|
Ft insert ucb berkeley shell L3000
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
HCPCS L3000
|
| Hospital Charge Code |
3133692
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$78.68 |
| Max. Negotiated Rate |
$1,124.00 |
| Rate for Payer: Aetna Commercial |
$252.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.66
|
| Rate for Payer: Aetna Managed Medicare |
$78.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$124.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$124.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$124.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.93
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$258.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$157.25
|
| Rate for Payer: Health EOS Commercial |
$250.09
|
| Rate for Payer: HFN Commercial |
$258.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.75
|
| Rate for Payer: Multiplan Commercial |
$224.80
|
| Rate for Payer: NAPHCARE Commercial |
$168.60
|
| Rate for Payer: Preferred Network Access Commercial |
$258.52
|
| Rate for Payer: Quartz Beloit One Network |
$137.69
|
| Rate for Payer: Quartz Commercial |
$182.65
|
| Rate for Payer: Quartz Medicare Advantage |
$168.60
|
| Rate for Payer: The Alliance Commercial |
$1,124.00
|
| Rate for Payer: WEA Trust Commercial |
$154.55
|
| Rate for Payer: WPS Commercial |
$208.14
|
|
|
Ft insert ucb berkeley shell L3000
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
HCPCS L3000
|
| Hospital Charge Code |
3133692
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$137.69 |
| Max. Negotiated Rate |
$258.52 |
| Rate for Payer: Aetna Commercial |
$252.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.93
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$258.52
|
| Rate for Payer: Health EOS Commercial |
$250.09
|
| Rate for Payer: HFN Commercial |
$258.52
|
| Rate for Payer: Multiplan Commercial |
$224.80
|
| Rate for Payer: NAPHCARE Commercial |
$168.60
|
| Rate for Payer: Preferred Network Access Commercial |
$258.52
|
| Rate for Payer: Quartz Beloit One Network |
$137.69
|
| Rate for Payer: Quartz Commercial |
$168.60
|
| Rate for Payer: WEA Trust Commercial |
$154.55
|
| Rate for Payer: WPS Commercial |
$208.14
|
|
|
FULKERSON/TIBIAL OSTEOTOMY
|
Facility
|
OP
|
$4,560.00
|
|
| Hospital Charge Code |
4524687
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,276.80 |
| Max. Negotiated Rate |
$18,240.00 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,276.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,964.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,280.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,188.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,551.78
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,420.00
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,964.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,736.00
|
| Rate for Payer: The Alliance Commercial |
$18,240.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
FULKERSON/TIBIAL OSTEOTOMY
|
Facility
|
IP
|
$4,560.00
|
|
| Hospital Charge Code |
4524687
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,234.40 |
| Max. Negotiated Rate |
$4,195.20 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,736.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
Full Assess and Care Planning Cognitive Impairment 99483
|
Facility
|
IP
|
$849.00
|
|
|
Service Code
|
CPT 99483
|
| Hospital Charge Code |
5344633
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$416.01 |
| Max. Negotiated Rate |
$781.08 |
| Rate for Payer: Aetna Commercial |
$764.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$730.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$449.97
|
| Rate for Payer: Cash Price |
$254.70
|
| Rate for Payer: Cigna Commercial |
$781.08
|
| Rate for Payer: Health EOS Commercial |
$755.61
|
| Rate for Payer: HFN Commercial |
$781.08
|
| Rate for Payer: Multiplan Commercial |
$679.20
|
| Rate for Payer: NAPHCARE Commercial |
$509.40
|
| Rate for Payer: Preferred Network Access Commercial |
$781.08
|
| Rate for Payer: Quartz Beloit One Network |
$416.01
|
| Rate for Payer: Quartz Commercial |
$509.40
|
| Rate for Payer: WEA Trust Commercial |
$466.95
|
| Rate for Payer: WPS Commercial |
$628.85
|
|
|
Full Assess and Care Planning Cognitive Impairment 99483
|
Facility
|
OP
|
$849.00
|
|
|
Service Code
|
CPT 99483
|
| Hospital Charge Code |
5344633
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$88.10 |
| Max. Negotiated Rate |
$781.08 |
| Rate for Payer: Aetna Commercial |
$764.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$730.14
|
| Rate for Payer: Aetna Managed Medicare |
$88.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$551.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$424.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$407.52
|
| Rate for Payer: Anthem Medicare Advantage |
$88.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$449.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$88.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$88.10
