|
Non-State Supplied - Td Charge
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.24 |
| Max. Negotiated Rate |
$232.00 |
| Rate for Payer: Aetna Commercial |
$52.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.88
|
| Rate for Payer: Aetna Managed Medicare |
$16.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.74
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$53.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.91
|
| Rate for Payer: Health EOS Commercial |
$51.62
|
| Rate for Payer: HFN Commercial |
$53.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.50
|
| Rate for Payer: Multiplan Commercial |
$46.40
|
| Rate for Payer: NAPHCARE Commercial |
$34.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.36
|
| Rate for Payer: Quartz Beloit One Network |
$28.42
|
| Rate for Payer: Quartz Commercial |
$37.70
|
| Rate for Payer: Quartz Medicare Advantage |
$34.80
|
| Rate for Payer: The Alliance Commercial |
$232.00
|
| Rate for Payer: WEA Trust Commercial |
$31.90
|
| Rate for Payer: WPS Commercial |
$47.07
|
|
|
Non-State Supplied - Varicella Charge
|
Professional
|
Both
|
$301.00
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
3013487
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.44 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Aetna Commercial |
$285.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.86
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$285.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$174.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$180.60
|
| Rate for Payer: Health EOS Commercial |
$273.91
|
| Rate for Payer: HFN Commercial |
$285.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$236.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$236.93
|
| Rate for Payer: Multiplan Commercial |
$240.80
|
| Rate for Payer: Preferred Network Access Commercial |
$285.95
|
| Rate for Payer: Quartz Beloit One Network |
$132.44
|
| Rate for Payer: Quartz Commercial |
$171.57
|
| Rate for Payer: The Alliance Commercial |
$150.50
|
| Rate for Payer: United Healthcare Medicaid |
$174.24
|
| Rate for Payer: WEA Trust Commercial |
$165.55
|
| Rate for Payer: WPS Commercial |
$222.95
|
|
|
Non-State Supplied - Varicella Charge
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
3013487
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$147.49 |
| Max. Negotiated Rate |
$276.92 |
| Rate for Payer: Aetna Commercial |
$270.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.53
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$276.92
|
| Rate for Payer: Health EOS Commercial |
$267.89
|
| Rate for Payer: HFN Commercial |
$276.92
|
| Rate for Payer: Multiplan Commercial |
$240.80
|
| Rate for Payer: NAPHCARE Commercial |
$180.60
|
| Rate for Payer: Preferred Network Access Commercial |
$276.92
|
| Rate for Payer: Quartz Beloit One Network |
$147.49
|
| Rate for Payer: Quartz Commercial |
$180.60
|
| Rate for Payer: WEA Trust Commercial |
$165.55
|
| Rate for Payer: WPS Commercial |
$222.95
|
|
|
Non-State Supplied - Varicella Charge
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
3013487
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.28 |
| Max. Negotiated Rate |
$1,204.00 |
| Rate for Payer: Aetna Commercial |
$270.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.86
|
| Rate for Payer: Aetna Managed Medicare |
$84.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$195.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$150.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$144.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.53
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$276.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$168.44
|
| Rate for Payer: Health EOS Commercial |
$267.89
|
| Rate for Payer: HFN Commercial |
$276.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$225.75
|
| Rate for Payer: Multiplan Commercial |
$240.80
|
| Rate for Payer: NAPHCARE Commercial |
$180.60
|
| Rate for Payer: Preferred Network Access Commercial |
$276.92
|
| Rate for Payer: Quartz Beloit One Network |
$147.49
|
| Rate for Payer: Quartz Commercial |
$195.65
|
| Rate for Payer: Quartz Medicare Advantage |
$180.60
|
| Rate for Payer: The Alliance Commercial |
$1,204.00
|
| Rate for Payer: WEA Trust Commercial |
$165.55
|
| Rate for Payer: WPS Commercial |
$222.95
|
|
|
NONTRAUMATIC STUPOR AND COMA WITH MCC
|
Facility
|
IP
|
$59,041.00
|
|
|
Service Code
|
MSDRG 080
|
| Min. Negotiated Rate |
$21,237.71 |
| Max. Negotiated Rate |
$59,041.00 |
| Rate for Payer: Aetna Managed Medicare |
$21,237.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46,365.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35,539.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33,764.38
|
| Rate for Payer: Anthem Medicare Advantage |
