|
Insulin-Like Growth Factor Binding Protein-3
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
977988
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$101.41 |
| Max. Negotiated Rate |
$190.40 |
| Rate for Payer: Aetna Commercial |
$186.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.69
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: Health EOS Commercial |
$184.19
|
| Rate for Payer: HFN Commercial |
$190.40
|
| Rate for Payer: Multiplan Commercial |
$165.57
|
| Rate for Payer: Preferred Network Access Commercial |
$190.40
|
| Rate for Payer: Quartz Beloit One Network |
$101.41
|
| Rate for Payer: Quartz Commercial |
$124.18
|
| Rate for Payer: WEA Trust Commercial |
$113.83
|
| Rate for Payer: WPS Commercial |
$153.29
|
|
|
Insulin-Like Growth Factor Binding Protein-3
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
977988
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$190.40 |
| Rate for Payer: Aetna Commercial |
$186.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.99
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$184.19
|
| Rate for Payer: HFN Commercial |
$190.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$165.57
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$190.40
|
| Rate for Payer: Quartz Beloit One Network |
$101.41
|
| Rate for Payer: Quartz Commercial |
$134.52
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$155.22
|
| Rate for Payer: WEA Trust Commercial |
$113.83
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$153.29
|
|
|
Insulin-Like Growth Factor Binding Protein-3
|
Professional
|
Both
|
$199.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
977988
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$196.61 |
| Rate for Payer: Aetna Commercial |
$196.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.99
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$196.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$103.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$188.33
|
| Rate for Payer: HFN Commercial |
$196.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$165.57
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$196.61
|
| Rate for Payer: Quartz Beloit One Network |
$91.06
|
| Rate for Payer: Quartz Commercial |
$117.97
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$113.83
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
Insulin-Like Growth Factor-I
|
Professional
|
Both
|
$651.00
|
|
|
Service Code
|
CPT 84305
|
| Hospital Charge Code |
1039281
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.11 |
| Max. Negotiated Rate |
$643.19 |
| Rate for Payer: Aetna Commercial |
$643.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.25
|
| Rate for Payer: Aetna Managed Medicare |
$22.11
|
| Rate for Payer: Anthem Medicare Advantage |
$22.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22.11
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna Commercial |
$643.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$338.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.11
|
| Rate for Payer: Health EOS Commercial |
$616.11
|
| Rate for Payer: HFN Commercial |
$643.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$78.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22.11
|
| Rate for Payer: Multiplan Commercial |
$541.63
|
| Rate for Payer: NAPHCARE Commercial |
$33.17
|
| Rate for Payer: Preferred Network Access Commercial |
$643.19
|
| Rate for Payer: Quartz Beloit One Network |
$297.90
|
| Rate for Payer: Quartz Commercial |
$385.91
|
| Rate for Payer: Quartz Medicare Advantage |
$22.11
|
| Rate for Payer: The Alliance Commercial |
$87.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.11
|
| Rate for Payer: WEA Trust Commercial |
$372.37
|
| Rate for Payer: WPS Commercial |
$97.29
|
|
|
Insulin-Like Growth Factor-I
|
Facility
|
IP
|
$651.00
|
|
|
Service Code
|
CPT 84305
|
| Hospital Charge Code |
1039281
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$331.75 |
| Max. Negotiated Rate |
$622.88 |
| Rate for Payer: Aetna Commercial |
$609.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.83
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna Commercial |
$622.88
|
| Rate for Payer: Health EOS Commercial |
$602.57
|
| Rate for Payer: HFN Commercial |
$622.88
|
| Rate for Payer: Multiplan Commercial |
$541.63
|
| Rate for Payer: Preferred Network Access Commercial |
$622.88
|
| Rate for Payer: Quartz Beloit One Network |
$331.75
|
| Rate for Payer: Quartz Commercial |
$406.22
|
| Rate for Payer: WEA Trust Commercial |
$372.37
|
| Rate for Payer: WPS Commercial |
$501.47
|
|
|
Insulin-Like Growth Factor-I
|
Facility
|
OP
