NEUROSES EXCEPT DEPRESSIVE
|
Facility
|
IP
|
$25,293.00
|
|
Service Code
|
MSDRG 882
|
Min. Negotiated Rate |
$9,098.07 |
Max. Negotiated Rate |
$25,293.00 |
Rate for Payer: Aetna Managed Medicare |
$9,098.07
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,721.20
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,116.14
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,361.32
|
Rate for Payer: Anthem Medicare Advantage |
$9,098.07
|
Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,098.07
|
Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,098.07
|
Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,098.07
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$15,942.38
|
Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,098.07
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,316.35
|
Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,098.07
|
Rate for Payer: Independent Care Health Plan Medicare |
$9,098.07
|
Rate for Payer: Managed Health Services Medicare Advantage |
$9,098.07
|
Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,098.07
|
Rate for Payer: NAPHCARE Commercial |
$13,647.10
|
Rate for Payer: Quartz Medicare Advantage |
$9,098.07
|
Rate for Payer: The Alliance Commercial |
$25,293.00
|
Rate for Payer: United Healthcare Medicare Advantage |
$9,098.07
|
Rate for Payer: United Healthcare PPO |
$14,259.51
|
Rate for Payer: Wellcare Medicare |
$9,098.07
|
|
NEURO SPINAL SURGERY
|
Facility
|
OP
|
$4,324.00
|
|
Hospital Charge Code |
2960249
|
Hospital Revenue Code
|
360
|
Min. Negotiated Rate |
$1,210.72 |
Max. Negotiated Rate |
$17,296.00 |
Rate for Payer: Aetna Commercial |
$3,891.60
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,718.64
|
Rate for Payer: Aetna Managed Medicare |
$1,210.72
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,810.60
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,162.00
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,075.52
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,291.72
|
Rate for Payer: Cash Price |
$1,297.20
|
Rate for Payer: Cigna Commercial |
$3,978.08
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$2,419.71
|
Rate for Payer: Health EOS Commercial |
$3,848.36
|
Rate for Payer: HFN Commercial |
$3,978.08
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,243.00
|
Rate for Payer: Multiplan Commercial |
$3,459.20
|
Rate for Payer: NAPHCARE Commercial |
$2,594.40
|
Rate for Payer: Preferred Network Access Commercial |
$3,978.08
|
Rate for Payer: Quartz Beloit One Network |
$2,118.76
|
Rate for Payer: Quartz Commercial |
$2,810.60
|
Rate for Payer: Quartz Medicare Advantage |
$2,594.40
|
Rate for Payer: The Alliance Commercial |
$17,296.00
|
Rate for Payer: WEA Trust Commercial |
$2,378.20
|
Rate for Payer: WPS Commercial |
$3,202.79
|
|
NEURO SPINAL SURGERY
|
Facility
|
IP
|
$4,324.00
|
|
Hospital Charge Code |
2960249
|
Hospital Revenue Code
|
360
|
Min. Negotiated Rate |
$2,118.76 |
Max. Negotiated Rate |
$3,978.08 |
Rate for Payer: Aetna Commercial |
$3,891.60
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,718.64
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,291.72
|
Rate for Payer: Cash Price |
$1,297.20
|
Rate for Payer: Cigna Commercial |
$3,978.08
|
Rate for Payer: Health EOS Commercial |
$3,848.36
|
Rate for Payer: HFN Commercial |
$3,978.08
|
Rate for Payer: Multiplan Commercial |
$3,459.20
|
Rate for Payer: NAPHCARE Commercial |
$2,594.40
|
Rate for Payer: Preferred Network Access Commercial |
$3,978.08
|
Rate for Payer: Quartz Beloit One Network |
$2,118.76
|
Rate for Payer: Quartz Commercial |
$2,594.40
|
Rate for Payer: WEA Trust Commercial |
$2,378.20
|
Rate for Payer: WPS Commercial |
$3,202.79
|
|
NEUROSTIMULATOR IMPLANTABLE INTERSTIM II (RECHARGE FREE) 3058
|
