|
FOREIGN BODY REMOVAL, EYE
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960059
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
FOREIGN BODY REMOVAL, FOOT
|
Facility
|
OP
|
$1,337.00
|
|
| Hospital Charge Code |
2960060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$374.36 |
| Max. Negotiated Rate |
$5,348.00 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Aetna Managed Medicare |
$374.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$869.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$668.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$641.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$748.19
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,002.75
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$869.05
|
| Rate for Payer: Quartz Medicare Advantage |
$802.20
|
| Rate for Payer: The Alliance Commercial |
$5,348.00
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
FOREIGN BODY REMOVAL, FOOT
|
Facility
|
IP
|
$1,337.00
|
|
| Hospital Charge Code |
2960060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$655.13 |
| Max. Negotiated Rate |
$1,230.04 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$802.20
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
FOREIGN BODY REMOVAL, HAND
|
Facility
|
IP
|
$1,337.00
|
|
| Hospital Charge Code |
2960061
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$655.13 |
| Max. Negotiated Rate |
$1,230.04 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$802.20
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
FOREIGN BODY REMOVAL, HAND
|
Facility
|
OP
|
$1,337.00
|
|
| Hospital Charge Code |
2960061
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$374.36 |
| Max. Negotiated Rate |
$5,348.00 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Aetna Managed Medicare |
$374.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$869.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$668.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$641.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$748.19
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,002.75
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$869.05
|
| Rate for Payer: Quartz Medicare Advantage |
$802.20
|
| Rate for Payer: The Alliance Commercial |
$5,348.00
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
FOREIGN BODY REMOVAL, NOSE
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960062
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
FOREIGN BODY REMOVAL, NOSE
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960062
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
FOREIGN BODY REMOVAL, OTHER
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960064
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
FOREIGN BODY REMOVAL, OTHER
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960064
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
FOREIGN BODY REMOVAL, PENIS
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960063
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
FOREIGN BODY REMOVAL, PENIS
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960063
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
Foreign Body Retrieval
|
Facility
|
IP
|
$4,689.00
|
|
|
Service Code
|
CPT 37197
|
| Hospital Charge Code |
3052433
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,297.61 |
| Max. Negotiated Rate |
$4,313.88 |
| Rate for Payer: Aetna Commercial |
$4,220.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,032.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,485.17
|
| Rate for Payer: Cash Price |
$1,406.70
|
| Rate for Payer: Cigna Commercial |
$4,313.88
|
| Rate for Payer: Health EOS Commercial |
$4,173.21
|
| Rate for Payer: HFN Commercial |
$4,313.88
|
| Rate for Payer: Multiplan Commercial |
$3,751.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,813.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,313.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,297.61
|
| Rate for Payer: Quartz Commercial |
$2,813.40
|
| Rate for Payer: WEA Trust Commercial |
$2,578.95
|
| Rate for Payer: WPS Commercial |
$3,473.14
|
|
|
Foreign Body Retrieval
|
Facility
|
OP
|
$4,689.00
|
|
|
Service Code
|
CPT 37197
|
| Hospital Charge Code |
3052433
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,297.61 |
| Max. Negotiated Rate |
$12,602.12 |
| Rate for Payer: Aetna Commercial |
$4,220.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,032.54
|
| Rate for Payer: Aetna Managed Medicare |
$3,150.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,150.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,485.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,150.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,150.53
|
| Rate for Payer: Cash Price |
$1,406.70
|
| Rate for Payer: Cash Price |
$1,406.70
|
| Rate for Payer: Cash Price |
$1,406.70
|
| Rate for Payer: Cigna Commercial |
$4,313.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,150.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,150.53
|
| Rate for Payer: Health EOS Commercial |
$4,173.21
|
