|
Felbamate Level
|
Professional
|
Both
|
$194.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
977949
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$191.67 |
| Rate for Payer: Aetna Commercial |
$191.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| 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 |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$191.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$100.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$183.60
|
| Rate for Payer: HFN Commercial |
$191.67
|
| 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 |
$161.41
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$191.67
|
| Rate for Payer: Quartz Beloit One Network |
$88.77
|
| Rate for Payer: Quartz Commercial |
$115.00
|
| 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 |
$110.97
|
| Rate for Payer: WPS Commercial |
$85.30
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$10,346.61
|
|
|
Service Code
|
APR-DRG 5313
|
| Min. Negotiated Rate |
$9,190.50 |
| Max. Negotiated Rate |
$10,346.61 |
| Rate for Payer: Anthem Medicaid |
$9,907.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,907.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,907.45
|
| Rate for Payer: Dean Health Medicaid |
$9,907.45
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9,190.50
|
| Rate for Payer: Managed Health Services Medicaid |
$10,346.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,907.45
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,907.45
|
| Rate for Payer: United Healthcare Medicaid |
$9,907.45
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$19,202.60
|
|
|
Service Code
|
APR-DRG 5314
|
| Min. Negotiated Rate |
$17,056.95 |
| Max. Negotiated Rate |
$19,202.60 |
| Rate for Payer: Anthem Medicaid |
$18,387.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$18,387.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18,387.55
|
| Rate for Payer: Dean Health Medicaid |
$18,387.55
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17,056.95
|
| Rate for Payer: Managed Health Services Medicaid |
$19,202.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,387.55
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18,387.55
|
| Rate for Payer: United Healthcare Medicaid |
$18,387.55
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$6,137.82
|
|
|
Service Code
|
APR-DRG 5312
|
| Min. Negotiated Rate |
$5,451.99 |
| Max. Negotiated Rate |
$6,137.82 |
| Rate for Payer: Anthem Medicaid |
$5,877.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,877.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,877.30
|
| Rate for Payer: Dean Health Medicaid |
$5,877.30
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,451.99
|
| Rate for Payer: Managed Health Services Medicaid |
$6,137.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,877.30
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,877.30
|
| Rate for Payer: United Healthcare Medicaid |
$5,877.30
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$4,647.20
|
|
|
Service Code
|
APR-DRG 5311
|
| Min. Negotiated Rate |
$4,127.94 |
| Max. Negotiated Rate |
$4,647.20 |
| Rate for Payer: Anthem Medicaid |
$4,449.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,449.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,449.95
|
| Rate for Payer: Dean Health Medicaid |
$4,449.95
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4,127.94
|
| Rate for Payer: Managed Health Services Medicaid |
$4,647.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,449.95
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,449.95
|
| Rate for Payer: United Healthcare Medicaid |
$4,449.95
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
OP
|
$94.34
|
|
|
Service Code
|
EAPG 00751
|
| Min. Negotiated Rate |
$90.71 |
| Max. Negotiated Rate |
$94.34 |
| Rate for Payer: Anthem Medicaid |
$90.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$90.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$90.71
|
| Rate for Payer: Dean Health Medicaid |
$90.71
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$90.71
|
| Rate for Payer: Managed Health Services Medicaid |
$94.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$90.71
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$90.71
|
| Rate for Payer: United Healthcare Medicaid |
$90.71
|
|
|
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
|
Facility
|
IP
|
$19,290.28
|
|
|
Service Code
|
APR-DRG 5304
|
| Min. Negotiated Rate |
$17,134.83 |
| Max. Negotiated Rate |
$19,290.28 |
| Rate for Payer: Anthem Medicaid |
$18,471.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$18,471.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18,471.51
|
| Rate for Payer: Dean Health Medicaid |
$18,471.51
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17,134.83
|
| Rate for Payer: Managed Health Services Medicaid |
$19,290.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,471.51
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18,471.51
|
| Rate for Payer: United Healthcare Medicaid |
$18,471.51
|
|
|
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
|
Facility
|
IP
|
$12,187.95
|
|
|
Service Code
|
APR-DRG 5303
|
| Min. Negotiated Rate |
$10,826.10 |
| Max. Negotiated Rate |
$12,187.95 |
| Rate for Payer: Anthem Medicaid |