Facility
|
OP
|
$71,120.00
|
|
Service Code
|
HCPCS C1767
|
Hospital Charge Code |
5349493
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$19,913.60 |
Max. Negotiated Rate |
$284,480.00 |
Rate for Payer: Aetna Commercial |
$64,008.00
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61,163.20
|
Rate for Payer: Aetna Managed Medicare |
$19,913.60
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46,228.00
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35,560.00
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34,137.60
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37,693.60
|
Rate for Payer: Cash Price |
$21,336.00
|
Rate for Payer: Cigna Commercial |
$65,430.40
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$39,798.75
|
Rate for Payer: Health EOS Commercial |
$63,296.80
|
Rate for Payer: HFN Commercial |
$65,430.40
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53,340.00
|
Rate for Payer: Multiplan Commercial |
$56,896.00
|
Rate for Payer: NAPHCARE Commercial |
$42,672.00
|
Rate for Payer: Preferred Network Access Commercial |
$65,430.40
|
Rate for Payer: Quartz Beloit One Network |
$34,848.80
|
Rate for Payer: Quartz Commercial |
$46,228.00
|
Rate for Payer: Quartz Medicare Advantage |
$42,672.00
|
Rate for Payer: The Alliance Commercial |
$284,480.00
|
Rate for Payer: WEA Trust Commercial |
$39,116.00
|
Rate for Payer: WPS Commercial |
$52,678.58
|
|
NEUROSTIMULATOR IMPLANTABLE INTERSTIM II (RECHARGE FREE) 3058
|
Facility
|
IP
|
$71,120.00
|
|
Service Code
|
HCPCS C1767
|
Hospital Charge Code |
5349493
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$34,848.80 |
Max. Negotiated Rate |
$65,430.40 |
Rate for Payer: Aetna Commercial |
$64,008.00
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61,163.20
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37,693.60
|
Rate for Payer: Cash Price |
$21,336.00
|
Rate for Payer: Cigna Commercial |
$65,430.40
|
Rate for Payer: Health EOS Commercial |
$63,296.80
|
Rate for Payer: HFN Commercial |
$65,430.40
|
Rate for Payer: Multiplan Commercial |
$56,896.00
|
Rate for Payer: NAPHCARE Commercial |
$42,672.00
|
Rate for Payer: Preferred Network Access Commercial |
$65,430.40
|
Rate for Payer: Quartz Beloit One Network |
$34,848.80
|
Rate for Payer: Quartz Commercial |
$42,672.00
|
Rate for Payer: WEA Trust Commercial |
$39,116.00
|
Rate for Payer: WPS Commercial |
$52,678.58
|
|
NEUROSTIMULATOR IMPLANTABLE INTERSTIM X (RECHARGE FREE) 97800
|
Facility
|
OP
|
$50,425.00
|
|
Hospital Charge Code |
6049662
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$14,119.00 |
Max. Negotiated Rate |
$201,700.00 |
Rate for Payer: Aetna Commercial |
$45,382.50
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43,365.50
|
Rate for Payer: Aetna Managed Medicare |
$14,119.00
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32,776.25
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,212.50
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,204.00
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26,725.25
|
Rate for Payer: Cash Price |
$15,127.50
|
Rate for Payer: Cigna Commercial |
$46,391.00
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$28,217.83
|
Rate for Payer: Health EOS Commercial |
$44,878.25
|
Rate for Payer: HFN Commercial |
$46,391.00
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37,818.75
|
Rate for Payer: Multiplan Commercial |
$40,340.00
|
Rate for Payer: NAPHCARE Commercial |
$30,255.00
|
Rate for Payer: Preferred Network Access Commercial |
$46,391.00
|
Rate for Payer: Quartz Beloit One Network |
$24,708.25
|
Rate for Payer: Quartz Commercial |
$32,776.25
|
Rate for Payer: Quartz Medicare Advantage |
$30,255.00
|
Rate for Payer: The Alliance Commercial |
$201,700.00
|
Rate for Payer: WEA Trust Commercial |