| Rate for Payer: HFN Commercial |
$4,313.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,719.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,150.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,150.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,150.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,150.53
|
| Rate for Payer: Multiplan Commercial |
$3,751.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,725.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,313.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,297.61
|
| Rate for Payer: Quartz Commercial |
$3,047.85
|
| Rate for Payer: Quartz Medicare Advantage |
$3,150.53
|
| Rate for Payer: The Alliance Commercial |
$12,602.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,150.53
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: WEA Trust Commercial |
$2,578.95
|
| Rate for Payer: Wellcare Medicare |
$3,150.53
|
| Rate for Payer: WPS Commercial |
$3,473.14
|
|
|
Foreskin Manipulationincluding Lysis Of Prepubital Adhesions And Stretching
|
Professional
|
Both
|
$289.00
|
|
|
Service Code
|
CPT 54450
|
| Hospital Charge Code |
1190847
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.73 |
| Max. Negotiated Rate |
$274.55 |
| Rate for Payer: Aetna Commercial |
$274.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$248.54
|
| Rate for Payer: Cash Price |
$86.70
|
| Rate for Payer: Cash Price |
$86.70
|
| Rate for Payer: Cash Price |
$86.70
|
| Rate for Payer: Cigna Commercial |
$274.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$173.40
|
| Rate for Payer: Health EOS Commercial |
$262.99
|
| Rate for Payer: HFN Commercial |
$274.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$190.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$190.62
|
| Rate for Payer: Multiplan Commercial |
$231.20
|
| Rate for Payer: Preferred Network Access Commercial |
$274.55
|
| Rate for Payer: Quartz Beloit One Network |
$127.16
|
| Rate for Payer: Quartz Commercial |
$164.73
|
| Rate for Payer: The Alliance Commercial |
$144.50
|
| Rate for Payer: United Healthcare Medicaid |
$25.73
|
| Rate for Payer: WEA Trust Commercial |
$158.95
|
| Rate for Payer: WPS Commercial |
$214.06
|
|
|
Fosphenytoin JW Waste Charge per 50 mg
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS Q2009 JW
|
| Hospital Charge Code |
5266711
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$8.28 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.77
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: Health EOS Commercial |
$8.01
|
| Rate for Payer: HFN Commercial |
$8.28
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: NAPHCARE Commercial |
$5.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8.28
|
| Rate for Payer: Quartz Beloit One Network |
$4.41
|
| Rate for Payer: Quartz Commercial |
$5.40
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$6.67
|
|
|
Fosphenytoin JW Waste Charge per 50 mg
|
Professional
|
Both
|
$9.00
|
|
|
Service Code
|
HCPCS Q2009 JW
|
| Hospital Charge Code |
5266711
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.40
|
| Rate for Payer: Health EOS Commercial |
$8.19
|
| Rate for Payer: HFN Commercial |
$8.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.07
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8.55
|
| Rate for Payer: Quartz Beloit One Network |
$3.96
|
| Rate for Payer: Quartz Commercial |
$5.13
|
| Rate for Payer: The Alliance Commercial |
$4.50
|
| Rate for Payer: United Healthcare Medicaid |
$1.41
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$6.67
|
|
|
Fosphenytoin JW Waste Charge per 50 mg
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS Q2009 JW
|
| Hospital Charge Code |
5266711
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.32 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Aetna Managed Medicare |
$4.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.32
|
| Rate for Payer: Anthem Medicare Advantage |
$4.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.80
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.04
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.80
|
| Rate for Payer: Health EOS Commercial |
$8.01
|
| Rate for Payer: HFN Commercial |
$8.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.80
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.80
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.80
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: NAPHCARE Commercial |
$7.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8.28
|
| Rate for Payer: Quartz Beloit One Network |
$4.41
|
| Rate for Payer: Quartz Commercial |
$5.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4.80
|
| Rate for Payer: The Alliance Commercial |
$19.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.80
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: Wellcare Medicare |
$4.80
|
| Rate for Payer: WPS Commercial |
$6.67
|
|
|
FRACTURES OF FEMUR WITH MCC
|
Facility
|
IP
|
$43,693.00
|
|
|
Service Code
|
MSDRG 533
|
| Min. Negotiated Rate |
$15,716.82 |
| Max. Negotiated Rate |
$43,693.00 |
| Rate for Payer: Aetna Managed Medicare |