|
| Rate for Payer: Cash Price |
$254.70
|
| Rate for Payer: Cash Price |
$254.70
|
| Rate for Payer: Cigna Commercial |
$781.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$88.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$475.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$88.10
|
| Rate for Payer: Health EOS Commercial |
$755.61
|
| Rate for Payer: HFN Commercial |
$781.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$327.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$88.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$88.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$88.10
|
| Rate for Payer: Multiplan Commercial |
$679.20
|
| Rate for Payer: NAPHCARE Commercial |
$132.15
|
| Rate for Payer: Preferred Network Access Commercial |
$781.08
|
| Rate for Payer: Quartz Beloit One Network |
$416.01
|
| Rate for Payer: Quartz Commercial |
$551.85
|
| Rate for Payer: Quartz Medicare Advantage |
$88.10
|
| Rate for Payer: The Alliance Commercial |
$352.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$88.10
|
| Rate for Payer: WEA Trust Commercial |
$466.95
|
| Rate for Payer: Wellcare Medicare |
$88.10
|
| Rate for Payer: WPS Commercial |
$628.85
|
|
|
FULL RING 140MM 4933-2-140
|
Facility
|
OP
|
$6,011.00
|
|
| Hospital Charge Code |
6001640
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,683.08 |
| Max. Negotiated Rate |
$24,044.00 |
| Rate for Payer: Aetna Commercial |
$5,409.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,169.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,683.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,907.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,005.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,885.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,185.83
|
| Rate for Payer: Cash Price |
$1,803.30
|
| Rate for Payer: Cigna Commercial |
$5,530.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,363.76
|
| Rate for Payer: Health EOS Commercial |
$5,349.79
|
| Rate for Payer: HFN Commercial |
$5,530.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,508.25
|
| Rate for Payer: Multiplan Commercial |
$4,808.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,606.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,530.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,945.39
|
| Rate for Payer: Quartz Commercial |
$3,907.15
|
| Rate for Payer: Quartz Medicare Advantage |
$3,606.60
|
| Rate for Payer: The Alliance Commercial |
$24,044.00
|
| Rate for Payer: WEA Trust Commercial |
$3,306.05
|
| Rate for Payer: WPS Commercial |
$4,452.35
|
|
|
FULL RING 140MM 4933-2-140
|
Facility
|
IP
|
$6,011.00
|
|
| Hospital Charge Code |
6001640
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,945.39 |
| Max. Negotiated Rate |
$5,530.12 |
| Rate for Payer: Aetna Commercial |
$5,409.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,169.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,185.83
|
| Rate for Payer: Cash Price |
$1,803.30
|
| Rate for Payer: Cigna Commercial |
$5,530.12
|
| Rate for Payer: Health EOS Commercial |
$5,349.79
|
| Rate for Payer: HFN Commercial |
$5,530.12
|
| Rate for Payer: Multiplan Commercial |
$4,808.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,606.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,530.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,945.39
|
| Rate for Payer: Quartz Commercial |
$3,606.60
|
| Rate for Payer: WEA Trust Commercial |
$3,306.05
|
| Rate for Payer: WPS Commercial |
$4,452.35
|
|
|
FULL RING 155MM 4933-2-155
|
Facility
|
OP
|
$6,251.00
|
|
| Hospital Charge Code |
5611674
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,750.28 |
| Max. Negotiated Rate |
$25,004.00 |
| Rate for Payer: Aetna Commercial |
$5,625.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,375.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,750.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,063.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,125.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,000.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,313.03
|
| Rate for Payer: Cash Price |
$1,875.30
|
| Rate for Payer: Cigna Commercial |
$5,750.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,498.06
|
| Rate for Payer: Health EOS Commercial |
$5,563.39
|
| Rate for Payer: HFN Commercial |
$5,750.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,688.25
|
| Rate for Payer: Multiplan Commercial |
$5,000.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,750.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,750.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,062.99
|
| Rate for Payer: Quartz Commercial |
$4,063.15
|
| Rate for Payer: Quartz Medicare Advantage |
$3,750.60
|
| Rate for Payer: The Alliance Commercial |
$25,004.00
|
| Rate for Payer: WEA Trust Commercial |
$3,438.05
|
| Rate for Payer: WPS Commercial |
$4,630.12
|
|
|
FULL RING 155MM 4933-2-155
|
Facility
|
IP
|
$6,251.00