$27,733.75
|
Rate for Payer: WPS Commercial |
$37,349.80
|
|
NEUROSTIMULATOR IMPLANTABLE INTERSTIM X (RECHARGE FREE) 97800
|
Facility
|
IP
|
$50,425.00
|
|
Hospital Charge Code |
6049662
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$24,708.25 |
Max. Negotiated Rate |
$46,391.00 |
Rate for Payer: Aetna Commercial |
$45,382.50
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43,365.50
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26,725.25
|
Rate for Payer: Cash Price |
$15,127.50
|
Rate for Payer: Cigna Commercial |
$46,391.00
|
Rate for Payer: Health EOS Commercial |
$44,878.25
|
Rate for Payer: HFN Commercial |
$46,391.00
|
Rate for Payer: Multiplan Commercial |
$40,340.00
|
Rate for Payer: NAPHCARE Commercial |
$30,255.00
|
Rate for Payer: Preferred Network Access Commercial |
$46,391.00
|
Rate for Payer: Quartz Beloit One Network |
$24,708.25
|
Rate for Payer: Quartz Commercial |
$30,255.00
|
Rate for Payer: WEA Trust Commercial |
$27,733.75
|
Rate for Payer: WPS Commercial |
$37,349.80
|
|
Neutrophil Function, Oxidative Burst
|
Facility
|
OP
|
$289.00
|
|
Service Code
|
CPT 82657
|
Hospital Charge Code |
3579519
|
Hospital Revenue Code
|
300
|
Min. Negotiated Rate |
$22.17 |
Max. Negotiated Rate |
$265.88 |
Rate for Payer: Aetna Commercial |
$260.10
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$248.54
|
Rate for Payer: Aetna Managed Medicare |
$22.17
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.14
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.80
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.80
|
Rate for Payer: Anthem Medicaid |
$22.91
|
Rate for Payer: Anthem Medicare Advantage |
$22.17
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.17
|
Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22.17
|
Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22.17
|
Rate for Payer: Cash Price |
$86.70
|
Rate for Payer: Cash Price |
$86.70
|
Rate for Payer: Cigna Commercial |
$265.88
|
Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$22.17
|
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.91
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$161.72
|
Rate for Payer: Dean Health Medicaid |
$22.91
|
Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$22.17
|
Rate for Payer: Health EOS Commercial |
$257.21
|
Rate for Payer: HFN Commercial |
$265.88
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.47
|
Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22.17
|
Rate for Payer: Independent Care Health Plan Medicaid |
$22.91
|
Rate for Payer: Independent Care Health Plan Medicare |
$22.17
|
Rate for Payer: Managed Health Services Medicaid |
$23.83
|
Rate for Payer: Managed Health Services Medicare Advantage |
$22.17
|
Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$22.17
|
Rate for Payer: Multiplan Commercial |
$231.20
|
Rate for Payer: NAPHCARE Commercial |
$33.26
|
Rate for Payer: Preferred Network Access Commercial |
$265.88
|
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$22.91
|
Rate for Payer: Quartz Beloit One Network |
$141.61
|
Rate for Payer: Quartz Commercial |
$187.85
|
Rate for Payer: Quartz Medicare Advantage |
$22.17
|
Rate for Payer: The Alliance Commercial |
$88.68
|
Rate for Payer: United Healthcare Medicaid |
$22.91
|
Rate for Payer: United Healthcare Medicare Advantage |
$22.17
|
Rate for Payer: United Healthcare PPO |
$216.75
|
Rate for Payer: WEA Trust Commercial |
$158.95
|
Rate for Payer: Wellcare Medicare |
$22.17
|
Rate for Payer: WMAP Medicaid |
$22.91
|
Rate for Payer: WPS Commercial |
$214.06
|
|
Neutrophil Function, Oxidative Burst
|
Professional
|
Both
|
$289.00
|
|
Service Code
|
CPT 82657
|
Hospital Charge Code |
3579519
|
Hospital Revenue Code
|
300
|
Min. Negotiated Rate |
$78.26 |
