|
Escitalopram Lvl
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040879
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$107.16 |
| Rate for Payer: Aetna Commercial |
$104.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$100.17
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.18
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$107.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$103.67
|
| Rate for Payer: HFN Commercial |
$107.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$93.18
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$107.16
|
| Rate for Payer: Quartz Beloit One Network |
$57.08
|
| Rate for Payer: Quartz Commercial |
$75.71
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$77.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: United Healthcare PPO |
$87.36
|
| Rate for Payer: WEA Trust Commercial |
$64.06
|
| Rate for Payer: Wellcare Medicare |
$19.39
|
| Rate for Payer: WPS Commercial |
$86.27
|
|
|
Escitalopram Lvl
|
Professional
|
Both
|
$112.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040879
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$110.66 |
| Rate for Payer: Aetna Commercial |
$110.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$100.17
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$110.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$58.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$106.00
|
| Rate for Payer: HFN Commercial |
$110.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$93.18
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$110.66
|
| Rate for Payer: Quartz Beloit One Network |
$51.25
|
| Rate for Payer: Quartz Commercial |
$66.39
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$76.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: WEA Trust Commercial |
$64.06
|
| Rate for Payer: WPS Commercial |
$85.30
|
|
|
Escitalopram Lvl
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040879
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.08 |
| Max. Negotiated Rate |
$107.16 |
| Rate for Payer: Aetna Commercial |
$104.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$100.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.73
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$107.16
|
| Rate for Payer: Health EOS Commercial |
$103.67
|
| Rate for Payer: HFN Commercial |
$107.16
|
| Rate for Payer: Multiplan Commercial |
$93.18
|
| Rate for Payer: Preferred Network Access Commercial |
$107.16
|
| Rate for Payer: Quartz Beloit One Network |
$57.08
|
| Rate for Payer: Quartz Commercial |
$69.89
|
| Rate for Payer: WEA Trust Commercial |
$64.06
|
| Rate for Payer: WPS Commercial |
$86.27
|
|
|
ESMARK BANDAGE 4INX9 FT STERILE DYNJ05916H (SUB)/961650 (SUB)
|
Facility
|
OP
|
$125.00
|
|
| Hospital Charge Code |
4858710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Aetna Managed Medicare |
$36.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$84.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$65.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$62.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.75
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.50
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: NAPHCARE Commercial |
$78.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$84.50
|
| Rate for Payer: Quartz Medicare Advantage |
$78.00
|
| Rate for Payer: The Alliance Commercial |
$65.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
ESMARK BANDAGE 4INX9 FT STERILE DYNJ05916H (SUB)/961650 (SUB)
|
Facility
|
IP
|
$125.00
|
|
| Hospital Charge Code |
4858710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
ESMARK BANDAGE 4X12 LF DYNJ05917/DYNJ05117AH (SUB)
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
3911538
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$52.42
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
ESMARK BANDAGE 4X12 LF DYNJ05917/DYNJ05117AH (SUB)
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
3911538
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Aetna Managed Medicare |
$24.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.89
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: NAPHCARE Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$56.78
|
| Rate for Payer: Quartz Medicare Advantage |
$52.42
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
ESMARK BANDAGE 6 IN DYNJ05919/DYNJ05918 (SUB)/TRN99304 (SUB)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2965841
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$170.21 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$208.42
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
ESMARK BANDAGE 6 IN DYNJ05919/DYNJ05918 (SUB)/TRN99304 (SUB)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2965841
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$97.26 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Aetna Managed Medicare |
$97.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$225.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$173.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$166.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.39
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.52
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: NAPHCARE Commercial |
$208.42
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$225.78
|
| Rate for Payer: Quartz Medicare Advantage |
$208.42
|
| Rate for Payer: The Alliance Commercial |
$173.68
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
Esophageal Motility Study with Interp 9101026
|
Professional
|
Both
|
$775.00
|
|
|
Service Code
|
CPT 91010 26
|
| Hospital Charge Code |
4602736
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.47 |
| Max. Negotiated Rate |
$765.70 |
| Rate for Payer: Aetna Commercial |
$765.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$693.16
|
| Rate for Payer: Aetna Managed Medicare |
$67.80
|
| Rate for Payer: Anthem Medicare Advantage |
$67.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$67.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$67.80
|
| Rate for Payer: Cash Price |
$232.50
|
| Rate for Payer: Cash Price |