|
|
| Hospital Charge Code |
5611674
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,062.99 |
| Max. Negotiated Rate |
$5,750.92 |
| Rate for Payer: Aetna Commercial |
$5,625.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,375.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,313.03
|
| Rate for Payer: Cash Price |
$1,875.30
|
| Rate for Payer: Cigna Commercial |
$5,750.92
|
| Rate for Payer: Health EOS Commercial |
$5,563.39
|
| Rate for Payer: HFN Commercial |
$5,750.92
|
| Rate for Payer: Multiplan Commercial |
$5,000.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,750.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,750.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,062.99
|
| Rate for Payer: Quartz Commercial |
$3,750.60
|
| Rate for Payer: WEA Trust Commercial |
$3,438.05
|
| Rate for Payer: WPS Commercial |
$4,630.12
|
|
|
FULL RING 180MM 4933-2-180
|
Facility
|
IP
|
$6,010.00
|
|
| Hospital Charge Code |
6165643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,944.90 |
| Max. Negotiated Rate |
$5,529.20 |
| Rate for Payer: Aetna Commercial |
$5,409.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,168.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,185.30
|
| Rate for Payer: Cash Price |
$1,803.00
|
| Rate for Payer: Cigna Commercial |
$5,529.20
|
| Rate for Payer: Health EOS Commercial |
$5,348.90
|
| Rate for Payer: HFN Commercial |
$5,529.20
|
| Rate for Payer: Multiplan Commercial |
$4,808.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,606.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,529.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,944.90
|
| Rate for Payer: Quartz Commercial |
$3,606.00
|
| Rate for Payer: WEA Trust Commercial |
$3,305.50
|
| Rate for Payer: WPS Commercial |
$4,451.61
|
|
|
FULL RING 180MM 4933-2-180
|
Facility
|
OP
|
$6,010.00
|
|
| Hospital Charge Code |
6165643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,682.80 |
| Max. Negotiated Rate |
$24,040.00 |
| Rate for Payer: Aetna Commercial |
$5,409.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,168.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,682.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,906.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,005.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,884.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,185.30
|
| Rate for Payer: Cash Price |
$1,803.00
|
| Rate for Payer: Cigna Commercial |
$5,529.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,363.20
|
| Rate for Payer: Health EOS Commercial |
$5,348.90
|
| Rate for Payer: HFN Commercial |
$5,529.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,507.50
|
| Rate for Payer: Multiplan Commercial |
$4,808.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,606.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,529.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,944.90
|
| Rate for Payer: Quartz Commercial |
$3,906.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,606.00
|
| Rate for Payer: The Alliance Commercial |
$24,040.00
|
| Rate for Payer: WEA Trust Commercial |
$3,305.50
|
| Rate for Payer: WPS Commercial |
$4,451.61
|
|
|
FULL RING 210MM 4933-2-210
|
Facility
|
OP
|
$6,501.00
|
|
| Hospital Charge Code |
5603592
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,820.28 |
| Max. Negotiated Rate |
$26,004.00 |
| Rate for Payer: Aetna Commercial |
$5,850.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,590.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,820.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,225.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,250.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,120.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,445.53
|
| Rate for Payer: Cash Price |
$1,950.30
|
| Rate for Payer: Cigna Commercial |
$5,980.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,637.96
|
| Rate for Payer: Health EOS Commercial |
$5,785.89
|
| Rate for Payer: HFN Commercial |
$5,980.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,875.75
|
| Rate for Payer: Multiplan Commercial |
$5,200.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,900.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,980.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,185.49
|
| Rate for Payer: Quartz Commercial |
$4,225.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,900.60
|
| Rate for Payer: The Alliance Commercial |
$26,004.00
|
| Rate for Payer: WEA Trust Commercial |
$3,575.55
|
| Rate for Payer: WPS Commercial |
$4,815.29
|
|
|
FULL RING 210MM 4933-2-210
|
Facility
|
IP
|
$6,501.00
|
|
| Hospital Charge Code |
5603592
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,185.49 |
| Max. Negotiated Rate |
$5,980.92 |
| Rate for Payer: Aetna Commercial |
$5,850.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,590.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,445.53
|
| Rate for Payer: Cash Price |
$1,950.30
|
| Rate for Payer: Cigna Commercial |