$15,716.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34,197.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,212.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,903.14
|
| Rate for Payer: Anthem Medicare Advantage |
$15,716.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,716.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,716.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,716.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,644.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,716.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,812.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,716.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,716.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,716.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,716.82
|
| Rate for Payer: NAPHCARE Commercial |
$23,575.23
|
| Rate for Payer: Quartz Medicare Advantage |
$15,716.82
|
| Rate for Payer: The Alliance Commercial |
$43,693.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,716.82
|
| Rate for Payer: United Healthcare PPO |
$24,766.28
|
| Rate for Payer: Wellcare Medicare |
$15,716.82
|
|
|
FRACTURES OF FEMUR WITHOUT MCC
|
Facility
|
IP
|
$21,855.00
|
|
|
Service Code
|
MSDRG 534
|
| Min. Negotiated Rate |
$7,861.52 |
| Max. Negotiated Rate |
$21,855.00 |
| Rate for Payer: Wellcare Medicare |
$7,861.52
|
| Rate for Payer: Aetna Managed Medicare |
$7,861.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,993.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,025.61
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,375.18
|
| Rate for Payer: Anthem Medicare Advantage |
$7,861.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,861.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,861.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,861.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,737.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,861.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,795.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,861.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,861.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,861.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,861.52
|
| Rate for Payer: NAPHCARE Commercial |
$11,792.28
|
| Rate for Payer: Quartz Medicare Advantage |
$7,861.52
|
| Rate for Payer: The Alliance Commercial |
$21,855.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,861.52
|
| Rate for Payer: United Healthcare PPO |
$12,296.61
|
|
|
FRACTURES OF HIP AND PELVIS WITH MCC
|
Facility
|
IP
|
$34,794.00
|
|
|
Service Code
|
MSDRG 535
|
| Min. Negotiated Rate |
$12,515.99 |
| Max. Negotiated Rate |
$34,794.00 |
| Rate for Payer: Aetna Managed Medicare |
$12,515.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,274.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,905.30
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19,861.40
|
| Rate for Payer: Anthem Medicare Advantage |
$12,515.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,515.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,515.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,515.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,047.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,515.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,285.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,515.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,515.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,515.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,515.99
|
| Rate for Payer: NAPHCARE Commercial |
$18,773.98
|
| Rate for Payer: Quartz Medicare Advantage |
$12,515.99
|
| Rate for Payer: The Alliance Commercial |
$34,794.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,515.99
|
| Rate for Payer: United Healthcare PPO |
$19,685.20
|
| Rate for Payer: Wellcare Medicare |
$12,515.99
|
|
|
FRACTURES OF HIP AND PELVIS WITHOUT MCC
|
Facility
|
IP
|
$21,246.00
|
|
|
Service Code
|
MSDRG 536
|
| Min. Negotiated Rate |
$7,642.53 |
| Max. Negotiated Rate |
$21,246.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,642.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,574.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,703.99
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,069.62
|
| Rate for Payer: Anthem Medicare Advantage |
$7,642.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,642.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,642.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,642.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,398.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,642.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,348.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,642.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,642.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,642.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,642.53
|
| Rate for Payer: NAPHCARE Commercial |
$11,463.80
|
| Rate for Payer: Quartz Medicare Advantage |
$7,642.53
|