Max. Negotiated Rate |
$274.55 |
Rate for Payer: Aetna Commercial |
$274.55
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$248.54
|
Rate for Payer: Cash Price |
$86.70
|
Rate for Payer: Cash Price |
$86.70
|
Rate for Payer: Cigna Commercial |
$274.55
|
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$144.50
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$173.40
|
Rate for Payer: Health EOS Commercial |
$262.99
|
Rate for Payer: HFN Commercial |
$274.55
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.26
|
Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$78.26
|
Rate for Payer: Multiplan Commercial |
$231.20
|
Rate for Payer: Preferred Network Access Commercial |
$274.55
|
Rate for Payer: Quartz Beloit One Network |
$127.16
|
Rate for Payer: Quartz Commercial |
$164.73
|
Rate for Payer: The Alliance Commercial |
$144.50
|
Rate for Payer: WEA Trust Commercial |
$158.95
|
Rate for Payer: WPS Commercial |
$214.06
|
|
Neutrophil Function, Oxidative Burst
|
Facility
|
IP
|
$289.00
|
|
Service Code
|
CPT 82657
|
Hospital Charge Code |
3579519
|
Hospital Revenue Code
|
300
|
Min. Negotiated Rate |
$141.61 |
Max. Negotiated Rate |
$265.88 |
Rate for Payer: Aetna Commercial |
$260.10
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$248.54
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.17
|
Rate for Payer: Cash Price |
$86.70
|
Rate for Payer: Cigna Commercial |
$265.88
|
Rate for Payer: Health EOS Commercial |
$257.21
|
Rate for Payer: HFN Commercial |
$265.88
|
Rate for Payer: Multiplan Commercial |
$231.20
|
Rate for Payer: NAPHCARE Commercial |
$173.40
|
Rate for Payer: Preferred Network Access Commercial |
$265.88
|
Rate for Payer: Quartz Beloit One Network |
$141.61
|
Rate for Payer: Quartz Commercial |
$173.40
|
Rate for Payer: WEA Trust Commercial |
$158.95
|
Rate for Payer: WPS Commercial |
$214.06
|
|
Newborn Follow-Up
|
Facility
|
OP
|
$128.00
|
|
Service Code
|
CPT 99211
|
Hospital Charge Code |
3000436
|
Hospital Revenue Code
|
514
|
Min. Negotiated Rate |
$35.84 |
Max. Negotiated Rate |
$512.00 |
Rate for Payer: Aetna Commercial |
$115.20
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
Rate for Payer: Aetna Managed Medicare |
$35.84
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.20
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.00
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.44
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
Rate for Payer: Cash Price |
$38.40
|
Rate for Payer: Cigna Commercial |
$117.76
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$71.63
|
Rate for Payer: Health EOS Commercial |
$113.92
|
Rate for Payer: HFN Commercial |
$117.76
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.00
|
Rate for Payer: Multiplan Commercial |
$102.40
|
Rate for Payer: NAPHCARE Commercial |
$76.80
|
Rate for Payer: Preferred Network Access Commercial |
$117.76
|
Rate for Payer: Quartz Beloit One Network |
$62.72
|
Rate for Payer: Quartz Commercial |
$83.20
|
Rate for Payer: Quartz Medicare Advantage |
$76.80
|
Rate for Payer: The Alliance Commercial |
$512.00
|
Rate for Payer: WEA Trust Commercial |
$70.40
|
Rate for Payer: WPS Commercial |
$94.81
|
|
Newborn Follow-Up
|
Facility
|
IP
|
$128.00
|
|
Service Code
|
CPT 99211
|
Hospital Charge Code |
3000436
|
Hospital Revenue Code
|
514
|
Min. Negotiated Rate |
$62.72 |
Max. Negotiated Rate |
$117.76 |
Rate for Payer: Aetna Commercial |
$115.20
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
Rate for Payer: Cash Price |
$38.40
|
Rate for Payer: Cigna Commercial |
$117.76
|
Rate for Payer: Health EOS Commercial |
$113.92
|
Rate for Payer: HFN Commercial |
$117.76
|
Rate for Payer: Multiplan Commercial |
$102.40
|
Rate for Payer: NAPHCARE Commercial |
$76.80
|