$5,980.92
|
| Rate for Payer: Health EOS Commercial |
$5,785.89
|
| Rate for Payer: HFN Commercial |
$5,980.92
|
| Rate for Payer: Multiplan Commercial |
$5,200.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,900.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,980.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,185.49
|
| Rate for Payer: Quartz Commercial |
$3,900.60
|
| Rate for Payer: WEA Trust Commercial |
$3,575.55
|
| Rate for Payer: WPS Commercial |
$4,815.29
|
|
|
FULL TERM NEONATE WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$112,229.00
|
|
|
Service Code
|
MSDRG 793
|
| Min. Negotiated Rate |
$2,400.00 |
| Max. Negotiated Rate |
$112,229.00 |
| Rate for Payer: Aetna Managed Medicare |
$40,370.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,079.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,446.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,273.00
|
| Rate for Payer: Anthem Medicare Advantage |
$40,370.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$40,370.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$40,370.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$40,370.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71,401.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$40,370.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82,081.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40,370.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$40,370.04
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$40,370.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$40,370.04
|
| Rate for Payer: NAPHCARE Commercial |
$60,555.06
|
| Rate for Payer: Quartz Medicare Advantage |
$40,370.04
|
| Rate for Payer: The Alliance Commercial |
$112,229.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40,370.04
|
| Rate for Payer: United Healthcare PPO |
$2,400.00
|
| Rate for Payer: Wellcare Medicare |
$40,370.04
|
|
|
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY
|
Facility
|
IP
|
$55,952.00
|
|
|
Service Code
|
MSDRG 934
|
| Min. Negotiated Rate |
$20,126.46 |
| Max. Negotiated Rate |
$55,952.00 |
| Rate for Payer: Wellcare Medicare |
$20,126.46
|
| Rate for Payer: Aetna Managed Medicare |
$20,126.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43,848.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33,609.29
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31,931.02
|
| Rate for Payer: Anthem Medicare Advantage |
$20,126.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20,126.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20,126.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20,126.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35,446.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20,126.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40,803.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20,126.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20,126.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20,126.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20,126.46
|
| Rate for Payer: NAPHCARE Commercial |
$30,189.69
|
| Rate for Payer: Quartz Medicare Advantage |
$20,126.46
|
| Rate for Payer: The Alliance Commercial |
$55,952.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20,126.46
|
| Rate for Payer: United Healthcare PPO |
$31,766.24
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC
|
Facility
|
IP
|
$184,287.00
|
|
|
Service Code
|
MSDRG 928
|
| Min. Negotiated Rate |
$66,290.40 |
| Max. Negotiated Rate |
$184,287.00 |
| Rate for Payer: Aetna Managed Medicare |
$66,290.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$145,181.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111,280.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$105,723.76
|
| Rate for Payer: Anthem Medicare Advantage |
$66,290.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$66,290.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$66,290.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$66,290.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$117,363.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$66,290.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$134,934.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66,290.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$66,290.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$66,290.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$66,290.40
|
| Rate for Payer: NAPHCARE Commercial |
$99,435.60
|
| Rate for Payer: Quartz Medicare Advantage |
$66,290.40
|
| Rate for Payer: The Alliance Commercial |
$184,287.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$66,290.40
|
| Rate for Payer: United Healthcare PPO |
$105,047.97
|
| Rate for Payer: Wellcare Medicare |
$66,290.40
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC
|
Facility
|
IP
|
$85,808.00
|
|
|
Service Code
|
MSDRG 929
|
| Min. Negotiated Rate |
$30,866.04 |
| Max. Negotiated Rate |
$85,808.00 |
| Rate for Payer: Aetna Managed Medicare |
