
|
APR-DRG 2402
|
| Min. Negotiated Rate |
$7,710.67 |
| Max. Negotiated Rate |
$8,680.63 |
| Rate for Payer: Anthem Medicaid |
$8,312.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,312.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,312.18
|
| Rate for Payer: Dean Health Medicaid |
$8,312.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,710.67
|
| Rate for Payer: Managed Health Services Medicaid |
$8,680.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,312.18
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,312.18
|
| Rate for Payer: United Healthcare Medicaid |
$8,312.18
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$12,714.05
|
|
|
Service Code
|
APR-DRG 2403
|
| Min. Negotiated Rate |
$11,293.41 |
| Max. Negotiated Rate |
$12,714.05 |
| Rate for Payer: Anthem Medicaid |
$12,174.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12,174.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12,174.40
|
| Rate for Payer: Dean Health Medicaid |
$12,174.40
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11,293.41
|
| Rate for Payer: Managed Health Services Medicaid |
$12,714.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,174.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12,174.40
|
| Rate for Payer: United Healthcare Medicaid |
$12,174.40
|
|
|
DIGESTIVE MALIGNANCY WITH CC
|
Facility
|
IP
|
$33,465.12
|
|
|
Service Code
|
MSDRG 375
|
| Min. Negotiated Rate |
$9,770.14 |
| Max. Negotiated Rate |
$33,465.12 |
| Rate for Payer: Aetna Managed Medicare |
$9,770.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26,392.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,229.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19,219.48
|
| Rate for Payer: Anthem Medicare Advantage |
$9,770.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,770.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,770.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,770.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21,335.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,770.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,301.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,770.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,770.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,770.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,770.14
|
| Rate for Payer: NAPHCARE Commercial |
$14,655.22
|
| Rate for Payer: Quartz Medicare Advantage |
$9,770.14
|
| Rate for Payer: The Alliance Commercial |
$33,465.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,770.14
|
| Rate for Payer: United Healthcare PPO |
$18,919.05
|
| Rate for Payer: Wellcare Medicare |
$9,770.14
|
|
|
DIGESTIVE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$58,368.96
|
|
|
Service Code
|
MSDRG 374
|
| Min. Negotiated Rate |
$16,885.37 |
| Max. Negotiated Rate |
$58,368.96 |
| Rate for Payer: Aetna Managed Medicare |
$16,885.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46,664.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35,768.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33,982.06
|
| Rate for Payer: Anthem Medicare Advantage |
$16,885.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,885.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,885.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,885.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37,723.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,885.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42,567.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,885.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,885.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,885.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,885.37
|
| Rate for Payer: NAPHCARE Commercial |
$25,328.05
|
| Rate for Payer: Quartz Medicare Advantage |
$16,885.37
|
| Rate for Payer: The Alliance Commercial |
$58,368.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,885.37
|
| Rate for Payer: United Healthcare PPO |
$33,139.52
|
| Rate for Payer: Wellcare Medicare |
$16,885.37
|
|
|
DIGESTIVE MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$24,979.76
|
|
|
Service Code
|
MSDRG 376
|
| Min. Negotiated Rate |
$7,585.25 |
| Max. Negotiated Rate |
$24,979.76 |
| Rate for Payer: Aetna Managed Medicare |
$7,585.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20,167.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,458.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,686.31
|
| Rate for Payer: Anthem Medicare Advantage |
$7,585.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,585.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,585.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,585.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16,303.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,585.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,077.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,585.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,585.25
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,585.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,585.25
|
| Rate for Payer: NAPHCARE Commercial |
$11,377.88
|
| Rate for Payer: Quartz Medicare Advantage |
$7,585.25
|
| Rate for Payer: The Alliance Commercial |
$24,979.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,585.25
|
| Rate for Payer: United Healthcare PPO |
$14,073.63
|
| Rate for Payer: Wellcare Medicare |
$7,585.25
|
|