$232.50
|
| Rate for Payer: Cigna Commercial |
$765.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$66.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.80
|
| Rate for Payer: Health EOS Commercial |
$733.46
|
| Rate for Payer: HFN Commercial |
$765.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$233.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$233.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$67.80
|
| Rate for Payer: Multiplan Commercial |
$644.80
|
| Rate for Payer: NAPHCARE Commercial |
$101.70
|
| Rate for Payer: Preferred Network Access Commercial |
$765.70
|
| Rate for Payer: Quartz Beloit One Network |
$354.64
|
| Rate for Payer: Quartz Commercial |
$459.42
|
| Rate for Payer: Quartz Medicare Advantage |
$67.80
|
| Rate for Payer: The Alliance Commercial |
$169.49
|
| Rate for Payer: United Healthcare Medicaid |
$66.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.80
|
| Rate for Payer: WEA Trust Commercial |
$443.30
|
| Rate for Payer: WPS Commercial |
$271.19
|
|
|
Esophageal Motility Study With Interpretation 91010
|
Professional
|
Both
|
$775.00
|
|
|
Service Code
|
CPT 91010
|
| Hospital Charge Code |
2957660
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$178.62 |
| Max. Negotiated Rate |
$978.89 |
| Rate for Payer: Aetna Commercial |
$765.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$693.16
|
| Rate for Payer: Aetna Managed Medicare |
$244.72
|
| Rate for Payer: Anthem Medicare Advantage |
$244.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$244.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$244.72
|
| Rate for Payer: Cash Price |
$232.50
|
| Rate for Payer: Cash Price |
$232.50
|
| Rate for Payer: Cigna Commercial |
$765.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$178.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$244.72
|
| Rate for Payer: Health EOS Commercial |
$733.46
|
| Rate for Payer: HFN Commercial |
$765.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$790.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$790.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$244.72
|
| Rate for Payer: Multiplan Commercial |
$644.80
|
| Rate for Payer: NAPHCARE Commercial |
$367.08
|
| Rate for Payer: Preferred Network Access Commercial |
$765.70
|
| Rate for Payer: Quartz Beloit One Network |
$354.64
|
| Rate for Payer: Quartz Commercial |
$459.42
|
| Rate for Payer: Quartz Medicare Advantage |
$244.72
|
| Rate for Payer: The Alliance Commercial |
$611.81
|
| Rate for Payer: United Healthcare Medicaid |
$178.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$244.72
|
| Rate for Payer: WEA Trust Commercial |
$443.30
|
| Rate for Payer: WPS Commercial |
$978.89
|
|
|
ESOPHAGECTOMY (CERVICAL) RECONSTRUCTION
|
Facility
|
IP
|
$4,981.00
|
|
| Hospital Charge Code |
2960022
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,538.32 |
| Max. Negotiated Rate |
$4,765.82 |
| Rate for Payer: Aetna Commercial |
$4,662.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,455.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,745.53
|
| Rate for Payer: Cash Price |
$1,494.30
|
| Rate for Payer: Cigna Commercial |
$4,765.82
|
| Rate for Payer: Health EOS Commercial |
$4,610.41
|
| Rate for Payer: HFN Commercial |
$4,765.82
|
| Rate for Payer: Multiplan Commercial |
$4,144.19
|
| Rate for Payer: Preferred Network Access Commercial |
$4,765.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,538.32
|
| Rate for Payer: Quartz Commercial |
$3,108.14
|
| Rate for Payer: WEA Trust Commercial |
$2,849.13
|
| Rate for Payer: WPS Commercial |
$3,836.86
|
|
|
ESOPHAGECTOMY (CERVICAL) RECONSTRUCTION
|
Facility
|
OP
|
$4,981.00
|
|
| Hospital Charge Code |
2960022
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,450.47 |
| Max. Negotiated Rate |
$4,765.82 |
| Rate for Payer: Aetna Commercial |
$4,662.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,455.01
|
| Rate for Payer: Aetna Managed Medicare |
$1,450.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,367.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,590.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,486.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,745.53
|
| Rate for Payer: Cash Price |
$1,494.30
|
| Rate for Payer: Cigna Commercial |
$4,765.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,898.94
|
| Rate for Payer: Health EOS Commercial |
$4,610.41
|
| Rate for Payer: HFN Commercial |
$4,765.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,885.18
|
| Rate for Payer: Multiplan Commercial |
$4,144.19
|
| Rate for Payer: NAPHCARE Commercial |
$3,108.14
|
| Rate for Payer: Preferred Network Access Commercial |
$4,765.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,538.32
|
| Rate for Payer: Quartz Commercial |
$3,367.16
|
| Rate for Payer: Quartz Medicare Advantage |
$3,108.14
|
| Rate for Payer: The Alliance Commercial |
$2,590.12
|
| Rate for Payer: WEA Trust Commercial |
$2,849.13
|
| Rate for Payer: WPS Commercial |
$3,836.86
|
|
|
ESOPHAGITIS AND OTHER ESOPHAGEAL DIAGNOSES
|
Facility
|
OP
|
$35.41
|
|
|
Service Code
|
EAPG 00623
|
| Min. Negotiated Rate |
$34.05 |
| Max. Negotiated Rate |
$35.41 |
| Rate for Payer: Anthem Medicaid |
$34.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$34.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.05
|
| Rate for Payer: Dean Health Medicaid |
$34.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$34.05
|
| Rate for Payer: Managed Health Services Medicaid |
$35.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.05
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$34.05
|
| Rate for Payer: United Healthcare Medicaid |
$34.05
|
|
|
ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC
|
Facility
|
IP
|
$35,605.44
|
|
|
Service Code
|
MSDRG 391
|
| Min. Negotiated Rate |
$10,219.67 |
| Max. Negotiated Rate |
$35,605.44 |
| Rate for Payer: Aetna Managed Medicare |
$10,219.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,673.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,211.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,152.17
|