$30,866.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67,555.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51,780.82
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49,195.16
|
| Rate for Payer: Anthem Medicare Advantage |
$30,866.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30,866.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30,866.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30,866.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54,611.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30,866.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62,702.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30,866.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30,866.04
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30,866.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30,866.04
|
| Rate for Payer: NAPHCARE Commercial |
$46,299.06
|
| Rate for Payer: Quartz Medicare Advantage |
$30,866.04
|
| Rate for Payer: The Alliance Commercial |
$85,808.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30,866.04
|
| Rate for Payer: United Healthcare PPO |
$48,814.51
|
| Rate for Payer: Wellcare Medicare |
$30,866.04
|
|
|
FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS
|
Facility
|
OP
|
$7,209.92
|
|
|
Service Code
|
CPT 15260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.48 |
| Max. Negotiated Rate |
$7,209.92 |
| Rate for Payer: Aetna Managed Medicare |
$1,802.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,802.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,802.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,802.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,705.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,802.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,802.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,802.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,802.48
|
| Rate for Payer: NAPHCARE Commercial |
$2,703.72
|
| Rate for Payer: Quartz Medicare Advantage |
$1,802.48
|
| Rate for Payer: The Alliance Commercial |
$7,209.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,802.48
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,802.48
|
|
|
FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS)
|
Facility
|
OP
|
$5,511.00
|
|
| Hospital Charge Code |
2950499
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,543.08 |
| Max. Negotiated Rate |
$22,044.00 |
| Rate for Payer: Aetna Commercial |
$4,959.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,739.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,543.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,582.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,755.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,645.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,920.83
|
| Rate for Payer: Cash Price |
$1,653.30
|
| Rate for Payer: Cigna Commercial |
$5,070.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,083.96
|
| Rate for Payer: Health EOS Commercial |
$4,904.79
|
| Rate for Payer: HFN Commercial |
$5,070.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,133.25
|
| Rate for Payer: Multiplan Commercial |
$4,408.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,306.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,070.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,700.39
|
| Rate for Payer: Quartz Commercial |
$3,582.15
|
| Rate for Payer: Quartz Medicare Advantage |
$3,306.60
|
| Rate for Payer: The Alliance Commercial |
$22,044.00
|
| Rate for Payer: WEA Trust Commercial |
$3,031.05
|
| Rate for Payer: WPS Commercial |
$4,082.00
|
|
|
FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS)
|
Facility
|
IP
|
$5,511.00
|
|
| Hospital Charge Code |
2950499
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,700.39 |
| Max. Negotiated Rate |
$5,070.12 |
| Rate for Payer: Aetna Commercial |
$4,959.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,739.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,920.83
|
| Rate for Payer: Cash Price |
$1,653.30
|
| Rate for Payer: Cigna Commercial |
$5,070.12
|
| Rate for Payer: Health EOS Commercial |
$4,904.79
|
| Rate for Payer: HFN Commercial |
$5,070.12
|
| Rate for Payer: Multiplan Commercial |
$4,408.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,306.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,070.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,700.39
|
| Rate for Payer: Quartz Commercial |
$3,306.60
|
| Rate for Payer: WEA Trust Commercial |
$3,031.05
|
| Rate for Payer: WPS Commercial |
$4,082.00
|
|
|
FUNCTIONAL ENDO SINUS SURGERY W/LANDMARK
|
Facility
|
OP
|
$7,351.00
|
|
| Hospital Charge Code |
2960069
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,058.28 |
| Max. Negotiated Rate |
$29,404.00 |
| Rate for Payer: Aetna Commercial |
$6,615.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,321.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,058.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,778.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,675.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,528.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,896.03
