|
AMPUTATION, ABOVE KNEE
|
Facility
|
OP
|
$1,757.00
|
|
| Hospital Charge Code |
2959785
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$511.64 |
| Max. Negotiated Rate |
$1,681.10 |
| Rate for Payer: Aetna Commercial |
$1,644.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,571.46
|
| Rate for Payer: Aetna Managed Medicare |
$511.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,187.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$913.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$877.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$968.46
|
| Rate for Payer: Cash Price |
$527.10
|
| Rate for Payer: Cigna Commercial |
$1,681.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,022.57
|
| Rate for Payer: Health EOS Commercial |
$1,626.28
|
| Rate for Payer: HFN Commercial |
$1,681.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,370.46
|
| Rate for Payer: Multiplan Commercial |
$1,461.82
|
| Rate for Payer: NAPHCARE Commercial |
$1,096.37
|
| Rate for Payer: Preferred Network Access Commercial |
$1,681.10
|
| Rate for Payer: Quartz Beloit One Network |
$895.37
|
| Rate for Payer: Quartz Commercial |
$1,187.73
|
| Rate for Payer: Quartz Medicare Advantage |
$1,096.37
|
| Rate for Payer: The Alliance Commercial |
$913.64
|
| Rate for Payer: WEA Trust Commercial |
$1,005.00
|
| Rate for Payer: WPS Commercial |
$1,353.42
|
|
|
AMPUTATION, BELOW KNEE/ANKLE
|
Facility
|
OP
|
$1,757.00
|
|
| Hospital Charge Code |
2959787
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$511.64 |
| Max. Negotiated Rate |
$1,681.10 |
| Rate for Payer: Aetna Commercial |
$1,644.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,571.46
|
| Rate for Payer: Aetna Managed Medicare |
$511.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,187.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$913.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$877.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$968.46
|
| Rate for Payer: Cash Price |
$527.10
|
| Rate for Payer: Cigna Commercial |
$1,681.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,022.57
|
| Rate for Payer: Health EOS Commercial |
$1,626.28
|
| Rate for Payer: HFN Commercial |
$1,681.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,370.46
|
| Rate for Payer: Multiplan Commercial |
$1,461.82
|
| Rate for Payer: NAPHCARE Commercial |
$1,096.37
|
| Rate for Payer: Preferred Network Access Commercial |
$1,681.10
|
| Rate for Payer: Quartz Beloit One Network |
$895.37
|
| Rate for Payer: Quartz Commercial |
$1,187.73
|
| Rate for Payer: Quartz Medicare Advantage |
$1,096.37
|
| Rate for Payer: The Alliance Commercial |
$913.64
|
| Rate for Payer: WEA Trust Commercial |
$1,005.00
|
| Rate for Payer: WPS Commercial |
$1,353.42
|
|
|
AMPUTATION, BELOW KNEE/ANKLE
|
Facility
|
IP
|
$1,757.00
|
|
| Hospital Charge Code |
2959787
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$895.37 |
| Max. Negotiated Rate |
$1,681.10 |
| Rate for Payer: Aetna Commercial |
$1,644.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,571.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$968.46
|
| Rate for Payer: Cash Price |
$527.10
|
| Rate for Payer: Cigna Commercial |
$1,681.10
|
| Rate for Payer: Health EOS Commercial |
$1,626.28
|
| Rate for Payer: HFN Commercial |
$1,681.10
|
| Rate for Payer: Multiplan Commercial |
$1,461.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,681.10
|
| Rate for Payer: Quartz Beloit One Network |
$895.37
|
| Rate for Payer: Quartz Commercial |
$1,096.37
|
| Rate for Payer: WEA Trust Commercial |
$1,005.00
|
| Rate for Payer: WPS Commercial |
$1,353.42
|
|
|
AMPUTATION, ELBOW/FOREARM/WRIST/HAND
|
Facility
|
IP
|
$1,632.00
|
|
| Hospital Charge Code |
2959788
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$831.67 |
| Max. Negotiated Rate |
$1,561.50 |
| Rate for Payer: Aetna Commercial |
$1,527.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,459.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$899.56
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cigna Commercial |
$1,561.50
|
| Rate for Payer: Health EOS Commercial |
$1,510.58
|
| Rate for Payer: HFN Commercial |
$1,561.50
|
| Rate for Payer: Multiplan Commercial |
$1,357.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,561.50
|
| Rate for Payer: Quartz Beloit One Network |
$831.67
|
| Rate for Payer: Quartz Commercial |
$1,018.37
|
| Rate for Payer: WEA Trust Commercial |
$933.50
|
| Rate for Payer: WPS Commercial |
$1,257.13
|
|
|
AMPUTATION, ELBOW/FOREARM/WRIST/HAND
|
Facility
|
OP
|
$1,632.00
|
|
| Hospital Charge Code |
2959788
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$475.24 |
| Max. Negotiated Rate |
$1,561.50 |
| Rate for Payer: Aetna Commercial |
$1,527.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,459.66
|
| Rate for Payer: Aetna Managed Medicare |
$475.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,103.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$848.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$814.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$899.56
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cigna Commercial |
