|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$21,745.41
|
|
|
Service Code
|
APR-DRG 3041
|
| Min. Negotiated Rate |
$19,315.63 |
| Max. Negotiated Rate |
$21,745.41 |
| Rate for Payer: Anthem Medicaid |
$20,822.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$20,822.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20,822.43
|
| Rate for Payer: Dean Health Medicaid |
$20,822.43
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19,315.63
|
| Rate for Payer: Managed Health Services Medicaid |
$21,745.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$20,822.43
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$20,822.43
|
| Rate for Payer: United Healthcare Medicaid |
$20,822.43
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$56,029.50
|
|
|
Service Code
|
APR-DRG 3044
|
| Min. Negotiated Rate |
$49,768.90 |
| Max. Negotiated Rate |
$56,029.50 |
| Rate for Payer: Anthem Medicaid |
$53,651.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$53,651.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53,651.33
|
| Rate for Payer: Dean Health Medicaid |
$53,651.33
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$49,768.90
|
| Rate for Payer: Managed Health Services Medicaid |
$56,029.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$53,651.33
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$53,651.33
|
| Rate for Payer: United Healthcare Medicaid |
$53,651.33
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$29,636.89
|
|
|
Service Code
|
APR-DRG 3042
|
| Min. Negotiated Rate |
$26,325.33 |
| Max. Negotiated Rate |
$29,636.89 |
| Rate for Payer: Anthem Medicaid |
$28,378.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$28,378.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28,378.95
|
| Rate for Payer: Dean Health Medicaid |
$28,378.95
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26,325.33
|
| Rate for Payer: Managed Health Services Medicaid |
$29,636.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$28,378.95
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$28,378.95
|
| Rate for Payer: United Healthcare Medicaid |
$28,378.95
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$40,071.18
|
|
|
Service Code
|
APR-DRG 3032
|
| Min. Negotiated Rate |
$35,593.72 |
| Max. Negotiated Rate |
$40,071.18 |
| Rate for Payer: Anthem Medicaid |
$38,370.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$38,370.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38,370.36
|
| Rate for Payer: Dean Health Medicaid |
$38,370.36
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$35,593.72
|
| Rate for Payer: Managed Health Services Medicaid |
$40,071.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$38,370.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$38,370.36
|
| Rate for Payer: United Healthcare Medicaid |
$38,370.36
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$34,722.51
|
|
|
Service Code
|
APR-DRG 3031
|
| Min. Negotiated Rate |
$30,842.70 |
| Max. Negotiated Rate |
$34,722.51 |
| Rate for Payer: Anthem Medicaid |
$33,248.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$33,248.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33,248.71
|
| Rate for Payer: Dean Health Medicaid |
$33,248.71
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$30,842.70
|
| Rate for Payer: Managed Health Services Medicaid |
$34,722.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$33,248.71
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$33,248.71
|
| Rate for Payer: United Healthcare Medicaid |
$33,248.71
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$55,152.67
|
|
|
Service Code
|
APR-DRG 3033
|
| Min. Negotiated Rate |
$48,990.04 |
| Max. Negotiated Rate |
$55,152.67 |
| Rate for Payer: Anthem Medicaid |
$52,811.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$52,811.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52,811.72
|
| Rate for Payer: Dean Health Medicaid |
$52,811.72
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$48,990.04
|
| Rate for Payer: Managed Health Services Medicaid |
$55,152.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$52,811.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$52,811.72
|
| Rate for Payer: United Healthcare Medicaid |
$52,811.72
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$79,440.89
|
|
|
Service Code
|
APR-DRG 3034
|
| Min. Negotiated Rate |
$70,564.35 |
| Max. Negotiated Rate |
$79,440.89 |
| Rate for Payer: Anthem Medicaid |
$76,069.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$76,069.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76,069.03
|
| Rate for Payer: Dean Health Medicaid |
$76,069.03
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$70,564.35
|