| Rate for Payer: Anthem Medicare Advantage |
$10,219.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,219.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,219.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,219.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,370.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,219.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,871.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,219.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,219.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,219.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,219.67
|
| Rate for Payer: NAPHCARE Commercial |
$15,329.51
|
| Rate for Payer: Quartz Medicare Advantage |
$10,219.67
|
| Rate for Payer: The Alliance Commercial |
$35,605.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,219.67
|
| Rate for Payer: United Healthcare PPO |
$20,141.06
|
| Rate for Payer: Wellcare Medicare |
$10,219.67
|
|
|
ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC
|
Facility
|
IP
|
$22,054.24
|
|
|
Service Code
|
MSDRG 392
|
| Min. Negotiated Rate |
$6,477.12 |
| Max. Negotiated Rate |
$22,054.24 |
| Rate for Payer: Aetna Managed Medicare |
$6,477.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,010.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,038.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,387.16
|
| Rate for Payer: Anthem Medicare Advantage |
$6,477.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,477.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,477.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,477.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,750.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,477.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,931.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,477.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,477.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,477.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,477.12
|
| Rate for Payer: NAPHCARE Commercial |
$9,715.68
|
| Rate for Payer: Quartz Medicare Advantage |
$6,477.12
|
| Rate for Payer: The Alliance Commercial |
$22,054.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,477.12
|
| Rate for Payer: United Healthcare PPO |
$12,403.24
|
| Rate for Payer: Wellcare Medicare |
$6,477.12
|
|
|
ESOPHAGOGASTRIC RESTRICTIVE PROCEDURES AND GASTRIC FUNDOPLICATION
|
Facility
|
OP
|
$1,126.66
|
|
|
Service Code
|
EAPG 00129
|
| Min. Negotiated Rate |
$1,083.32 |
| Max. Negotiated Rate |
$1,126.66 |
| Rate for Payer: Anthem Medicaid |
$1,083.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$1,083.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,083.32
|
| Rate for Payer: Dean Health Medicaid |
$1,083.32
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$1,083.32
|
| Rate for Payer: Managed Health Services Medicaid |
$1,126.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,083.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$1,083.32
|
| Rate for Payer: United Healthcare Medicaid |
$1,083.32
|
|
|
ESOPHAGOGASTRODUODENOSCOPY
|
Facility
|
OP
|
$6,438.00
|
|
| Hospital Charge Code |
2960003
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1,874.75 |
| Max. Negotiated Rate |
$6,159.88 |
| Rate for Payer: Aetna Commercial |
$6,025.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,758.15
|
| Rate for Payer: Aetna Managed Medicare |
$1,874.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,352.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,347.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,213.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,548.63
|
| Rate for Payer: Cash Price |
$1,931.40
|
| Rate for Payer: Cigna Commercial |
$6,159.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,746.92
|
| Rate for Payer: Health EOS Commercial |
$5,959.01
|
| Rate for Payer: HFN Commercial |
$6,159.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,021.64
|
| Rate for Payer: Multiplan Commercial |
$5,356.42
|
| Rate for Payer: NAPHCARE Commercial |
$4,017.31
|
| Rate for Payer: Preferred Network Access Commercial |
$6,159.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,280.80
|
| Rate for Payer: Quartz Commercial |
$4,352.09
|
| Rate for Payer: Quartz Medicare Advantage |
$4,017.31
|
| Rate for Payer: The Alliance Commercial |
$3,347.76
|
| Rate for Payer: WEA Trust Commercial |
$3,682.54
|
| Rate for Payer: WPS Commercial |
$4,959.19
|
|
|
ESOPHAGOGASTRODUODENOSCOPY
|
Facility
|
IP
|
$6,438.00
|
|
| Hospital Charge Code |
2960003
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$3,280.80 |
| Max. Negotiated Rate |
$6,159.88 |
| Rate for Payer: Aetna Commercial |
$6,025.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,758.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,548.63
|
| Rate for Payer: Cash Price |
$1,931.40
|
| Rate for Payer: Cigna Commercial |
$6,159.88
|
| Rate for Payer: Health EOS Commercial |
$5,959.01
|
| Rate for Payer: HFN Commercial |
$6,159.88
|
| Rate for Payer: Multiplan Commercial |
$5,356.42
|
| Rate for Payer: Preferred Network Access Commercial |
$6,159.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,280.80
|
| Rate for Payer: Quartz Commercial |
$4,017.31
|
| Rate for Payer: WEA Trust Commercial |
$3,682.54
|
| Rate for Payer: WPS Commercial |
$4,959.19
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 43235
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$954.50 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Managed Medicare |
$954.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Anthem Medicare Advantage |
$954.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$954.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$954.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$954.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$954.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,550.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$954.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$954.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$954.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$954.50
