|
Eylea 2mg - Eylea Med Charge
|
Professional
|
Both
|
$5,335.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$773.35 |
| Max. Negotiated Rate |
$5,270.98 |
| Rate for Payer: Aetna Commercial |
$5,270.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,771.62
|
| Rate for Payer: Aetna Managed Medicare |
$773.35
|
| Rate for Payer: Anthem Medicare Advantage |
$773.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$773.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$773.35
|
| Rate for Payer: Cash Price |
$1,600.50
|
| Rate for Payer: Cash Price |
$1,600.50
|
| Rate for Payer: Cigna Commercial |
$5,270.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$794.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$874.77
|
| Rate for Payer: Health EOS Commercial |
$5,049.04
|
| Rate for Payer: HFN Commercial |
$5,270.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,395.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,395.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$773.35
|
| Rate for Payer: Multiplan Commercial |
$4,438.72
|
| Rate for Payer: NAPHCARE Commercial |
$1,160.03
|
| Rate for Payer: Preferred Network Access Commercial |
$5,270.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,441.30
|
| Rate for Payer: Quartz Commercial |
$3,162.59
|
| Rate for Payer: Quartz Medicare Advantage |
$773.35
|
| Rate for Payer: The Alliance Commercial |
$2,126.72
|
| Rate for Payer: United Healthcare Medicaid |
$794.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$773.35
|
| Rate for Payer: WEA Trust Commercial |
$3,051.62
|
| Rate for Payer: WPS Commercial |
$2,186.93
|
|
|
Eylea 2mg - Eylea Med Charge
|
Facility
|
IP
|
$5,335.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,718.72 |
| Max. Negotiated Rate |
$5,104.53 |
| Rate for Payer: Aetna Commercial |
$4,993.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,771.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,940.65
|
| Rate for Payer: Cash Price |
$1,600.50
|
| Rate for Payer: Cigna Commercial |
$5,104.53
|
| Rate for Payer: Health EOS Commercial |
$4,938.08
|
| Rate for Payer: HFN Commercial |
$5,104.53
|
| Rate for Payer: Multiplan Commercial |
$4,438.72
|
| Rate for Payer: Preferred Network Access Commercial |
$5,104.53
|
| Rate for Payer: Quartz Beloit One Network |
$2,718.72
|
| Rate for Payer: Quartz Commercial |
$3,329.04
|
| Rate for Payer: WEA Trust Commercial |
$3,051.62
|
| Rate for Payer: WPS Commercial |
$4,109.55
|
|
|
Eylea 8mg - Eylea Med Charge
|
Facility
|
IP
|
$5,305.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
6230615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,703.43 |
| Max. Negotiated Rate |
$5,075.82 |
| Rate for Payer: Aetna Commercial |
$4,965.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,744.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,924.12
|
| Rate for Payer: Cash Price |
$1,591.50
|
| Rate for Payer: Cigna Commercial |
$5,075.82
|
| Rate for Payer: Health EOS Commercial |
$4,910.31
|
| Rate for Payer: HFN Commercial |
$5,075.82
|
| Rate for Payer: Multiplan Commercial |
$4,413.76
|
| Rate for Payer: Preferred Network Access Commercial |
$5,075.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,703.43
|
| Rate for Payer: Quartz Commercial |
$3,310.32
|
| Rate for Payer: WEA Trust Commercial |
$3,034.46
|
| Rate for Payer: WPS Commercial |
$4,086.44
|
|
|
Eylea 8mg - Eylea Med Charge
|
Facility
|
OP
|
$5,305.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
6230615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,544.82 |
| Max. Negotiated Rate |
$5,075.82 |
| Rate for Payer: Aetna Commercial |
$4,965.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,744.79
|
| Rate for Payer: Aetna Managed Medicare |
$1,544.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,586.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,758.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,648.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,924.12
|
| Rate for Payer: Cash Price |
$1,591.50
|
| Rate for Payer: Cigna Commercial |
$5,075.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,087.51
|
| Rate for Payer: Health EOS Commercial |
$4,910.31
|
| Rate for Payer: HFN Commercial |
$5,075.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,137.90
|
| Rate for Payer: Multiplan Commercial |
$4,413.76
|
| Rate for Payer: NAPHCARE Commercial |
$3,310.32
|