| Rate for Payer: Managed Health Services Medicaid |
$79,440.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$76,069.03
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$76,069.03
|
| Rate for Payer: United Healthcare Medicaid |
$76,069.03
|
|
|
DORSAL BLOCKING SPLINT SMALL
|
Facility
|
OP
|
$769.00
|
|
| Hospital Charge Code |
2971619
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$223.93 |
| Max. Negotiated Rate |
$735.78 |
| Rate for Payer: Aetna Commercial |
$719.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$687.79
|
| Rate for Payer: Aetna Managed Medicare |
$223.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$519.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$399.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$383.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$423.87
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$735.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$447.56
|
| Rate for Payer: Health EOS Commercial |
$711.79
|
| Rate for Payer: HFN Commercial |
$735.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$599.82
|
| Rate for Payer: Multiplan Commercial |
$639.81
|
| Rate for Payer: NAPHCARE Commercial |
$479.86
|
| Rate for Payer: Preferred Network Access Commercial |
$735.78
|
| Rate for Payer: Quartz Beloit One Network |
$391.88
|
| Rate for Payer: Quartz Commercial |
$519.84
|
| Rate for Payer: Quartz Medicare Advantage |
$479.86
|
| Rate for Payer: The Alliance Commercial |
$399.88
|
| Rate for Payer: WEA Trust Commercial |
$439.87
|
| Rate for Payer: WPS Commercial |
$592.36
|
|
|
DORSAL BLOCKING SPLINT SMALL
|
Facility
|
IP
|
$769.00
|
|
| Hospital Charge Code |
2971619
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$391.88 |
| Max. Negotiated Rate |
$735.78 |
| Rate for Payer: Aetna Commercial |
$719.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$687.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$423.87
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$735.78
|
| Rate for Payer: Health EOS Commercial |
$711.79
|
| Rate for Payer: HFN Commercial |
$735.78
|
| Rate for Payer: Multiplan Commercial |
$639.81
|
| Rate for Payer: Preferred Network Access Commercial |
$735.78
|
| Rate for Payer: Quartz Beloit One Network |
$391.88
|
| Rate for Payer: Quartz Commercial |
$479.86
|
| Rate for Payer: WEA Trust Commercial |
$439.87
|
| Rate for Payer: WPS Commercial |
$592.36
|
|
|
DORSAL SLIT
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2959997
|
|
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
|
|
|
DORSAL SLIT
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2959997
|
|
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
|
|
|
Dorzolamide Ophth Solution 5ml [Med]
|
Facility
|
OP
|
$145.00
|
|
| Hospital Charge Code |
2974995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.22 |
| Max. Negotiated Rate |
$138.74 |
| Rate for Payer: Aetna Commercial |
$135.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.69
|
| Rate for Payer: Aetna Managed Medicare |
$42.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.92
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$138.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.39
|
| Rate for Payer: Health EOS Commercial |
$134.21
|
| Rate for Payer: HFN Commercial |
$138.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.10
|
| Rate for Payer: Multiplan Commercial |
$120.64
|
| Rate for Payer: NAPHCARE Commercial |
$90.48
|
| Rate for Payer: Preferred Network Access Commercial |
$138.74
|
| Rate for Payer: Quartz Beloit One Network |
$73.89
|
| Rate for Payer: Quartz Commercial |
$98.02
|
| Rate for Payer: Quartz Medicare Advantage |
$90.48
|
| Rate for Payer: The Alliance Commercial |
$75.40
|
| Rate for Payer: WEA Trust Commercial |
$82.94
|
| Rate for Payer: WPS Commercial |
$111.69
|
|
|
Dorzolamide Ophth Solution 5ml [Med]
|
Facility
|
IP
|
$145.00
|
|
| Hospital Charge Code |
2974995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.89 |
| Max. Negotiated Rate |
$138.74 |
| Rate for Payer: Aetna Commercial |
$135.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.92
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$138.74
|
| Rate for Payer: Health EOS Commercial |
$134.21
|
| Rate for Payer: HFN Commercial |
$138.74
|
| Rate for Payer: Multiplan Commercial |
$120.64
|
| Rate for Payer: Preferred Network Access Commercial |
$138.74
|
| Rate for Payer: Quartz Beloit One Network |
$73.89
|
| Rate for Payer: Quartz Commercial |
$90.48
|
| Rate for Payer: WEA Trust Commercial |
$82.94
|
| Rate for Payer: WPS Commercial |
$111.69
|
|
|
Dosimetry Plan, Total Body 7732126
|
Professional
|
Both
|
$681.00
|
|
|
Service Code
|
CPT 77321 26
|
| Hospital Charge Code |
5258632