Rate for Payer: Preferred Network Access Commercial |
$117.76
|
Rate for Payer: Quartz Beloit One Network |
$62.72
|
Rate for Payer: Quartz Commercial |
$76.80
|
Rate for Payer: WEA Trust Commercial |
$70.40
|
Rate for Payer: WPS Commercial |
$94.81
|
|
Newborn Follow-Up: Lactation visit <30 minutes - Outpatient Newborn Follow-Up Charges
|
Facility
|
OP
|
$158.00
|
|
Service Code
|
CPT 99211
|
Hospital Charge Code |
5356647
|
Hospital Revenue Code
|
510
|
Min. Negotiated Rate |
$44.24 |
Max. Negotiated Rate |
$632.00 |
Rate for Payer: Aetna Commercial |
$142.20
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
Rate for Payer: Aetna Managed Medicare |
$44.24
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.70
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.00
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.84
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
Rate for Payer: Cash Price |
$47.40
|
Rate for Payer: Cigna Commercial |
$145.36
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$88.42
|
Rate for Payer: Health EOS Commercial |
$140.62
|
Rate for Payer: HFN Commercial |
$145.36
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$118.50
|
Rate for Payer: Multiplan Commercial |
$126.40
|
Rate for Payer: NAPHCARE Commercial |
$94.80
|
Rate for Payer: Preferred Network Access Commercial |
$145.36
|
Rate for Payer: Quartz Beloit One Network |
$77.42
|
Rate for Payer: Quartz Commercial |
$102.70
|
Rate for Payer: Quartz Medicare Advantage |
$94.80
|
Rate for Payer: The Alliance Commercial |
$632.00
|
Rate for Payer: WEA Trust Commercial |
$86.90
|
Rate for Payer: WPS Commercial |
$117.03
|
|
Newborn Follow-Up: Lactation visit <30 minutes - Outpatient Newborn Follow-Up Charges
|
Facility
|
IP
|
$158.00
|
|
Service Code
|
CPT 99211
|
Hospital Charge Code |
5356647
|
Hospital Revenue Code
|
510
|
Min. Negotiated Rate |
$77.42 |
Max. Negotiated Rate |
$145.36 |
Rate for Payer: Aetna Commercial |
$142.20
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
Rate for Payer: Cash Price |
$47.40
|
Rate for Payer: Cigna Commercial |
$145.36
|
Rate for Payer: Health EOS Commercial |
$140.62
|
Rate for Payer: HFN Commercial |
$145.36
|
Rate for Payer: Multiplan Commercial |
$126.40
|
Rate for Payer: NAPHCARE Commercial |
$94.80
|
Rate for Payer: Preferred Network Access Commercial |
$145.36
|
Rate for Payer: Quartz Beloit One Network |
$77.42
|
Rate for Payer: Quartz Commercial |
$94.80
|
Rate for Payer: WEA Trust Commercial |
$86.90
|
Rate for Payer: WPS Commercial |
$117.03
|
|
Newborn Follow-Up: Lactation visit >30 minutes - Outpatient Newborn Follow-Up Charges
|
Facility
|
OP
|
$194.00
|
|
Service Code
|
CPT 99211
|
Hospital Charge Code |
5356646
|
Hospital Revenue Code
|
514
|
Min. Negotiated Rate |
$54.32 |
Max. Negotiated Rate |
$776.00 |
Rate for Payer: Aetna Commercial |
$174.60
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
Rate for Payer: Aetna Managed Medicare |
$54.32
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.10
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.00
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.12
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
Rate for Payer: Cash Price |
$58.20
|
Rate for Payer: Cigna Commercial |
$178.48
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$108.56
|
Rate for Payer: Health EOS Commercial |
$172.66
|
Rate for Payer: HFN Commercial |
$178.48
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.50
|
Rate for Payer: Multiplan Commercial |
$155.20
|
Rate for Payer: NAPHCARE Commercial |
$116.40
|
Rate for Payer: Preferred Network Access Commercial |
$178.48
|
Rate for Payer: Quartz Beloit One Network |
$95.06
|
Rate for Payer: Quartz Commercial |
$126.10
|
Rate for Payer: Quartz Medicare Advantage |
$116.40
|