$11,670.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$11,670.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11,670.63
|
| Rate for Payer: Dean Health Medicaid |
$11,670.63
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$10,826.10
|
| Rate for Payer: Managed Health Services Medicaid |
$12,187.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,670.63
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11,670.63
|
| Rate for Payer: United Healthcare Medicaid |
$11,670.63
|
|
|
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
|
Facility
|
OP
|
$86.48
|
|
|
Service Code
|
EAPG 00750
|
| Min. Negotiated Rate |
$83.15 |
| Max. Negotiated Rate |
$86.48 |
| Rate for Payer: Anthem Medicaid |
$83.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$83.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$83.15
|
| Rate for Payer: Dean Health Medicaid |
$83.15
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$83.15
|
| Rate for Payer: Managed Health Services Medicaid |
$86.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$83.15
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$83.15
|
| Rate for Payer: United Healthcare Medicaid |
$83.15
|
|
|
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
|
Facility
|
IP
|
$6,313.18
|
|
|
Service Code
|
APR-DRG 5301
|
| Min. Negotiated Rate |
$5,607.76 |
| Max. Negotiated Rate |
$6,313.18 |
| Rate for Payer: Anthem Medicaid |
$6,045.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,045.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,045.22
|
| Rate for Payer: Dean Health Medicaid |
$6,045.22
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,607.76
|
| Rate for Payer: Managed Health Services Medicaid |
$6,313.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,045.22
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,045.22
|
| Rate for Payer: United Healthcare Medicaid |
$6,045.22
|
|
|
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
|
Facility
|
IP
|
$7,979.16
|
|
|
Service Code
|
APR-DRG 5302
|
| Min. Negotiated Rate |
$7,087.59 |
| Max. Negotiated Rate |
$7,979.16 |
| Rate for Payer: Anthem Medicaid |
$7,640.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$7,640.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,640.49
|
| Rate for Payer: Dean Health Medicaid |
$7,640.49
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,087.59
|
| Rate for Payer: Managed Health Services Medicaid |
$7,979.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,640.49
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7,640.49
|
| Rate for Payer: United Healthcare Medicaid |
$7,640.49
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$9,294.41
|
|
|
Service Code
|
APR-DRG 5141
|
| Min. Negotiated Rate |
$8,255.87 |
| Max. Negotiated Rate |
$9,294.41 |
| Rate for Payer: Anthem Medicaid |
$8,899.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,899.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,899.91
|
| Rate for Payer: Dean Health Medicaid |
$8,899.91
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,255.87
|
| Rate for Payer: Managed Health Services Medicaid |
$9,294.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,899.91
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,899.91
|
| Rate for Payer: United Healthcare Medicaid |
$8,899.91
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$17,361.25
|
|
|
Service Code
|
APR-DRG 5143
|
| Min. Negotiated Rate |
$15,421.35 |
| Max. Negotiated Rate |
$17,361.25 |
| Rate for Payer: Anthem Medicaid |
$16,624.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$16,624.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16,624.36
|
| Rate for Payer: Dean Health Medicaid |
$16,624.36
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15,421.35
|
| Rate for Payer: Managed Health Services Medicaid |
$17,361.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,624.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16,624.36
|
| Rate for Payer: United Healthcare Medicaid |
$16,624.36
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$39,177.84
|
|
|
Service Code
|
MSDRG 748
|
| Min. Negotiated Rate |
$11,131.01 |
| Max. Negotiated Rate |
$39,177.84 |
| Rate for Payer: Aetna Managed Medicare |
$11,131.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30,269.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23,201.54
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22,042.98
|
| Rate for Payer: Anthem Medicare Advantage |
$11,131.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,131.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,131.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,131.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24,469.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,131.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,491.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,131.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,131.01
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,131.01
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,131.01
|
| Rate for Payer: NAPHCARE Commercial |
$16,696.51
|
| Rate for Payer: Quartz Medicare Advantage |
$11,131.01
|
| Rate for Payer: The Alliance Commercial |
$39,177.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,131.01
|
| Rate for Payer: United Healthcare PPO |
$22,180.90
|
| Rate for Payer: Wellcare Medicare |