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.03 |
| Max. Negotiated Rate |
$672.83 |
| Rate for Payer: Aetna Commercial |
$672.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$609.09
|
| Rate for Payer: Aetna Managed Medicare |
$50.03
|
| Rate for Payer: Anthem Medicare Advantage |
$50.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$50.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$50.03
|
| Rate for Payer: Cash Price |
$204.30
|
| Rate for Payer: Cash Price |
$204.30
|
| Rate for Payer: Cash Price |
$204.30
|
| Rate for Payer: Cigna Commercial |
$672.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$354.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.03
|
| Rate for Payer: Health EOS Commercial |
$644.50
|
| Rate for Payer: HFN Commercial |
$672.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$178.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$178.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$50.03
|
| Rate for Payer: Multiplan Commercial |
$566.59
|
| Rate for Payer: NAPHCARE Commercial |
$75.05
|
| Rate for Payer: Preferred Network Access Commercial |
$672.83
|
| Rate for Payer: Quartz Beloit One Network |
$311.63
|
| Rate for Payer: Quartz Commercial |
$403.70
|
| Rate for Payer: Quartz Medicare Advantage |
$50.03
|
| Rate for Payer: The Alliance Commercial |
$190.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.03
|
| Rate for Payer: WEA Trust Commercial |
$389.53
|
| Rate for Payer: WPS Commercial |
$250.17
|
|
|
Dotatate
|
Facility
|
OP
|
$11,922.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
5454948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.62 |
| Max. Negotiated Rate |
$11,406.97 |
| Rate for Payer: Aetna Commercial |
$11,158.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,663.04
|
| Rate for Payer: Aetna Managed Medicare |
$51.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,059.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,199.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,951.46
|
| Rate for Payer: Anthem Medicare Advantage |
$51.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,571.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$51.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$51.62
|
| Rate for Payer: Cash Price |
$3,576.60
|
| Rate for Payer: Cash Price |
$3,576.60
|
| Rate for Payer: Cigna Commercial |
$11,406.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$51.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,938.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$51.62
|
| Rate for Payer: Health EOS Commercial |
$11,035.00
|
| Rate for Payer: HFN Commercial |
$11,406.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$192.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$51.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$51.62
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$51.62
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$51.62
|
| Rate for Payer: Multiplan Commercial |
$9,919.10
|
| Rate for Payer: NAPHCARE Commercial |
$77.42
|
| Rate for Payer: Preferred Network Access Commercial |
$11,406.97
|
| Rate for Payer: Quartz Beloit One Network |
$6,075.45
|
| Rate for Payer: Quartz Commercial |
$8,059.27
|
| Rate for Payer: Quartz Medicare Advantage |
$51.62
|
| Rate for Payer: The Alliance Commercial |
$206.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51.62
|
| Rate for Payer: WEA Trust Commercial |
$6,819.38
|
| Rate for Payer: Wellcare Medicare |
$51.62
|
| Rate for Payer: WPS Commercial |
$9,183.52
|
|
|
Dotatate
|
Professional
|
Both
|
$11,922.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
5454948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.10 |
| Max. Negotiated Rate |
$11,778.94 |
| Rate for Payer: Aetna Commercial |
$11,778.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,663.04
|
| Rate for Payer: Cash Price |
$3,576.60
|
| Rate for Payer: Cash Price |
$3,576.60
|
| Rate for Payer: Cigna Commercial |
$11,778.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,199.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,439.33
|
| Rate for Payer: Health EOS Commercial |
$11,282.98
|
| Rate for Payer: HFN Commercial |
$11,778.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$118.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$118.10
|
| Rate for Payer: Multiplan Commercial |
$9,919.10
|
| Rate for Payer: Preferred Network Access Commercial |
$11,778.94
|
| Rate for Payer: Quartz Beloit One Network |
$5,455.51
|
| Rate for Payer: Quartz Commercial |
$7,067.36
|
| Rate for Payer: The Alliance Commercial |
$6,199.44
|
| Rate for Payer: WEA Trust Commercial |
$6,819.38
|
| Rate for Payer: WPS Commercial |
$9,183.52
|
|
|
Dotatate
|
Facility
|
IP
|