|
$651.00
|
|
|
Service Code
|
CPT 84305
|
| Hospital Charge Code |
1039281
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.11 |
| Max. Negotiated Rate |
$622.88 |
| Rate for Payer: Aetna Commercial |
$609.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.25
|
| Rate for Payer: Aetna Managed Medicare |
$22.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$82.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.70
|
| Rate for Payer: Anthem Medicare Advantage |
$22.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22.11
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna Commercial |
$622.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$22.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$378.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$22.11
|
| Rate for Payer: Health EOS Commercial |
$602.57
|
| Rate for Payer: HFN Commercial |
$622.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$22.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$22.11
|
| Rate for Payer: Multiplan Commercial |
$541.63
|
| Rate for Payer: NAPHCARE Commercial |
$33.17
|
| Rate for Payer: Preferred Network Access Commercial |
$622.88
|
| Rate for Payer: Quartz Beloit One Network |
$331.75
|
| Rate for Payer: Quartz Commercial |
$440.08
|
| Rate for Payer: Quartz Medicare Advantage |
$22.11
|
| Rate for Payer: The Alliance Commercial |
$88.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.11
|
| Rate for Payer: United Healthcare PPO |
$507.78
|
| Rate for Payer: WEA Trust Commercial |
$372.37
|
| Rate for Payer: Wellcare Medicare |
$22.11
|
| Rate for Payer: WPS Commercial |
$501.47
|
|
|
Insulin-Like Growth Factor II
|
Facility
|
IP
|
$394.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
978125
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$200.78 |
| Max. Negotiated Rate |
$376.98 |
| Rate for Payer: Aetna Commercial |
$368.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.17
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$376.98
|
| Rate for Payer: Health EOS Commercial |
$364.69
|
| Rate for Payer: HFN Commercial |
$376.98
|
| Rate for Payer: Multiplan Commercial |
$327.81
|
| Rate for Payer: Preferred Network Access Commercial |
$376.98
|
| Rate for Payer: Quartz Beloit One Network |
$200.78
|
| Rate for Payer: Quartz Commercial |
$245.86
|
| Rate for Payer: WEA Trust Commercial |
$225.37
|
| Rate for Payer: WPS Commercial |
$303.50
|
|
|
Insulin-Like Growth Factor II
|
Professional
|
Both
|
$394.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
978125
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$389.27 |
| Rate for Payer: Aetna Commercial |
$389.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.39
|
| Rate for Payer: Aetna Managed Medicare |
$19.14
|
| Rate for Payer: Anthem Medicare Advantage |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.14
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$389.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$204.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$372.88
|
| Rate for Payer: HFN Commercial |
$389.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$67.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$327.81
|
| Rate for Payer: NAPHCARE Commercial |
$28.70
|
| Rate for Payer: Preferred Network Access Commercial |
$389.27
|
| Rate for Payer: Quartz Beloit One Network |
$180.29
|
| Rate for Payer: Quartz Commercial |
$233.56
|
| Rate for Payer: Quartz Medicare Advantage |
$19.14
|
| Rate for Payer: The Alliance Commercial |
$75.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.14
|
| Rate for Payer: WEA Trust Commercial |
$225.37
|
| Rate for Payer: WPS Commercial |
$84.20
|
|
|
Insulin-Like Growth Factor II
|
Facility
|
OP
|
$394.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
978125
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$376.98 |
| Rate for Payer: Aetna Commercial |
$368.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.39
|
| Rate for Payer: Aetna Managed Medicare |
$19.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.49
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.77
|
| Rate for Payer: Anthem Medicare Advantage |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.14
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$376.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$229.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$364.69
|
| Rate for Payer: HFN Commercial |
$376.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$327.81
|
| Rate for Payer: NAPHCARE Commercial |
$28.70
|
| Rate for Payer: Preferred Network Access Commercial |
$376.98
|
| Rate for Payer: Quartz Beloit One Network |