| Rate for Payer: Preferred Network Access Commercial |
$5,075.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,703.43
|
| Rate for Payer: Quartz Commercial |
$3,586.18
|
| Rate for Payer: Quartz Medicare Advantage |
$3,310.32
|
| Rate for Payer: The Alliance Commercial |
$2,758.60
|
| Rate for Payer: WEA Trust Commercial |
$3,034.46
|
| Rate for Payer: WPS Commercial |
$4,086.44
|
|
|
Eylea 8mg - Eylea Med Charge
|
Professional
|
Both
|
$5,305.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
6230615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,427.57 |
| Max. Negotiated Rate |
$5,241.34 |
| Rate for Payer: Aetna Commercial |
$5,241.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,744.79
|
| Rate for Payer: Cash Price |
$1,591.50
|
| Rate for Payer: Cigna Commercial |
$5,241.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,758.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,310.32
|
| Rate for Payer: Health EOS Commercial |
$5,020.65
|
| Rate for Payer: HFN Commercial |
$5,241.34
|
| Rate for Payer: Multiplan Commercial |
$4,413.76
|
| Rate for Payer: Preferred Network Access Commercial |
$5,241.34
|
| Rate for Payer: Quartz Beloit One Network |
$2,427.57
|
| Rate for Payer: Quartz Commercial |
$3,144.80
|
| Rate for Payer: The Alliance Commercial |
$2,758.60
|
| Rate for Payer: WEA Trust Commercial |
$3,034.46
|
| Rate for Payer: WPS Commercial |
$4,086.44
|
|
|
Eylea HD per 8mg inj J0178 man
|
Facility
|
IP
|
$663.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$337.86 |
| Max. Negotiated Rate |
$634.36 |
| Rate for Payer: Aetna Commercial |
$620.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$592.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$365.45
|
| Rate for Payer: Cash Price |
$198.90
|
| Rate for Payer: Cigna Commercial |
$634.36
|
| Rate for Payer: Health EOS Commercial |
$613.67
|
| Rate for Payer: HFN Commercial |
$634.36
|
| Rate for Payer: Multiplan Commercial |
$551.62
|
| Rate for Payer: Preferred Network Access Commercial |
$634.36
|
| Rate for Payer: Quartz Beloit One Network |
$337.86
|
| Rate for Payer: Quartz Commercial |
$413.71
|
| Rate for Payer: WEA Trust Commercial |
$379.24
|
| Rate for Payer: WPS Commercial |
$510.71
|
|
|
Eylea HD per 8mg inj J0178 man
|
Facility
|
OP
|
$663.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$330.97 |
| Max. Negotiated Rate |
$3,093.42 |
| Rate for Payer: Aetna Commercial |
$620.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$592.99
|
| Rate for Payer: Aetna Managed Medicare |
$773.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$448.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$344.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$330.97
|
| Rate for Payer: Anthem Medicare Advantage |
$773.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$365.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$773.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$773.35
|
| Rate for Payer: Cash Price |
$198.90
|
| Rate for Payer: Cash Price |
$198.90
|
| Rate for Payer: Cigna Commercial |
$634.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$773.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,157.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$773.35
|
| Rate for Payer: Health EOS Commercial |
$613.67
|
| Rate for Payer: HFN Commercial |
$634.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,876.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$773.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$773.35
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$773.35
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$773.35
|
| Rate for Payer: Multiplan Commercial |
$551.62
|
| Rate for Payer: NAPHCARE Commercial |
$1,160.03
|
| Rate for Payer: Preferred Network Access Commercial |
$634.36
|
| Rate for Payer: Quartz Beloit One Network |
$337.86
|
| Rate for Payer: Quartz Commercial |
$448.19
|
| Rate for Payer: Quartz Medicare Advantage |
$773.35
|
| Rate for Payer: The Alliance Commercial |
$3,093.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$773.35
|
| Rate for Payer: WEA Trust Commercial |
$379.24
|
| Rate for Payer: Wellcare Medicare |
$773.35
|
| Rate for Payer: WPS Commercial |
$2,186.93
|
|
|
Eylea HD per 8mg inj J0178 man
|
Professional
|
Both
|
$663.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$303.39 |
| Max. Negotiated Rate |
$2,186.93 |
| Rate for Payer: Aetna Commercial |