$1,561.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$949.82
|
| Rate for Payer: Health EOS Commercial |
$1,510.58
|
| Rate for Payer: HFN Commercial |
$1,561.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,272.96
|
| Rate for Payer: Multiplan Commercial |
$1,357.82
|
| Rate for Payer: NAPHCARE Commercial |
$1,018.37
|
| Rate for Payer: Preferred Network Access Commercial |
$1,561.50
|
| Rate for Payer: Quartz Beloit One Network |
$831.67
|
| Rate for Payer: Quartz Commercial |
$1,103.23
|
| Rate for Payer: Quartz Medicare Advantage |
$1,018.37
|
| Rate for Payer: The Alliance Commercial |
$848.64
|
| Rate for Payer: WEA Trust Commercial |
$933.50
|
| Rate for Payer: WPS Commercial |
$1,257.13
|
|
|
AMPUTATION, FINGER
|
Facility
|
OP
|
$1,757.00
|
|
| Hospital Charge Code |
2959789
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$511.64 |
| Max. Negotiated Rate |
$1,681.10 |
| Rate for Payer: Aetna Commercial |
$1,644.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,571.46
|
| Rate for Payer: Aetna Managed Medicare |
$511.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,187.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$913.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$877.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$968.46
|
| Rate for Payer: Cash Price |
$527.10
|
| Rate for Payer: Cigna Commercial |
$1,681.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,022.57
|
| Rate for Payer: Health EOS Commercial |
$1,626.28
|
| Rate for Payer: HFN Commercial |
$1,681.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,370.46
|
| Rate for Payer: Multiplan Commercial |
$1,461.82
|
| Rate for Payer: NAPHCARE Commercial |
$1,096.37
|
| Rate for Payer: Preferred Network Access Commercial |
$1,681.10
|
| Rate for Payer: Quartz Beloit One Network |
$895.37
|
| Rate for Payer: Quartz Commercial |
$1,187.73
|
| Rate for Payer: Quartz Medicare Advantage |
$1,096.37
|
| Rate for Payer: The Alliance Commercial |
$913.64
|
| Rate for Payer: WEA Trust Commercial |
$1,005.00
|
| Rate for Payer: WPS Commercial |
$1,353.42
|
|
|
AMPUTATION, FINGER
|
Facility
|
IP
|
$1,757.00
|
|
| Hospital Charge Code |
2959789
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$895.37 |
| Max. Negotiated Rate |
$1,681.10 |
| Rate for Payer: Aetna Commercial |
$1,644.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,571.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$968.46
|
| Rate for Payer: Cash Price |
$527.10
|
| Rate for Payer: Cigna Commercial |
$1,681.10
|
| Rate for Payer: Health EOS Commercial |
$1,626.28
|
| Rate for Payer: HFN Commercial |
$1,681.10
|
| Rate for Payer: Multiplan Commercial |
$1,461.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,681.10
|
| Rate for Payer: Quartz Beloit One Network |
$895.37
|
| Rate for Payer: Quartz Commercial |
$1,096.37
|
| Rate for Payer: WEA Trust Commercial |
$1,005.00
|
| Rate for Payer: WPS Commercial |
$1,353.42
|
|
|
AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 26951
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
|
AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH LOCAL ADVANCEMENT FLAPS (V-Y, HOOD)
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 26952
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,107.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
|
AMPUTATION, FOOT/TOE/SYME
|
Facility
|
IP
|
$1,757.00
|
|
| Hospital Charge Code |
2959791
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$895.37 |
| Max. Negotiated Rate |
$1,681.10 |
| Rate for Payer: Aetna Commercial |
$1,644.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,571.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$968.46
|
| Rate for Payer: Cash Price |
$527.10
|
| Rate for Payer: Cigna Commercial |
$1,681.10
|
| Rate for Payer: Health EOS Commercial |
$1,626.28
|
| Rate for Payer: HFN Commercial |
$1,681.10
|
| Rate for Payer: Multiplan Commercial |
$1,461.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,681.10
|
| Rate for Payer: Quartz Beloit One Network |
$895.37
|
| Rate for Payer: Quartz Commercial |
$1,096.37
|
| Rate for Payer: WEA Trust Commercial |
$1,005.00
|
| Rate for Payer: WPS Commercial |
$1,353.42
|
|
|
AMPUTATION, FOOT/TOE/SYME
|
Facility
|
OP
|
$1,757.00
|
|
| Hospital Charge Code |
2959791
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$511.64 |
| Max. Negotiated Rate |
$1,681.10 |
| Rate for Payer: Aetna Commercial |
$1,644.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,571.46
|
| Rate for Payer: Aetna Managed Medicare |
$511.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,187.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$913.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$877.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$968.46
|
| Rate for Payer: Cash Price |
$527.10
|
| Rate for Payer: Cigna Commercial |
$1,681.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,022.57
|
| Rate for Payer: Health EOS Commercial |
$1,626.28
|
| Rate for Payer: HFN Commercial |
$1,681.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,370.46
|
| Rate for Payer: Multiplan Commercial |
$1,461.82
|