$200.78
|
| Rate for Payer: Quartz Commercial |
$266.34
|
| Rate for Payer: Quartz Medicare Advantage |
$19.14
|
| Rate for Payer: The Alliance Commercial |
$76.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.14
|
| Rate for Payer: United Healthcare PPO |
$307.32
|
| Rate for Payer: WEA Trust Commercial |
$225.37
|
| Rate for Payer: Wellcare Medicare |
$19.14
|
| Rate for Payer: WPS Commercial |
$303.50
|
|
|
INTELLECTUAL DISABILITY
|
Facility
|
OP
|
$89.10
|
|
|
Service Code
|
EAPG 00828
|
| Min. Negotiated Rate |
$85.67 |
| Max. Negotiated Rate |
$89.10 |
| Rate for Payer: Anthem Medicaid |
$85.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$85.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$85.67
|
| Rate for Payer: Dean Health Medicaid |
$85.67
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$85.67
|
| Rate for Payer: Managed Health Services Medicaid |
$89.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.67
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$85.67
|
| Rate for Payer: United Healthcare Medicaid |
$85.67
|
|
|
Intensity Mod Radiotherapy Plan 7730126
|
Professional
|
Both
|
$3,796.00
|
|
|
Service Code
|
CPT 77301 26
|
| Hospital Charge Code |
5258629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$421.32 |
| Max. Negotiated Rate |
$3,750.45 |
| Rate for Payer: Aetna Commercial |
$3,750.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,395.14
|
| Rate for Payer: Aetna Managed Medicare |
$421.32
|
| Rate for Payer: Anthem Medicare Advantage |
$421.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$421.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$421.32
|
| Rate for Payer: Cash Price |
$1,138.80
|
| Rate for Payer: Cash Price |
$1,138.80
|
| Rate for Payer: Cash Price |
$1,138.80
|
| Rate for Payer: Cigna Commercial |
$3,750.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,973.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$421.32
|
| Rate for Payer: Health EOS Commercial |
$3,592.53
|
| Rate for Payer: HFN Commercial |
$3,750.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,496.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,496.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$421.32
|
| Rate for Payer: Multiplan Commercial |
$3,158.27
|
| Rate for Payer: NAPHCARE Commercial |
$631.99
|
| Rate for Payer: Preferred Network Access Commercial |
$3,750.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,737.05
|
| Rate for Payer: Quartz Commercial |
$2,250.27
|
| Rate for Payer: Quartz Medicare Advantage |
$421.32
|
| Rate for Payer: The Alliance Commercial |
$1,601.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$421.32
|
| Rate for Payer: WEA Trust Commercial |
$2,171.31
|
| Rate for Payer: WPS Commercial |
$2,106.62
|
|
|
INTENSIVE OUTPATIENT PSYCHIATRIC TREATMENT
|
Facility
|
OP
|
$100.89
|
|
|
Service Code
|
EAPG 00327
|
| Min. Negotiated Rate |
$97.01 |
| Max. Negotiated Rate |
$100.89 |
| Rate for Payer: Anthem Medicaid |
$97.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$97.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$97.01
|
| Rate for Payer: Dean Health Medicaid |
$97.01
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$97.01
|
| Rate for Payer: Managed Health Services Medicaid |
$100.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$97.01
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$97.01
|
| Rate for Payer: United Healthcare Medicaid |
$97.01
|
|
|
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE
|
Facility
|
IP
|
$5,260.99
|
|
|
Service Code
|
APR-DRG 8172
|
| Min. Negotiated Rate |
$4,673.14 |
| Max. Negotiated Rate |
$5,260.99 |
| Rate for Payer: Anthem Medicaid |
$5,037.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,037.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,037.68
|
| Rate for Payer: Dean Health Medicaid |
$5,037.68
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4,673.14
|
| Rate for Payer: Managed Health Services Medicaid |
$5,260.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,037.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,037.68
|
| Rate for Payer: United Healthcare Medicaid |
$5,037.68
|
|
|
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE
|
Facility
|
OP
|
$117.93
|
|
|
Service Code
|
EAPG 00832
|
| Min. Negotiated Rate |
$113.39 |
| Max. Negotiated Rate |
$117.93 |
| Rate for Payer: Anthem Medicaid |
$113.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$113.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$113.39
|
| Rate for Payer: Dean Health Medicaid |
$113.39
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$113.39
|
| Rate for Payer: Managed Health Services Medicaid |