$655.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$592.99
|
| Rate for Payer: Aetna Managed Medicare |
$773.35
|
| Rate for Payer: Anthem Medicare Advantage |
$773.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$773.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$773.35
|
| Rate for Payer: Cash Price |
$198.90
|
| Rate for Payer: Cash Price |
$198.90
|
| Rate for Payer: Cigna Commercial |
$655.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$794.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$874.77
|
| Rate for Payer: Health EOS Commercial |
$627.46
|
| Rate for Payer: HFN Commercial |
$655.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,395.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,395.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$773.35
|
| Rate for Payer: Multiplan Commercial |
$551.62
|
| Rate for Payer: NAPHCARE Commercial |
$1,160.03
|
| Rate for Payer: Preferred Network Access Commercial |
$655.04
|
| Rate for Payer: Quartz Beloit One Network |
$303.39
|
| Rate for Payer: Quartz Commercial |
$393.03
|
| Rate for Payer: Quartz Medicare Advantage |
$773.35
|
| Rate for Payer: The Alliance Commercial |
$2,126.72
|
| Rate for Payer: United Healthcare Medicaid |
$794.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$773.35
|
| Rate for Payer: WEA Trust Commercial |
$379.24
|
| Rate for Payer: WPS Commercial |
$2,186.93
|
|
|
FACE LIFT/RHYTIDOPLASTY/RHYTIDECTOMY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960356
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
FACE LIFT/RHYTIDOPLASTY/RHYTIDECTOMY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960356
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
FACEMASK GI PROCEDURE 52070002
|
Facility
|
OP
|
$642.00
|
|
| Hospital Charge Code |
3511505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$186.95 |
| Max. Negotiated Rate |
$614.27 |
| Rate for Payer: Aetna Commercial |
$600.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.20
|
| Rate for Payer: Aetna Managed Medicare |
$186.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$433.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$333.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$320.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$353.87
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$614.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$373.64
|
| Rate for Payer: Health EOS Commercial |
$594.24
|
| Rate for Payer: HFN Commercial |
$614.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$500.76
|
| Rate for Payer: Multiplan Commercial |
$534.14
|
| Rate for Payer: NAPHCARE Commercial |
$400.61
|
| Rate for Payer: Preferred Network Access Commercial |
$614.27
|
| Rate for Payer: Quartz Beloit One Network |
$327.16
|
| Rate for Payer: Quartz Commercial |
$433.99
|
| Rate for Payer: Quartz Medicare Advantage |
$400.61
|
| Rate for Payer: The Alliance Commercial |
$333.84
|
| Rate for Payer: WEA Trust Commercial |
$367.22
|
| Rate for Payer: WPS Commercial |
$494.53
|
|
|
FACEMASK GI PROCEDURE 52070002
|
Facility
|
IP
|
$642.00
|
|
| Hospital Charge Code |
3511505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$327.16 |
| Max. Negotiated Rate |
$614.27 |
| Rate for Payer: Aetna Commercial |
$600.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$353.87
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$614.27
|
| Rate for Payer: Health EOS Commercial |
$594.24
|
| Rate for Payer: HFN Commercial |
$614.27
|
| Rate for Payer: Multiplan Commercial |
$534.14
|
| Rate for Payer: Preferred Network Access Commercial |
$614.27
|
| Rate for Payer: Quartz Beloit One Network |
$327.16
|
| Rate for Payer: Quartz Commercial |
$400.61
|
| Rate for Payer: WEA Trust Commercial |
$367.22
|
| Rate for Payer: WPS Commercial |
$494.53
|
|
|
FACET INJECTION
|
Facility
|
OP
|
$270.00
|
|
| Hospital Charge Code |
2960044
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$78.62 |
| Max. Negotiated Rate |
$258.34 |
| Rate for Payer: Aetna Commercial |
$252.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.49
|
| Rate for Payer: Aetna Managed Medicare |
$78.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$182.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$140.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$134.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.82
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$258.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$157.14