| Rate for Payer: NAPHCARE Commercial |
$1,096.37
|
| Rate for Payer: Preferred Network Access Commercial |
$1,681.10
|
| Rate for Payer: Quartz Beloit One Network |
$895.37
|
| Rate for Payer: Quartz Commercial |
$1,187.73
|
| Rate for Payer: Quartz Medicare Advantage |
$1,096.37
|
| Rate for Payer: The Alliance Commercial |
$913.64
|
| Rate for Payer: WEA Trust Commercial |
$1,005.00
|
| Rate for Payer: WPS Commercial |
$1,353.42
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC
|
Facility
|
IP
|
$78,006.24
|
|
|
Service Code
|
MSDRG 240
|
| Min. Negotiated Rate |
$22,336.46 |
| Max. Negotiated Rate |
$78,006.24 |
| Rate for Payer: Aetna Managed Medicare |
$22,336.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62,195.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$47,672.45
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45,291.94
|
| Rate for Payer: Anthem Medicare Advantage |
$22,336.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22,336.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22,336.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$22,336.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50,278.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$22,336.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56,970.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22,336.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22,336.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$22,336.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$22,336.46
|
| Rate for Payer: NAPHCARE Commercial |
$33,504.70
|
| Rate for Payer: Quartz Medicare Advantage |
$22,336.46
|
| Rate for Payer: The Alliance Commercial |
$78,006.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22,336.46
|
| Rate for Payer: United Healthcare PPO |
$44,352.33
|
| Rate for Payer: Wellcare Medicare |
$22,336.46
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC
|
Facility
|
IP
|
$133,238.56
|
|
|
Service Code
|
MSDRG 239
|
| Min. Negotiated Rate |
$38,198.13 |
| Max. Negotiated Rate |
$133,238.56 |
| Rate for Payer: Aetna Managed Medicare |
$38,198.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$107,387.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82,311.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78,201.48
|
| Rate for Payer: Anthem Medicare Advantage |
$38,198.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$38,198.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$38,198.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$38,198.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86,810.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$38,198.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97,481.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$38,198.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$38,198.13
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$38,198.13
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$38,198.13
|
| Rate for Payer: NAPHCARE Commercial |
$57,297.19
|
| Rate for Payer: Quartz Medicare Advantage |
$38,198.13
|
| Rate for Payer: The Alliance Commercial |
$133,238.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38,198.13
|
| Rate for Payer: United Healthcare PPO |
$75,890.91
|
| Rate for Payer: Wellcare Medicare |
$38,198.13
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC
|
Facility
|
IP
|
$38,876.24
|
|
|
Service Code
|
MSDRG 241
|
| Min. Negotiated Rate |
$11,108.79 |
| Max. Negotiated Rate |
$38,876.24 |
| Rate for Payer: Aetna Managed Medicare |
$11,108.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30,206.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23,153.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,996.90
|
| Rate for Payer: Anthem Medicare Advantage |
$11,108.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,108.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,108.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,108.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24,418.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,108.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,185.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,108.79
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,108.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,108.79
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,108.79
|
| Rate for Payer: NAPHCARE Commercial |
$16,663.19
|
| Rate for Payer: Quartz Medicare Advantage |
$11,108.79
|
| Rate for Payer: The Alliance Commercial |
$38,876.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,108.79
|
| Rate for Payer: United Healthcare PPO |
$21,942.49
|
| Rate for Payer: Wellcare Medicare |
$11,108.79
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC
|
Facility
|
IP
|
$59,632.56
|
|
|
Service Code
|
MSDRG 475
|
| Min. Negotiated Rate |
$17,934.54 |
| Max. Negotiated Rate |
$59,632.56 |
| Rate for Payer: Aetna Managed Medicare |
$17,934.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49,653.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38,059.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36,158.87
|
| Rate for Payer: Anthem Medicare Advantage |