$117.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$113.39
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$113.39
|
| Rate for Payer: United Healthcare Medicaid |
$113.39
|
|
|
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE
|
Facility
|
IP
|
$20,167.11
|
|
|
Service Code
|
APR-DRG 8174
|
| Min. Negotiated Rate |
$17,913.69 |
| Max. Negotiated Rate |
$20,167.11 |
| Rate for Payer: Anthem Medicaid |
$19,311.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$19,311.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19,311.12
|
| Rate for Payer: Dean Health Medicaid |
$19,311.12
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17,913.69
|
| Rate for Payer: Managed Health Services Medicaid |
$20,167.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,311.12
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19,311.12
|
| Rate for Payer: United Healthcare Medicaid |
$19,311.12
|
|
|
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE
|
Facility
|
IP
|
$9,908.19
|
|
|
Service Code
|
APR-DRG 8173
|
| Min. Negotiated Rate |
$8,801.07 |
| Max. Negotiated Rate |
$9,908.19 |
| Rate for Payer: Anthem Medicaid |
$9,487.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,487.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,487.64
|
| Rate for Payer: Dean Health Medicaid |
$9,487.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,801.07
|
| Rate for Payer: Managed Health Services Medicaid |
$9,908.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,487.64
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,487.64
|
| Rate for Payer: United Healthcare Medicaid |
$9,487.64
|
|
|
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE
|
Facility
|
IP
|
$3,595.01
|
|
|
Service Code
|
APR-DRG 8171
|
| Min. Negotiated Rate |
$3,193.31 |
| Max. Negotiated Rate |
$3,595.01 |
| Rate for Payer: Anthem Medicaid |
$3,442.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$3,442.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,442.42
|
| Rate for Payer: Dean Health Medicaid |
$3,442.42
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,193.31
|
| Rate for Payer: Managed Health Services Medicaid |
$3,595.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,442.42
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3,442.42
|
| Rate for Payer: United Healthcare Medicaid |
$3,442.42
|
|
|
INTERCEED ABSORBABLE ADHESION BARRIER 4350
|
Facility
|
IP
|
$3,817.00
|
|
| Hospital Charge Code |
3525511
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,945.14 |
| Max. Negotiated Rate |
$3,652.11 |
| Rate for Payer: Aetna Commercial |
$3,572.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,413.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,103.93
|
| Rate for Payer: Cash Price |
$1,145.10
|
| Rate for Payer: Cigna Commercial |
$3,652.11
|
| Rate for Payer: Health EOS Commercial |
$3,533.02
|
| Rate for Payer: HFN Commercial |
$3,652.11
|
| Rate for Payer: Multiplan Commercial |
$3,175.74
|
| Rate for Payer: Preferred Network Access Commercial |
$3,652.11
|
| Rate for Payer: Quartz Beloit One Network |
$1,945.14
|
| Rate for Payer: Quartz Commercial |
$2,381.81
|
| Rate for Payer: WEA Trust Commercial |
$2,183.32
|
| Rate for Payer: WPS Commercial |
$2,940.24
|
|
|
INTERCEED ABSORBABLE ADHESION BARRIER 4350
|
Facility
|
OP
|
$3,817.00
|
|
| Hospital Charge Code |
3525511
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,111.51 |
| Max. Negotiated Rate |
$3,652.11 |
| Rate for Payer: Aetna Commercial |
$3,572.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,413.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,111.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,580.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,984.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,905.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,103.93
|
| Rate for Payer: Cash Price |
$1,145.10
|
| Rate for Payer: Cigna Commercial |
$3,652.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,221.49
|
| Rate for Payer: Health EOS Commercial |
$3,533.02
|
| Rate for Payer: HFN Commercial |
$3,652.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,977.26
|
| Rate for Payer: Multiplan Commercial |
$3,175.74
|
| Rate for Payer: NAPHCARE Commercial |
$2,381.81
|
| Rate for Payer: Preferred Network Access Commercial |
$3,652.11
|
| Rate for Payer: Quartz Beloit One Network |
$1,945.14
|
| Rate for Payer: Quartz Commercial |
$2,580.29
|
| Rate for Payer: Quartz Medicare Advantage |
$2,381.81
|
| Rate for Payer: The Alliance Commercial |
$1,984.84
|
| Rate for Payer: WEA Trust Commercial |
$2,183.32
|
| Rate for Payer: WPS Commercial |