Rate for Payer: The Alliance Commercial |
$776.00
|
Rate for Payer: WEA Trust Commercial |
$106.70
|
Rate for Payer: WPS Commercial |
$143.70
|
|
Newborn Follow-Up: Lactation visit >30 minutes - Outpatient Newborn Follow-Up Charges
|
Facility
|
IP
|
$194.00
|
|
Service Code
|
CPT 99211
|
Hospital Charge Code |
5356646
|
Hospital Revenue Code
|
514
|
Min. Negotiated Rate |
$95.06 |
Max. Negotiated Rate |
$178.48 |
Rate for Payer: Aetna Commercial |
$174.60
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
Rate for Payer: Cash Price |
$58.20
|
Rate for Payer: Cigna Commercial |
$178.48
|
Rate for Payer: Health EOS Commercial |
$172.66
|
Rate for Payer: HFN Commercial |
$178.48
|
Rate for Payer: Multiplan Commercial |
$155.20
|
Rate for Payer: NAPHCARE Commercial |
$116.40
|
Rate for Payer: Preferred Network Access Commercial |
$178.48
|
Rate for Payer: Quartz Beloit One Network |
$95.06
|
Rate for Payer: Quartz Commercial |
$116.40
|
Rate for Payer: WEA Trust Commercial |
$106.70
|
Rate for Payer: WPS Commercial |
$143.70
|
|
Newborn Follow-Up - Outpatient Newborn Follow-Up Charges
|
Facility
|
OP
|
$128.00
|
|
Service Code
|
CPT 99211
|
Hospital Charge Code |
5356648
|
Hospital Revenue Code
|
514
|
Min. Negotiated Rate |
$35.84 |
Max. Negotiated Rate |
$512.00 |
Rate for Payer: Aetna Commercial |
$115.20
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
Rate for Payer: Aetna Managed Medicare |
$35.84
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.20
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.00
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.44
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
Rate for Payer: Cash Price |
$38.40
|
Rate for Payer: Cigna Commercial |
$117.76
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$71.63
|
Rate for Payer: Health EOS Commercial |
$113.92
|
Rate for Payer: HFN Commercial |
$117.76
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.00
|
Rate for Payer: Multiplan Commercial |
$102.40
|
Rate for Payer: NAPHCARE Commercial |
$76.80
|
Rate for Payer: Preferred Network Access Commercial |
$117.76
|
Rate for Payer: Quartz Beloit One Network |
$62.72
|
Rate for Payer: Quartz Commercial |
$83.20
|
Rate for Payer: Quartz Medicare Advantage |
$76.80
|
Rate for Payer: The Alliance Commercial |
$512.00
|
Rate for Payer: WEA Trust Commercial |
$70.40
|
Rate for Payer: WPS Commercial |
$94.81
|
|
Newborn Follow-Up - Outpatient Newborn Follow-Up Charges
|
Facility
|
IP
|
$128.00
|
|
Service Code
|
CPT 99211
|
Hospital Charge Code |
5356648
|
Hospital Revenue Code
|
514
|
Min. Negotiated Rate |
$62.72 |
Max. Negotiated Rate |
$117.76 |
Rate for Payer: Aetna Commercial |
$115.20
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
Rate for Payer: Cash Price |
$38.40
|
Rate for Payer: Cigna Commercial |
$117.76
|
Rate for Payer: Health EOS Commercial |
$113.92
|
Rate for Payer: HFN Commercial |
$117.76
|
Rate for Payer: Multiplan Commercial |
$102.40
|
Rate for Payer: NAPHCARE Commercial |
$76.80
|
Rate for Payer: Preferred Network Access Commercial |
$117.76
|
Rate for Payer: Quartz Beloit One Network |
$62.72
|
Rate for Payer: Quartz Commercial |
$76.80
|
Rate for Payer: WEA Trust Commercial |
$70.40
|
Rate for Payer: WPS Commercial |
$94.81
|
|
New major dressing charge
|
Facility
|
OP
|
$196.00
|
|
Service Code
|
CPT 99202
|
Hospital Charge Code |
3228203
|
Hospital Revenue Code
|
272
|
Min. Negotiated Rate |
$54.88 |
Max. Negotiated Rate |
$784.00 |
Rate for Payer: Aetna Commercial |
$176.40
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
Rate for Payer: Aetna Managed Medicare |
$54.88
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$127.40
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$98.00
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94.08