$17,934.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,934.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,934.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,934.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40,139.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,934.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43,494.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,934.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,934.54
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,934.54
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,934.54
|
| Rate for Payer: NAPHCARE Commercial |
$26,901.81
|
| Rate for Payer: Quartz Medicare Advantage |
$17,934.54
|
| Rate for Payer: The Alliance Commercial |
$59,632.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,934.54
|
| Rate for Payer: United Healthcare PPO |
$33,861.04
|
| Rate for Payer: Wellcare Medicare |
$17,934.54
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC
|
Facility
|
IP
|
$119,302.56
|
|
|
Service Code
|
MSDRG 474
|
| Min. Negotiated Rate |
$33,382.65 |
| Max. Negotiated Rate |
$119,302.56 |
| Rate for Payer: Aetna Managed Medicare |
$33,382.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93,667.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71,795.49
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68,210.40
|
| Rate for Payer: Anthem Medicare Advantage |
$33,382.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33,382.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33,382.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$33,382.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75,719.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$33,382.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87,260.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33,382.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33,382.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$33,382.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$33,382.65
|
| Rate for Payer: NAPHCARE Commercial |
$50,073.97
|
| Rate for Payer: Quartz Medicare Advantage |
$33,382.65
|
| Rate for Payer: The Alliance Commercial |
$119,302.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33,382.65
|
| Rate for Payer: United Healthcare PPO |
$67,933.64
|
| Rate for Payer: Wellcare Medicare |
$33,382.65
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$32,873.36
|
|
|
Service Code
|
MSDRG 476
|
| Min. Negotiated Rate |
$9,544.98 |
| Max. Negotiated Rate |
$32,873.36 |
| Rate for Payer: Aetna Managed Medicare |
$9,544.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,751.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,737.95
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,752.34
|
| Rate for Payer: Anthem Medicare Advantage |
$9,544.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,544.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,544.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,544.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,816.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,544.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,867.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,544.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,544.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,544.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,544.98
|
| Rate for Payer: NAPHCARE Commercial |
$14,317.48
|
| Rate for Payer: Quartz Medicare Advantage |
$9,544.98
|
| Rate for Payer: The Alliance Commercial |
$32,873.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,544.98
|
| Rate for Payer: United Healthcare PPO |
$18,581.18
|
| Rate for Payer: Wellcare Medicare |
$9,544.98
|
|
|
AMPUTATION, HIP
|
Facility
|
OP
|
$4,324.00
|
|
| Hospital Charge Code |
2959793
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,259.15 |
| Max. Negotiated Rate |
$4,137.20 |
| Rate for Payer: Aetna Commercial |
$4,047.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,867.39
|
| Rate for Payer: Aetna Managed Medicare |
$1,259.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,923.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,248.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,158.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.39
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$4,137.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,516.57
|
| Rate for Payer: Health EOS Commercial |
$4,002.29
|
| Rate for Payer: HFN Commercial |
$4,137.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,372.72
|
| Rate for Payer: Multiplan Commercial |
$3,597.57
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.18
|
| Rate for Payer: Preferred Network Access Commercial |
$4,137.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,203.51
|
| Rate for Payer: Quartz Commercial |
$2,923.02
|
| Rate for Payer: Quartz Medicare Advantage |
$2,698.18
|
| Rate for Payer: The Alliance Commercial |
$2,248.48
|
| Rate for Payer: WEA Trust Commercial |
$2,473.33
|
| Rate for Payer: WPS Commercial |
$3,330.78
|
|
|
AMPUTATION, HIP
|
Facility
|
IP
|
$4,324.00
|
|
| Hospital Charge Code |