|
| Rate for Payer: NAPHCARE Commercial |
$1,431.75
|
| Rate for Payer: Quartz Medicare Advantage |
$954.50
|
| Rate for Payer: The Alliance Commercial |
$3,818.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$954.50
|
| Rate for Payer: United Healthcare PPO |
$2,347.28
|
| Rate for Payer: Wellcare Medicare |
$954.50
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
|
Facility
|
OP
|
$8,077.76
|
|
|
Service Code
|
CPT 43270
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,019.44 |
| Max. Negotiated Rate |
$8,077.76 |
| Rate for Payer: Aetna Managed Medicare |
$2,019.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$2,019.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,019.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,019.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,019.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,019.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,512.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,019.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,019.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,019.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,019.44
|
| Rate for Payer: NAPHCARE Commercial |
$3,029.16
|
| Rate for Payer: Quartz Medicare Advantage |
$2,019.44
|
| Rate for Payer: The Alliance Commercial |
$8,077.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,019.44
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$2,019.44
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices
|
Facility
|
OP
|
$8,077.76
|
|
|
Service Code
|
CPT 43244
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,019.44 |
| Max. Negotiated Rate |
$8,077.76 |
| Rate for Payer: Aetna Managed Medicare |
$2,019.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$2,019.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,019.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,019.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,019.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,019.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,512.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,019.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,019.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,019.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,019.44
|
| Rate for Payer: NAPHCARE Commercial |
$3,029.16
|
| Rate for Payer: Quartz Medicare Advantage |
$2,019.44
|
| Rate for Payer: The Alliance Commercial |
$8,077.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,019.44
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$2,019.44
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
|
Facility
|
OP
|
$4,947.89
|
|
|
Service Code
|
CPT 43239
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$954.50 |
| Max. Negotiated Rate |
$4,947.89 |
| Rate for Payer: Aetna Managed Medicare |
$954.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Anthem Medicare Advantage |
$954.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$954.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$954.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$954.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$954.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,550.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$954.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$954.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$954.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$954.50
|
| Rate for Payer: NAPHCARE Commercial |
$1,431.75
|
| Rate for Payer: Quartz Medicare Advantage |
$954.50
|
| Rate for Payer: The Alliance Commercial |
$3,818.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$954.50
|
| Rate for Payer: United Healthcare PPO |
$2,347.28
|
| Rate for Payer: Wellcare Medicare |
$954.50
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
|
Facility
|
OP
|
$4,947.89
|
|
|
Service Code
|
CPT 43239
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$954.50 |
| Max. Negotiated Rate |
$4,947.89 |
| Rate for Payer: Aetna Managed Medicare |
$954.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Anthem Medicare Advantage |
$954.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$954.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$954.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$954.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$954.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,550.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$954.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$954.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$954.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$954.50
|
| Rate for Payer: NAPHCARE Commercial |
$1,431.75
|
| Rate for Payer: Quartz Medicare Advantage |
$954.50
|
| Rate for Payer: The Alliance Commercial |
$3,818.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$954.50
|
| Rate for Payer: United Healthcare PPO |
$2,347.28
|
| Rate for Payer: Wellcare Medicare |
$954.50
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method
|
Facility
|
OP
|
$8,077.76
|
|
|
Service Code
|
CPT 43255
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,019.44 |
| Max. Negotiated Rate |
$8,077.76 |
| Rate for Payer: NAPHCARE Commercial |
$3,029.16
|
| Rate for Payer: Quartz Medicare Advantage |
$2,019.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,019.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$2,019.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,019.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,019.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,019.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,019.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,512.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,019.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,019.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,019.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,019.44
|
| Rate for Payer: The Alliance Commercial |
$8,077.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,019.44
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$2,019.44
|
|