$11,131.01
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$13,853.93
|
|
|
Service Code
|
APR-DRG 5142
|
| Min. Negotiated Rate |
$12,305.92 |
| Max. Negotiated Rate |
$13,853.93 |
| Rate for Payer: Anthem Medicaid |
$13,265.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$13,265.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13,265.90
|
| Rate for Payer: Dean Health Medicaid |
$13,265.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12,305.92
|
| Rate for Payer: Managed Health Services Medicaid |
$13,853.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,265.90
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13,265.90
|
| Rate for Payer: United Healthcare Medicaid |
$13,265.90
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$35,950.07
|
|
|
Service Code
|
APR-DRG 5144
|
| Min. Negotiated Rate |
$31,933.10 |
| Max. Negotiated Rate |
$35,950.07 |
| Rate for Payer: Anthem Medicaid |
$34,424.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$34,424.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34,424.17
|
| Rate for Payer: Dean Health Medicaid |
$34,424.17
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$31,933.10
|
| Rate for Payer: Managed Health Services Medicaid |
$35,950.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$34,424.17
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$34,424.17
|
| Rate for Payer: United Healthcare Medicaid |
$34,424.17
|
|
|
FEM COMP C-RT LPS FLEX 5960-13-52
|
Facility
|
IP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,477.54 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$11,605.15
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEM COMP C-RT LPS FLEX 5960-13-52
|
Facility
|
OP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,415.74 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Aetna Managed Medicare |
$5,415.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,572.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,670.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,284.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,824.04
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,506.44
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: NAPHCARE Commercial |
$11,605.15
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$12,572.25
|
| Rate for Payer: Quartz Medicare Advantage |
$11,605.15
|
| Rate for Payer: The Alliance Commercial |
$9,670.96
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEM COMPONENT D RT TI-NIDIUM
|
Facility
|
IP
|
$22,629.00
|
|
| Hospital Charge Code |
2967466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,531.74 |
| Max. Negotiated Rate |
$21,651.43 |
| Rate for Payer: Aetna Commercial |
$21,180.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,239.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,473.10
|
| Rate for Payer: Cash Price |
$6,788.70
|
| Rate for Payer: Cigna Commercial |
$21,651.43
|
| Rate for Payer: Health EOS Commercial |
$20,945.40
|
| Rate for Payer: HFN Commercial |
$21,651.43
|
| Rate for Payer: Multiplan Commercial |
$18,827.33
|
| Rate for Payer: Preferred Network Access Commercial |
$21,651.43
|
| Rate for Payer: Quartz Beloit One Network |
$11,531.74
|
| Rate for Payer: Quartz Commercial |
$14,120.50
|
| Rate for Payer: WEA Trust Commercial |
$12,943.79
|
| Rate for Payer: WPS Commercial |
$17,431.12
|
|
|
FEM COMPONENT D RT TI-NIDIUM
|
Facility
|
OP
|
$22,629.00
|
|
| Hospital Charge Code |
2967466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,589.56 |
| Max. Negotiated Rate |
$21,651.43 |
| Rate for Payer: Aetna Commercial |
$21,180.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,239.38
|
| Rate for Payer: Aetna Managed Medicare |
$6,589.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,297.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,767.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,296.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,473.10
|
| Rate for Payer: Cash Price |
$6,788.70
|
| Rate for Payer: Cigna Commercial |
$21,651.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,170.08
|
| Rate for Payer: Health EOS Commercial |
$20,945.40
|
| Rate for Payer: HFN Commercial |
$21,651.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,650.62
|
| Rate for Payer: Multiplan Commercial |
$18,827.33
|
| Rate for Payer: NAPHCARE Commercial |
$14,120.50
|
| Rate for Payer: Preferred Network Access Commercial |
$21,651.43
|
| Rate for Payer: Quartz Beloit One Network |
$11,531.74
|
| Rate for Payer: Quartz Commercial |
$15,297.20
|
| Rate for Payer: Quartz Medicare Advantage |
$14,120.50
|
| Rate for Payer: The Alliance Commercial |
$11,767.08
|
| Rate for Payer: WEA Trust Commercial |
$12,943.79
|
| Rate for Payer: WPS Commercial |
$17,431.12
|
|
|
FEM HEAD VERSYS 36MM -3.5 8018-36-01
|
Facility
|
IP
|
$9,076.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3227468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,625.13 |
| Max. Negotiated Rate |
$8,683.92 |
| Rate for Payer: Aetna Commercial |
$8,495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,117.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,002.69
|
| Rate for Payer: Cash Price |
$2,722.80
|
| Rate for Payer: Cigna Commercial |
$8,683.92
|
| Rate for Payer: Health EOS Commercial |
$8,400.75
|
| Rate for Payer: HFN Commercial |
$8,683.92