| Rate for Payer: The Alliance Commercial |
$21,246.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,642.53
|
| Rate for Payer: United Healthcare PPO |
$11,948.97
|
| Rate for Payer: Wellcare Medicare |
$7,642.53
|
|
|
FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC
|
Facility
|
IP
|
$40,750.00
|
|
|
Service Code
|
MSDRG 562
|
| Min. Negotiated Rate |
$14,658.17 |
| Max. Negotiated Rate |
$40,750.00 |
| Rate for Payer: Aetna Managed Medicare |
$14,658.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31,889.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,443.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23,222.56
|
| Rate for Payer: Anthem Medicare Advantage |
$14,658.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,658.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,658.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,658.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25,779.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,658.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,653.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,658.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,658.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,658.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,658.17
|
| Rate for Payer: NAPHCARE Commercial |
$21,987.26
|
| Rate for Payer: Quartz Medicare Advantage |
$14,658.17
|
| Rate for Payer: The Alliance Commercial |
$40,750.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,658.17
|
| Rate for Payer: United Healthcare PPO |
$23,085.75
|
| Rate for Payer: Wellcare Medicare |
$14,658.17
|
|
|
FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC
|
Facility
|
IP
|
$24,131.00
|
|
|
Service Code
|
MSDRG 563
|
| Min. Negotiated Rate |
$8,680.15 |
| Max. Negotiated Rate |
$24,131.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,680.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,882.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,472.90
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,750.20
|
| Rate for Payer: Anthem Medicare Advantage |
$8,680.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,680.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,680.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,680.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,263.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,680.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,464.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,680.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,680.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,680.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,680.15
|
| Rate for Payer: NAPHCARE Commercial |
$13,020.22
|
| Rate for Payer: Quartz Medicare Advantage |
$8,680.15
|
| Rate for Payer: The Alliance Commercial |
$24,131.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,680.15
|
| Rate for Payer: United Healthcare PPO |
$13,596.10
|
| Rate for Payer: Wellcare Medicare |
$8,680.15
|
|
|
Fragile X DNA Detection
|
Professional
|
Both
|
$1,372.00
|
|
|
Service Code
|
CPT 81243
|
| Hospital Charge Code |
977952
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$201.35 |
| Max. Negotiated Rate |
$1,303.40 |
| Rate for Payer: Aetna Commercial |
$1,303.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,179.92
|
| Rate for Payer: Cash Price |
$411.60
|
| Rate for Payer: Cash Price |
$411.60
|
| Rate for Payer: Cigna Commercial |
$1,303.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$686.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$823.20
|
| Rate for Payer: Health EOS Commercial |
$1,248.52
|
| Rate for Payer: HFN Commercial |
$1,303.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$201.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$201.35
|
| Rate for Payer: Multiplan Commercial |
$1,097.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,303.40
|
| Rate for Payer: Quartz Beloit One Network |
$603.68
|
| Rate for Payer: Quartz Commercial |
$782.04
|
| Rate for Payer: The Alliance Commercial |
$686.00
|
| Rate for Payer: WEA Trust Commercial |
$754.60
|
| Rate for Payer: WPS Commercial |
$1,016.24
|
|
|
Fragile X DNA Detection
|
Facility
|
IP
|
$1,372.00
|
|
|
Service Code
|
CPT 81243
|
| Hospital Charge Code |
977952
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$672.28 |
| Max. Negotiated Rate |
$1,262.24 |
| Rate for Payer: Aetna Commercial |
$1,234.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,179.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$727.16
|
| Rate for Payer: Cash Price |
$411.60
|
| Rate for Payer: Cigna Commercial |
$1,262.24
|
| Rate for Payer: Health EOS Commercial |
$1,221.08
|
| Rate for Payer: HFN Commercial |
$1,262.24
|
| Rate for Payer: Multiplan Commercial |
$1,097.60
|
| Rate for Payer: NAPHCARE Commercial |
$823.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,262.24
|
| Rate for Payer: Quartz Beloit One Network |
$672.28
|
| Rate for Payer: Quartz Commercial |
$823.20
|
| Rate for Payer: WEA Trust Commercial |
$754.60
|
| Rate for Payer: WPS Commercial |
$1,016.24
|
|