$2,940.24
|
|
|
Interleukin 1 Beta
|
Professional
|
Both
|
$370.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4464670
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$365.56 |
| Rate for Payer: Aetna Commercial |
$365.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$365.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$350.17
|
| Rate for Payer: HFN Commercial |
$365.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$365.56
|
| Rate for Payer: Quartz Beloit One Network |
$169.31
|
| Rate for Payer: Quartz Commercial |
$219.34
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
Interleukin 1 Beta
|
Facility
|
IP
|
$370.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4464670
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$188.55 |
| Max. Negotiated Rate |
$354.02 |
| Rate for Payer: Aetna Commercial |
$346.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.94
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$354.02
|
| Rate for Payer: Health EOS Commercial |
$342.47
|
| Rate for Payer: HFN Commercial |
$354.02
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: Preferred Network Access Commercial |
$354.02
|
| Rate for Payer: Quartz Beloit One Network |
$188.55
|
| Rate for Payer: Quartz Commercial |
$230.88
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
Interleukin 1 Beta
|
Facility
|
OP
|
$370.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4464670
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$354.02 |
| Rate for Payer: Aetna Commercial |
$346.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$354.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$342.47
|
| Rate for Payer: HFN Commercial |
$354.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$354.02
|
| Rate for Payer: Quartz Beloit One Network |
$188.55
|
| Rate for Payer: Quartz Commercial |
$250.12
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$288.60
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
Interleukin 6 High Sensitive, ELISA
|
Facility
|
OP
|
$318.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4464671
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$304.26 |
| Rate for Payer: Aetna Commercial |
$297.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$284.42
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$175.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$304.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$185.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$294.34
|
| Rate for Payer: HFN Commercial |
$304.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$264.58
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$304.26
|
| Rate for Payer: Quartz Beloit One Network |
$162.05
|
| Rate for Payer: Quartz Commercial |
$214.97
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$248.04
|
| Rate for Payer: WEA Trust Commercial |
$181.90
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$244.96
|
|
|
Interleukin 6 High Sensitive, ELISA
|
Professional
|
Both
|
$318.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4464671
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$314.18 |
| Rate for Payer: Aetna Commercial |
$314.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$284.42
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$314.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$165.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$300.96
|
| Rate for Payer: HFN Commercial |
$314.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$264.58
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$314.18
|
| Rate for Payer: Quartz Beloit One Network |
$145.52
|
| Rate for Payer: Quartz Commercial |
$188.51
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$181.90
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
Interleukin 6 High Sensitive, ELISA
|
Facility
|
IP
|
$318.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4464671
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$162.05 |
| Max. Negotiated Rate |
$304.26 |
| Rate for Payer: Aetna Commercial |
$297.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$284.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$175.28
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$304.26
|
| Rate for Payer: Health EOS Commercial |
$294.34
|
| Rate for Payer: HFN Commercial |
$304.26
|
| Rate for Payer: Multiplan Commercial |
$264.58
|
| Rate for Payer: Preferred Network Access Commercial |
$304.26
|
| Rate for Payer: Quartz Beloit One Network |
$162.05
|
| Rate for Payer: Quartz Commercial |
$198.43
|
| Rate for Payer: WEA Trust Commercial |
$181.90
|
| Rate for Payer: WPS Commercial |
$244.96
|
|