|
| Rate for Payer: Multiplan Commercial |
$7,551.23
|
| Rate for Payer: Preferred Network Access Commercial |
$8,683.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,625.13
|
| Rate for Payer: Quartz Commercial |
$5,663.42
|
| Rate for Payer: WEA Trust Commercial |
$5,191.47
|
| Rate for Payer: WPS Commercial |
$6,991.24
|
|
|
FEM HEAD VERSYS 36MM -3.5 8018-36-01
|
Facility
|
OP
|
$9,076.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3227468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,642.93 |
| Max. Negotiated Rate |
$8,683.92 |
| Rate for Payer: Aetna Commercial |
$8,495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,117.57
|
| Rate for Payer: Aetna Managed Medicare |
$2,642.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,135.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,719.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,530.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,002.69
|
| Rate for Payer: Cash Price |
$2,722.80
|
| Rate for Payer: Cigna Commercial |
$8,683.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,282.23
|
| Rate for Payer: Health EOS Commercial |
$8,400.75
|
| Rate for Payer: HFN Commercial |
$8,683.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,079.28
|
| Rate for Payer: Multiplan Commercial |
$7,551.23
|
| Rate for Payer: NAPHCARE Commercial |
$5,663.42
|
| Rate for Payer: Preferred Network Access Commercial |
$8,683.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,625.13
|
| Rate for Payer: Quartz Commercial |
$6,135.38
|
| Rate for Payer: Quartz Medicare Advantage |
$5,663.42
|
| Rate for Payer: The Alliance Commercial |
$4,719.52
|
| Rate for Payer: WEA Trust Commercial |
$5,191.47
|
| Rate for Payer: WPS Commercial |
$6,991.24
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 4 4MM CEMENTED 1547-04-001
|
Facility
|
IP
|
$9,128.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,651.63 |
| Max. Negotiated Rate |
$8,733.67 |
| Rate for Payer: Aetna Commercial |
$8,543.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,164.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,031.35
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,733.67
|
| Rate for Payer: Health EOS Commercial |
$8,448.88
|
| Rate for Payer: HFN Commercial |
$8,733.67
|
| Rate for Payer: Multiplan Commercial |
$7,594.50
|
| Rate for Payer: Preferred Network Access Commercial |
$8,733.67
|
| Rate for Payer: Quartz Beloit One Network |
$4,651.63
|
| Rate for Payer: Quartz Commercial |
$5,695.87
|
| Rate for Payer: WEA Trust Commercial |
$5,221.22
|
| Rate for Payer: WPS Commercial |
$7,031.30
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 4 4MM CEMENTED 1547-04-001
|
Facility
|
OP
|
$9,128.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,658.07 |
| Max. Negotiated Rate |
$8,733.67 |
| Rate for Payer: Aetna Commercial |
$8,543.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,164.08
|
| Rate for Payer: Aetna Managed Medicare |
$2,658.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,170.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,746.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,556.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,031.35
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,733.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,312.50
|
| Rate for Payer: Health EOS Commercial |
$8,448.88
|
| Rate for Payer: HFN Commercial |
$8,733.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,119.84
|
| Rate for Payer: Multiplan Commercial |
$7,594.50
|
| Rate for Payer: NAPHCARE Commercial |
$5,695.87
|
| Rate for Payer: Preferred Network Access Commercial |
$8,733.67
|
| Rate for Payer: Quartz Beloit One Network |
$4,651.63
|
| Rate for Payer: Quartz Commercial |
$6,170.53
|
| Rate for Payer: Quartz Medicare Advantage |
$5,695.87
|
| Rate for Payer: The Alliance Commercial |
$4,746.56
|
| Rate for Payer: WEA Trust Commercial |
$5,221.22
|
| Rate for Payer: WPS Commercial |
$7,031.30
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 4 8MM CEMENTED 1547-04-002
|
Facility
|
OP
|
$9,128.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,658.07 |
| Max. Negotiated Rate |
$8,733.67 |
| Rate for Payer: Aetna Commercial |
$8,543.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,164.08
|
| Rate for Payer: Aetna Managed Medicare |
$2,658.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,170.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,746.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,556.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,031.35
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,733.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,312.50
|
| Rate for Payer: Health EOS Commercial |
$8,448.88
|
| Rate for Payer: HFN Commercial |
$8,733.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,119.84
|
| Rate for Payer: Multiplan Commercial |
$7,594.50
|
| Rate for Payer: NAPHCARE Commercial |
$5,695.87
|
| Rate for Payer: Preferred Network Access Commercial |
$8,733.67
|
| Rate for Payer: Quartz Beloit One Network |
$4,651.63
|
| Rate for Payer: Quartz Commercial |
$6,170.53
|
| Rate for Payer: Quartz Medicare Advantage |
$5,695.87
|
| Rate for Payer: The Alliance Commercial |
$4,746.56
|
| Rate for Payer: WEA Trust Commercial |
$5,221.22
|
| Rate for Payer: WPS Commercial |
$7,031.30
|
|