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
Rate for Payer: Cash Price |
$58.80
|
Rate for Payer: Cigna Commercial |
$180.32
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$109.68
|
Rate for Payer: Health EOS Commercial |
$174.44
|
Rate for Payer: HFN Commercial |
$180.32
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.00
|
Rate for Payer: Multiplan Commercial |
$156.80
|
Rate for Payer: NAPHCARE Commercial |
$117.60
|
Rate for Payer: Preferred Network Access Commercial |
$180.32
|
Rate for Payer: Quartz Beloit One Network |
$96.04
|
Rate for Payer: Quartz Commercial |
$127.40
|
Rate for Payer: Quartz Medicare Advantage |
$117.60
|
Rate for Payer: The Alliance Commercial |
$784.00
|
Rate for Payer: WEA Trust Commercial |
$107.80
|
Rate for Payer: WPS Commercial |
$145.18
|
|
New major dressing charge
|
Facility
|
IP
|
$196.00
|
|
Service Code
|
CPT 99202
|
Hospital Charge Code |
3228203
|
Hospital Revenue Code
|
272
|
Min. Negotiated Rate |
$96.04 |
Max. Negotiated Rate |
$180.32 |
Rate for Payer: Aetna Commercial |
$176.40
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
Rate for Payer: Cash Price |
$58.80
|
Rate for Payer: Cigna Commercial |
$180.32
|
Rate for Payer: Health EOS Commercial |
$174.44
|
Rate for Payer: HFN Commercial |
$180.32
|
Rate for Payer: Multiplan Commercial |
$156.80
|
Rate for Payer: NAPHCARE Commercial |
$117.60
|
Rate for Payer: Preferred Network Access Commercial |
$180.32
|
Rate for Payer: Quartz Beloit One Network |
$96.04
|
Rate for Payer: Quartz Commercial |
$117.60
|
Rate for Payer: WEA Trust Commercial |
$107.80
|
Rate for Payer: WPS Commercial |
$145.18
|
|
NEXGEN PATELLA 26MM 5973-65-26
|
Facility
|
OP
|
$4,778.00
|
|
Hospital Charge Code |
2967757
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,337.84 |
Max. Negotiated Rate |
$19,112.00 |
Rate for Payer: Aetna Commercial |
$4,300.20
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,109.08
|
Rate for Payer: Aetna Managed Medicare |
$1,337.84
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,105.70
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,389.00
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,293.44
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,532.34
|
Rate for Payer: Cash Price |
$1,433.40
|
Rate for Payer: Cigna Commercial |
$4,395.76
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$2,673.77
|
Rate for Payer: Health EOS Commercial |
$4,252.42
|
Rate for Payer: HFN Commercial |
$4,395.76
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,583.50
|
Rate for Payer: Multiplan Commercial |
$3,822.40
|
Rate for Payer: NAPHCARE Commercial |
$2,866.80
|
Rate for Payer: Preferred Network Access Commercial |
$4,395.76
|
Rate for Payer: Quartz Beloit One Network |
$2,341.22
|
Rate for Payer: Quartz Commercial |
$3,105.70
|
Rate for Payer: Quartz Medicare Advantage |
$2,866.80
|
Rate for Payer: The Alliance Commercial |
$19,112.00
|
Rate for Payer: WEA Trust Commercial |
$2,627.90
|
Rate for Payer: WPS Commercial |
$3,539.06
|
|
NEXGEN PATELLA 26MM 5973-65-26
|
Facility
|
IP
|
$4,778.00
|
|
Hospital Charge Code |
2967757
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$2,341.22 |
Max. Negotiated Rate |
$4,395.76 |
Rate for Payer: Aetna Commercial |
$4,300.20
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,109.08
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,532.34
|
Rate for Payer: Cash Price |
$1,433.40
|
Rate for Payer: Cigna Commercial |
$4,395.76
|
Rate for Payer: Health EOS Commercial |
$4,252.42
|
Rate for Payer: HFN Commercial |
$4,395.76
|
Rate for Payer: Multiplan Commercial |
$3,822.40
|
Rate for Payer: NAPHCARE Commercial |
$2,866.80
|
Rate for Payer: Preferred Network Access Commercial |
$4,395.76
|