$11,922.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
5454948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,075.45 |
| Max. Negotiated Rate |
$11,406.97 |
| Rate for Payer: Aetna Commercial |
$11,158.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,663.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,571.41
|
| Rate for Payer: Cash Price |
$3,576.60
|
| Rate for Payer: Cigna Commercial |
$11,406.97
|
| Rate for Payer: Health EOS Commercial |
$11,035.00
|
| Rate for Payer: HFN Commercial |
$11,406.97
|
| Rate for Payer: Multiplan Commercial |
$9,919.10
|
| Rate for Payer: Preferred Network Access Commercial |
$11,406.97
|
| Rate for Payer: Quartz Beloit One Network |
$6,075.45
|
| Rate for Payer: Quartz Commercial |
$7,439.33
|
| Rate for Payer: WEA Trust Commercial |
$6,819.38
|
| Rate for Payer: WPS Commercial |
$9,183.52
|
|
|
DOUBLE CUT 4.0MM X 13CM AR-8400DC
|
Facility
|
IP
|
$925.00
|
|
| Hospital Charge Code |
5106647
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$471.38 |
| Max. Negotiated Rate |
$885.04 |
| Rate for Payer: Aetna Commercial |
$865.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$827.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$509.86
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$885.04
|
| Rate for Payer: Health EOS Commercial |
$856.18
|
| Rate for Payer: HFN Commercial |
$885.04
|
| Rate for Payer: Multiplan Commercial |
$769.60
|
| Rate for Payer: Preferred Network Access Commercial |
$885.04
|
| Rate for Payer: Quartz Beloit One Network |
$471.38
|
| Rate for Payer: Quartz Commercial |
$577.20
|
| Rate for Payer: WEA Trust Commercial |
$529.10
|
| Rate for Payer: WPS Commercial |
$712.53
|
|
|
DOUBLE CUT 4.0MM X 13CM AR-8400DC
|
Facility
|
OP
|
$925.00
|
|
| Hospital Charge Code |
5106647
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$269.36 |
| Max. Negotiated Rate |
$885.04 |
| Rate for Payer: Aetna Commercial |
$865.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$827.32
|
| Rate for Payer: Aetna Managed Medicare |
$269.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$625.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$481.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$461.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$509.86
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$885.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$538.35
|
| Rate for Payer: Health EOS Commercial |
$856.18
|
| Rate for Payer: HFN Commercial |
$885.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$721.50
|
| Rate for Payer: Multiplan Commercial |
$769.60
|
| Rate for Payer: NAPHCARE Commercial |
$577.20
|
| Rate for Payer: Preferred Network Access Commercial |
$885.04
|
| Rate for Payer: Quartz Beloit One Network |
$471.38
|
| Rate for Payer: Quartz Commercial |
$625.30
|
| Rate for Payer: Quartz Medicare Advantage |
$577.20
|
| Rate for Payer: The Alliance Commercial |
$481.00
|
| Rate for Payer: WEA Trust Commercial |
$529.10
|
| Rate for Payer: WPS Commercial |
$712.53
|
|
|
Doxepin Lvl / 826
|
Professional
|
Both
|
$226.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977929
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$223.29 |
| Rate for Payer: Aetna Commercial |
$223.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.13
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cigna Commercial |
$223.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.02
|
| Rate for Payer: Health EOS Commercial |
$213.89
|
| Rate for Payer: HFN Commercial |
$223.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$188.03
|
| Rate for Payer: Preferred Network Access Commercial |
$223.29
|
| Rate for Payer: Quartz Beloit One Network |
$103.42
|
| Rate for Payer: Quartz Commercial |
$133.97
|
| Rate for Payer: The Alliance Commercial |
$117.52
|
| Rate for Payer: WEA Trust Commercial |
$129.27
|
| Rate for Payer: WPS Commercial |
$174.09
|
|
|
Doxepin Lvl / 826
|
Facility
|
OP
|
$226.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977929
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.81 |
| Max. Negotiated Rate |
$216.24 |
| Rate for Payer: Aetna Commercial |
$211.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.13
|
| Rate for Payer: Aetna Managed Medicare |
$65.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$152.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$117.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$112.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.57
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cigna Commercial |
$216.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$131.53
|
| Rate for Payer: Health EOS Commercial |
$209.19
|
| Rate for Payer: HFN Commercial |