2959793
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,203.51 |
| Max. Negotiated Rate |
$4,137.20 |
| Rate for Payer: Aetna Commercial |
$4,047.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,867.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.39
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$4,137.20
|
| Rate for Payer: Health EOS Commercial |
$4,002.29
|
| Rate for Payer: HFN Commercial |
$4,137.20
|
| Rate for Payer: Multiplan Commercial |
$3,597.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,137.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,203.51
|
| Rate for Payer: Quartz Commercial |
$2,698.18
|
| Rate for Payer: WEA Trust Commercial |
$2,473.33
|
| Rate for Payer: WPS Commercial |
$3,330.78
|
|
|
AMPUTATION, METATARSAL, WITH TOE, SINGLE
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 28810
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
|
AMPUTATION OF LOWER LIMB EXCEPT TOES
|
Facility
|
IP
|
$9,732.82
|
|
|
Service Code
|
APR-DRG 3051
|
| Min. Negotiated Rate |
$8,645.30 |
| Max. Negotiated Rate |
$9,732.82 |
| Rate for Payer: Anthem Medicaid |
$9,319.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,319.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,319.72
|
| Rate for Payer: Dean Health Medicaid |
$9,319.72
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,645.30
|
| Rate for Payer: Managed Health Services Medicaid |
$9,732.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,319.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,319.72
|
| Rate for Payer: United Healthcare Medicaid |
$9,319.72
|
|
|
AMPUTATION OF LOWER LIMB EXCEPT TOES
|
Facility
|
IP
|
$20,342.48
|
|
|
Service Code
|
APR-DRG 3053
|
| Min. Negotiated Rate |
$18,069.46 |
| Max. Negotiated Rate |
$20,342.48 |
| Rate for Payer: Anthem Medicaid |
$19,479.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$19,479.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19,479.04
|
| Rate for Payer: Dean Health Medicaid |
$19,479.04
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18,069.46
|
| Rate for Payer: Managed Health Services Medicaid |
$20,342.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,479.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19,479.04
|
| Rate for Payer: United Healthcare Medicaid |
$19,479.04
|
|
|
AMPUTATION OF LOWER LIMB EXCEPT TOES
|
Facility
|
IP
|
$13,240.15
|
|
|
Service Code
|
APR-DRG 3052
|
| Min. Negotiated Rate |
$11,760.73 |
| Max. Negotiated Rate |
$13,240.15 |
| Rate for Payer: Anthem Medicaid |
$12,678.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12,678.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12,678.17
|
| Rate for Payer: Dean Health Medicaid |
$12,678.17
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11,760.73
|
| Rate for Payer: Managed Health Services Medicaid |
$13,240.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,678.17
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12,678.17
|
| Rate for Payer: United Healthcare Medicaid |
$12,678.17
|
|
|
AMPUTATION OF LOWER LIMB EXCEPT TOES
|
Facility
|
IP
|
$33,494.94
|
|
|
Service Code
|
APR-DRG 3054
|
| Min. Negotiated Rate |
$29,752.30 |
| Max. Negotiated Rate |
$33,494.94 |
| Rate for Payer: Anthem Medicaid |
$32,073.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$32,073.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32,073.25
|
| Rate for Payer: Dean Health Medicaid |
$32,073.25
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$29,752.30
|
| Rate for Payer: Managed Health Services Medicaid |
$33,494.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$32,073.25
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$32,073.25
|
| Rate for Payer: United Healthcare Medicaid |
$32,073.25
|
|
|
AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC
|
Facility
|
IP
|
$55,203.20
|
|
|
Service Code
|
MSDRG 617
|
| Min. Negotiated Rate |
$15,264.69 |
| Max. Negotiated Rate |
$55,203.20 |
| Rate for Payer: Aetna Managed Medicare |
$15,264.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40,808.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31,279.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29,717.42
|
| Rate for Payer: Anthem Medicare Advantage |
$15,264.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,264.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,264.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,264.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32,989.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,264.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40,245.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,264.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,264.69
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,264.69
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,264.69
|
| Rate for Payer: NAPHCARE Commercial |
$22,897.04
|
| Rate for Payer: Quartz Medicare Advantage |
$15,264.69
|
| Rate for Payer: The Alliance Commercial |
$55,203.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,264.69
|
| Rate for Payer: United Healthcare PPO |
$31,331.76
|
| Rate for Payer: Wellcare Medicare |
$15,264.69
|
|