Rate for Payer: Quartz Beloit One Network |
$2,341.22
|
Rate for Payer: Quartz Commercial |
$2,866.80
|
Rate for Payer: WEA Trust Commercial |
$2,627.90
|
Rate for Payer: WPS Commercial |
$3,539.06
|
|
Nexplanon 1 Unit Charge
|
Facility
|
IP
|
$1,575.00
|
|
Service Code
|
HCPCS J7307
|
Hospital Charge Code |
2958857
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$771.75 |
Max. Negotiated Rate |
$1,449.00 |
Rate for Payer: Aetna Commercial |
$1,417.50
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,354.50
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$834.75
|
Rate for Payer: Cash Price |
$472.50
|
Rate for Payer: Cigna Commercial |
$1,449.00
|
Rate for Payer: Health EOS Commercial |
$1,401.75
|
Rate for Payer: HFN Commercial |
$1,449.00
|
Rate for Payer: Multiplan Commercial |
$1,260.00
|
Rate for Payer: NAPHCARE Commercial |
$945.00
|
Rate for Payer: Preferred Network Access Commercial |
$1,449.00
|
Rate for Payer: Quartz Beloit One Network |
$771.75
|
Rate for Payer: Quartz Commercial |
$945.00
|
Rate for Payer: WEA Trust Commercial |
$866.25
|
Rate for Payer: WPS Commercial |
$1,166.60
|
|
Nexplanon 1 Unit Charge
|
Professional
|
Both
|
$1,575.00
|
|
Service Code
|
HCPCS J7307
|
Hospital Charge Code |
2958857
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$693.00 |
Max. Negotiated Rate |
$1,496.25 |
Rate for Payer: Aetna Commercial |
$1,496.25
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,354.50
|
Rate for Payer: Anthem Commercial |
$981.56
|
Rate for Payer: Cash Price |
$472.50
|
Rate for Payer: Cash Price |
$472.50
|
Rate for Payer: Cigna Commercial |
$1,496.25
|
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,156.28
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$945.00
|
Rate for Payer: Health EOS Commercial |
$1,433.25
|
Rate for Payer: HFN Commercial |
$1,496.25
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,468.91
|
Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,468.91
|
Rate for Payer: Multiplan Commercial |
$1,260.00
|
Rate for Payer: Preferred Network Access Commercial |
$1,496.25
|
Rate for Payer: Quartz Beloit One Network |
$693.00
|
Rate for Payer: Quartz Commercial |
$897.75
|
Rate for Payer: The Alliance Commercial |
$787.50
|
Rate for Payer: United Healthcare Medicaid |
$1,156.28
|
Rate for Payer: WEA Trust Commercial |
$866.25
|
Rate for Payer: WPS Commercial |
$1,166.60
|
|
Nexplanon 1 Unit Charge
|
Facility
|
OP
|
$1,575.00
|
|
Service Code
|
HCPCS J7307
|
Hospital Charge Code |
2958857
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$441.00 |
Max. Negotiated Rate |
$6,300.00 |
Rate for Payer: Aetna Commercial |
$1,417.50
|
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,354.50
|
Rate for Payer: Aetna Managed Medicare |
$441.00
|
Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,023.75
|
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$787.50
|
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$756.00
|
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$834.75
|
Rate for Payer: Cash Price |
$472.50
|
Rate for Payer: Cigna Commercial |
$1,449.00
|
Rate for Payer: Dean Health DHI/DHP/ASO |
$881.37
|
Rate for Payer: Health EOS Commercial |
$1,401.75
|
Rate for Payer: HFN Commercial |
$1,449.00
|
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,181.25
|
Rate for Payer: Multiplan Commercial |
$1,260.00
|
Rate for Payer: NAPHCARE Commercial |
$945.00
|
Rate for Payer: Preferred Network Access Commercial |
$1,449.00
|
Rate for Payer: Quartz Beloit One Network |
$771.75
|
Rate for Payer: Quartz Commercial |
$1,023.75
|
Rate for Payer: Quartz Medicare Advantage |
$945.00
|
Rate for Payer: The Alliance Commercial |
$6,300.00
|
Rate for Payer: WEA Trust Commercial |
$866.25
|
Rate for Payer: WPS Commercial |
$1,166.60
|
|