|
| Rate for Payer: Health EOS Commercial |
$249.91
|
| Rate for Payer: HFN Commercial |
$258.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.60
|
| Rate for Payer: Multiplan Commercial |
$224.64
|
| Rate for Payer: NAPHCARE Commercial |
$168.48
|
| Rate for Payer: Preferred Network Access Commercial |
$258.34
|
| Rate for Payer: Quartz Beloit One Network |
$137.59
|
| Rate for Payer: Quartz Commercial |
$182.52
|
| Rate for Payer: Quartz Medicare Advantage |
$168.48
|
| Rate for Payer: The Alliance Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$154.44
|
| Rate for Payer: WPS Commercial |
$207.98
|
|
|
FACET INJECTION
|
Facility
|
IP
|
$270.00
|
|
| Hospital Charge Code |
2960044
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$137.59 |
| Max. Negotiated Rate |
$258.34 |
| Rate for Payer: Aetna Commercial |
$252.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.82
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$258.34
|
| Rate for Payer: Health EOS Commercial |
$249.91
|
| Rate for Payer: HFN Commercial |
$258.34
|
| Rate for Payer: Multiplan Commercial |
$224.64
|
| Rate for Payer: Preferred Network Access Commercial |
$258.34
|
| Rate for Payer: Quartz Beloit One Network |
$137.59
|
| Rate for Payer: Quartz Commercial |
$168.48
|
| Rate for Payer: WEA Trust Commercial |
$154.44
|
| Rate for Payer: WPS Commercial |
$207.98
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$13,853.93
|
|
|
Service Code
|
APR-DRG 0921
|
| 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
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$17,361.25
|
|
|
Service Code
|
APR-DRG 0922
|
| 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
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$25,515.78
|
|
|
Service Code
|
APR-DRG 0923
|
| Min. Negotiated Rate |
$22,664.71 |
| Max. Negotiated Rate |
$25,515.78 |
| Rate for Payer: Anthem Medicaid |
$24,432.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$24,432.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24,432.77
|
| Rate for Payer: Dean Health Medicaid |
$24,432.77
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$22,664.71
|
| Rate for Payer: Managed Health Services Medicaid |
$25,515.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,432.77
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$24,432.77
|
| Rate for Payer: United Healthcare Medicaid |
$24,432.77
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$44,893.75
|
|
|
Service Code
|
APR-DRG 0924
|
| Min. Negotiated Rate |
$39,877.43 |
| Max. Negotiated Rate |
$44,893.75 |
| Rate for Payer: Anthem Medicaid |
$42,988.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$42,988.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42,988.24
|
| Rate for Payer: Dean Health Medicaid |
$42,988.24
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$39,877.43
|
| Rate for Payer: Managed Health Services Medicaid |
$44,893.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$42,988.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$42,988.24
|
| Rate for Payer: United Healthcare Medicaid |
$42,988.24
|
|
|
FACIAL SKELETAL SURGERY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960045
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
FACIAL SKELETAL SURGERY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960045
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
FACIAL WRAP UNIVERSAL 2020
|
Facility
|
IP
|
$268.00
|
|
| Hospital Charge Code |
4132073
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$136.57 |
| Max. Negotiated Rate |
$256.42 |
| Rate for Payer: Aetna Commercial |
$250.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$147.72
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$256.42
|
| Rate for Payer: Health EOS Commercial |
$248.06
|
| Rate for Payer: HFN Commercial |
$256.42
|
| Rate for Payer: Multiplan Commercial |
$222.98
|
| Rate for Payer: Preferred Network Access Commercial |
$256.42
|
| Rate for Payer: Quartz Beloit One Network |
$136.57
|
| Rate for Payer: Quartz Commercial |
$167.23
|
| Rate for Payer: WEA Trust Commercial |
$153.30
|
| Rate for Payer: WPS Commercial |
$206.44
|
|
|
FACIAL WRAP UNIVERSAL 2020
|
Facility
|
OP
|
$268.00
|
|
| Hospital Charge Code |
4132073
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$78.04 |
| Max. Negotiated Rate |
$256.42 |
| Rate for Payer: Aetna Commercial |