$216.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$176.28
|
| Rate for Payer: Multiplan Commercial |
$188.03
|
| Rate for Payer: NAPHCARE Commercial |
$141.02
|
| Rate for Payer: Preferred Network Access Commercial |
$216.24
|
| Rate for Payer: Quartz Beloit One Network |
$115.17
|
| Rate for Payer: Quartz Commercial |
$152.78
|
| Rate for Payer: Quartz Medicare Advantage |
$141.02
|
| Rate for Payer: The Alliance Commercial |
$117.52
|
| Rate for Payer: United Healthcare PPO |
$176.28
|
| Rate for Payer: WEA Trust Commercial |
$129.27
|
| Rate for Payer: WPS Commercial |
$174.09
|
|
|
Doxepin Lvl / 826
|
Facility
|
IP
|
$226.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977929
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$115.17 |
| Max. Negotiated Rate |
$216.24 |
| Rate for Payer: Aetna Commercial |
$211.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.57
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cigna Commercial |
$216.24
|
| Rate for Payer: Health EOS Commercial |
$209.19
|
| Rate for Payer: HFN Commercial |
$216.24
|
| Rate for Payer: Multiplan Commercial |
$188.03
|
| Rate for Payer: Preferred Network Access Commercial |
$216.24
|
| Rate for Payer: Quartz Beloit One Network |
$115.17
|
| Rate for Payer: Quartz Commercial |
$141.02
|
| Rate for Payer: WEA Trust Commercial |
$129.27
|
| Rate for Payer: WPS Commercial |
$174.09
|
|
|
DRAIN 15FR HUBLESS 3/4 FLUTED SILICONE CHANNEL 072228
|
Facility
|
OP
|
$234.00
|
|
| Hospital Charge Code |
5729793
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.14 |
| Max. Negotiated Rate |
$223.89 |
| Rate for Payer: Aetna Commercial |
$219.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.29
|
| Rate for Payer: Aetna Managed Medicare |
$68.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$158.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$121.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$116.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.98
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$223.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.19
|
| Rate for Payer: Health EOS Commercial |
$216.59
|
| Rate for Payer: HFN Commercial |
$223.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.52
|
| Rate for Payer: Multiplan Commercial |
$194.69
|
| Rate for Payer: NAPHCARE Commercial |
$146.02
|
| Rate for Payer: Preferred Network Access Commercial |
$223.89
|
| Rate for Payer: Quartz Beloit One Network |
$119.25
|
| Rate for Payer: Quartz Commercial |
$158.18
|
| Rate for Payer: Quartz Medicare Advantage |
$146.02
|
| Rate for Payer: The Alliance Commercial |
$121.68
|
| Rate for Payer: WEA Trust Commercial |
$133.85
|
| Rate for Payer: WPS Commercial |
$180.25
|
|
|
DRAIN 15FR HUBLESS 3/4 FLUTED SILICONE CHANNEL 072228
|
Facility
|
IP
|
$234.00
|
|
| Hospital Charge Code |
5729793
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$119.25 |
| Max. Negotiated Rate |
$223.89 |
| Rate for Payer: Aetna Commercial |
$219.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.98
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$223.89
|
| Rate for Payer: Health EOS Commercial |
$216.59
|
| Rate for Payer: HFN Commercial |
$223.89
|
| Rate for Payer: Multiplan Commercial |
$194.69
|
| Rate for Payer: Preferred Network Access Commercial |
$223.89
|
| Rate for Payer: Quartz Beloit One Network |
$119.25
|
| Rate for Payer: Quartz Commercial |
$146.02
|
| Rate for Payer: WEA Trust Commercial |
$133.85
|
| Rate for Payer: WPS Commercial |
$180.25
|
|
|
DRAIN 24FR HUBLESS FULL-FLUTED 072234
|
Facility
|
OP
|
$400.00
|
|
| Hospital Charge Code |
2964765
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$382.72 |
| Rate for Payer: Aetna Commercial |
$374.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$357.76
|
| Rate for Payer: Aetna Managed Medicare |
$116.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$270.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$199.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$220.48
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$382.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$232.80
|
| Rate for Payer: Health EOS Commercial |
$370.24
|
| Rate for Payer: HFN Commercial |
$382.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.00
|
| Rate for Payer: Multiplan Commercial |
$332.80
|
| Rate for Payer: NAPHCARE Commercial |
$249.60
|
| Rate for Payer: Preferred Network Access Commercial |
$382.72
|
| Rate for Payer: Quartz Beloit One Network |
$203.84
|
| Rate for Payer: Quartz Commercial |
$270.40
|
| Rate for Payer: Quartz Medicare Advantage |
$249.60
|
| Rate for Payer: The Alliance Commercial |
$208.00
|
| Rate for Payer: WEA Trust Commercial |
$228.80
|
| Rate for Payer: WPS Commercial |
$308.12
|
|