|
| Rate for Payer: Cash Price |
$2,205.30
|
| Rate for Payer: Cigna Commercial |
$6,762.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,113.62
|
| Rate for Payer: Health EOS Commercial |
$6,542.39
|
| Rate for Payer: HFN Commercial |
$6,762.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,513.25
|
| Rate for Payer: Multiplan Commercial |
$5,880.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,410.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,762.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,601.99
|
| Rate for Payer: Quartz Commercial |
$4,778.15
|
| Rate for Payer: Quartz Medicare Advantage |
$4,410.60
|
| Rate for Payer: The Alliance Commercial |
$29,404.00
|
| Rate for Payer: WEA Trust Commercial |
$4,043.05
|
| Rate for Payer: WPS Commercial |
$5,444.89
|
|
|
FUNCTIONAL ENDO SINUS SURGERY W/LANDMARK
|
Facility
|
IP
|
$7,351.00
|
|
| Hospital Charge Code |
2960069
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,601.99 |
| Max. Negotiated Rate |
$6,762.92 |
| Rate for Payer: Aetna Commercial |
$6,615.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,321.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,896.03
|
| Rate for Payer: Cash Price |
$2,205.30
|
| Rate for Payer: Cigna Commercial |
$6,762.92
|
| Rate for Payer: Health EOS Commercial |
$6,542.39
|
| Rate for Payer: HFN Commercial |
$6,762.92
|
| Rate for Payer: Multiplan Commercial |
$5,880.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,410.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,762.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,601.99
|
| Rate for Payer: Quartz Commercial |
$4,410.60
|
| Rate for Payer: WEA Trust Commercial |
$4,043.05
|
| Rate for Payer: WPS Commercial |
$5,444.89
|
|
|
Functional Residual Capacity - Pulmonary Function Test Charge
|
Facility
|
IP
|
$706.00
|
|
|
Service Code
|
CPT 94013
|
| Hospital Charge Code |
3006995
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$345.94 |
| Max. Negotiated Rate |
$649.52 |
| Rate for Payer: Aetna Commercial |
$635.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$607.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$374.18
|
| Rate for Payer: Cash Price |
$211.80
|
| Rate for Payer: Cigna Commercial |
$649.52
|
| Rate for Payer: Health EOS Commercial |
$628.34
|
| Rate for Payer: HFN Commercial |
$649.52
|
| Rate for Payer: Multiplan Commercial |
$564.80
|
| Rate for Payer: NAPHCARE Commercial |
$423.60
|
| Rate for Payer: Preferred Network Access Commercial |
$649.52
|
| Rate for Payer: Quartz Beloit One Network |
$345.94
|
| Rate for Payer: Quartz Commercial |
$423.60
|
| Rate for Payer: WEA Trust Commercial |
$388.30
|
| Rate for Payer: WPS Commercial |
$522.93
|
|
|
Functional Residual Capacity - Pulmonary Function Test Charge
|
Facility
|
OP
|
$706.00
|
|
|
Service Code
|
CPT 94013
|
| Hospital Charge Code |
3006995
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$338.88 |
| Max. Negotiated Rate |
$2,119.08 |
| Rate for Payer: Aetna Commercial |
$635.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$607.16
|
| Rate for Payer: Aetna Managed Medicare |
$529.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$458.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$353.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$338.88
|
| Rate for Payer: Anthem Medicare Advantage |
$529.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$374.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$529.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$529.77
|
| Rate for Payer: Cash Price |
$211.80
|
| Rate for Payer: Cash Price |
$211.80
|
| Rate for Payer: Cigna Commercial |
$649.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$529.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$395.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$529.77
|
| Rate for Payer: Health EOS Commercial |
$628.34
|
| Rate for Payer: HFN Commercial |
$649.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,970.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$529.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$529.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$529.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$529.77
|
| Rate for Payer: Multiplan Commercial |
$564.80
|
| Rate for Payer: NAPHCARE Commercial |
$794.66
|
| Rate for Payer: Preferred Network Access Commercial |
$649.52
|
| Rate for Payer: Quartz Beloit One Network |
$345.94
|
| Rate for Payer: Quartz Commercial |
$458.90
|
| Rate for Payer: Quartz Medicare Advantage |
$529.77
|
| Rate for Payer: The Alliance Commercial |
$2,119.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$529.77
|
| Rate for Payer: United Healthcare PPO |
$529.50
|
| Rate for Payer: WEA Trust Commercial |
$388.30
|
| Rate for Payer: Wellcare Medicare |
$529.77
|
| Rate for Payer: WPS Commercial |
$522.93
|
|