$250.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.70
|
| Rate for Payer: Aetna Managed Medicare |
$78.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$181.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$139.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$133.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$147.72
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$256.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.98
|
| Rate for Payer: Health EOS Commercial |
$248.06
|
| Rate for Payer: HFN Commercial |
$256.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$209.04
|
| Rate for Payer: Multiplan Commercial |
$222.98
|
| Rate for Payer: NAPHCARE Commercial |
$167.23
|
| Rate for Payer: Preferred Network Access Commercial |
$256.42
|
| Rate for Payer: Quartz Beloit One Network |
$136.57
|
| Rate for Payer: Quartz Commercial |
$181.17
|
| Rate for Payer: Quartz Medicare Advantage |
$167.23
|
| Rate for Payer: The Alliance Commercial |
$139.36
|
| Rate for Payer: WEA Trust Commercial |
$153.30
|
| Rate for Payer: WPS Commercial |
$206.44
|
|
|
Factor II Activity, Clotting
|
Facility
|
IP
|
$232.00
|
|
|
Service Code
|
CPT 85210
|
| Hospital Charge Code |
5438905
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$118.23 |
| Max. Negotiated Rate |
$221.98 |
| Rate for Payer: Aetna Commercial |
$217.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.88
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$221.98
|
| Rate for Payer: Health EOS Commercial |
$214.74
|
| Rate for Payer: HFN Commercial |
$221.98
|
| Rate for Payer: Multiplan Commercial |
$193.02
|
| Rate for Payer: Preferred Network Access Commercial |
$221.98
|
| Rate for Payer: Quartz Beloit One Network |
$118.23
|
| Rate for Payer: Quartz Commercial |
$144.77
|
| Rate for Payer: WEA Trust Commercial |
$132.70
|
| Rate for Payer: WPS Commercial |
$178.71
|
|
|
Factor II Activity, Clotting
|
Professional
|
Both
|
$232.00
|
|
|
Service Code
|
CPT 85210
|
| Hospital Charge Code |
5438905
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$229.22 |
| Rate for Payer: Aetna Commercial |
$229.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.50
|
| Rate for Payer: Aetna Managed Medicare |
$13.50
|
| Rate for Payer: Anthem Medicare Advantage |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.50
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$229.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.50
|
| Rate for Payer: Health EOS Commercial |
$219.56
|
| Rate for Payer: HFN Commercial |
$229.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$193.02
|
| Rate for Payer: NAPHCARE Commercial |
$20.25
|
| Rate for Payer: Preferred Network Access Commercial |
$229.22
|
| Rate for Payer: Quartz Beloit One Network |
$106.16
|
| Rate for Payer: Quartz Commercial |
$137.53
|
| Rate for Payer: Quartz Medicare Advantage |
$13.50
|
| Rate for Payer: The Alliance Commercial |
$53.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.50
|
| Rate for Payer: WEA Trust Commercial |
$132.70
|
| Rate for Payer: WPS Commercial |
$59.40
|
|
|
Factor II Activity, Clotting
|
Facility
|
OP
|
$232.00
|
|
|
Service Code
|
CPT 85210
|
| Hospital Charge Code |
5438905
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$221.98 |
| Rate for Payer: Aetna Commercial |
$217.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.50
|
| Rate for Payer: Aetna Managed Medicare |
$13.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.41
|
| Rate for Payer: Anthem Medicare Advantage |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.50
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$221.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.50
|
| Rate for Payer: Health EOS Commercial |
$214.74
|
| Rate for Payer: HFN Commercial |
$221.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$193.02
|
| Rate for Payer: NAPHCARE Commercial |
$20.25
|
| Rate for Payer: Preferred Network Access Commercial |
$221.98
|
| Rate for Payer: Quartz Beloit One Network |
$118.23
|
| Rate for Payer: Quartz Commercial |
$156.83
|
| Rate for Payer: Quartz Medicare Advantage |
$13.50
|
| Rate for Payer: The Alliance Commercial |
$54.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.50
|
| Rate for Payer: United Healthcare PPO |
$180.96
|
| Rate for Payer: WEA Trust Commercial |
$132.70
|
| Rate for Payer: Wellcare Medicare |
$13.50
|
| Rate for Payer: WPS Commercial |
$178.71
|
|