$21,237.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21,237.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21,237.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21,237.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37,481.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21,237.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43,069.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21,237.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21,237.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21,237.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21,237.71
|
| Rate for Payer: NAPHCARE Commercial |
$31,856.56
|
| Rate for Payer: Quartz Medicare Advantage |
$21,237.71
|
| Rate for Payer: The Alliance Commercial |
$59,041.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21,237.71
|
| Rate for Payer: United Healthcare PPO |
$33,530.27
|
| Rate for Payer: Wellcare Medicare |
$21,237.71
|
|
|
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC
|
Facility
|
IP
|
$24,500.00
|
|
|
Service Code
|
MSDRG 081
|
| Min. Negotiated Rate |
$8,813.09 |
| Max. Negotiated Rate |
$24,500.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,813.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,091.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,633.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,902.98
|
| Rate for Payer: Anthem Medicare Advantage |
$8,813.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,813.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,813.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,813.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,433.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,813.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,735.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,813.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,813.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,813.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,813.09
|
| Rate for Payer: NAPHCARE Commercial |
$13,219.64
|
| Rate for Payer: Quartz Medicare Advantage |
$8,813.09
|
| Rate for Payer: The Alliance Commercial |
$24,500.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,813.09
|
| Rate for Payer: United Healthcare PPO |
$13,807.12
|
| Rate for Payer: Wellcare Medicare |
$8,813.09
|
|
|
Norepinephrine Level
|
Facility
|
OP
|
$258.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5144622
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.09 |
| Max. Negotiated Rate |
$237.36 |
| Rate for Payer: Aetna Commercial |
$232.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.88
|
| Rate for Payer: Aetna Managed Medicare |
$24.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$90.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.99
|
| Rate for Payer: Anthem Medicaid |
$24.89
|
| Rate for Payer: Anthem Medicare Advantage |
$24.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.09
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$237.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$24.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.38
|
| Rate for Payer: Dean Health Medicaid |
$24.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$24.09
|
| Rate for Payer: Health EOS Commercial |
$229.62
|
| Rate for Payer: HFN Commercial |
$237.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$24.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.09
|
| Rate for Payer: Managed Health Services Medicaid |
$25.89
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$24.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$24.09
|
| Rate for Payer: Multiplan Commercial |
$206.40
|
| Rate for Payer: NAPHCARE Commercial |
$36.14
|
| Rate for Payer: Preferred Network Access Commercial |
$237.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$24.89
|
| Rate for Payer: Quartz Beloit One Network |
$126.42
|
| Rate for Payer: Quartz Commercial |
$167.70
|
| Rate for Payer: Quartz Medicare Advantage |
$24.09
|
| Rate for Payer: The Alliance Commercial |
$96.36
|
| Rate for Payer: United Healthcare Medicaid |
$24.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.09
|
| Rate for Payer: United Healthcare PPO |
$193.50
|
| Rate for Payer: WEA Trust Commercial |
$141.90
|
| Rate for Payer: Wellcare Medicare |
$24.09
|
| Rate for Payer: WMAP Medicaid |
$24.89
|
| Rate for Payer: WPS Commercial |
$191.10
|
|
|
Norepinephrine Level
|
Professional
|
Both
|
$258.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5144622
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$85.04 |
| Max. Negotiated Rate |
$245.10 |
| Rate for Payer: Aetna Commercial |
$245.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.88
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$245.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$129.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$154.80
|
| Rate for Payer: Health EOS Commercial |
$234.78
|
| Rate for Payer: HFN Commercial |
$245.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$85.04
|
| Rate for Payer: Multiplan Commercial |
$206.40
|
| Rate for Payer: Preferred Network Access Commercial |
$245.10
|
| Rate for Payer: Quartz Beloit One Network |
$113.52
|
| Rate for Payer: Quartz Commercial |
$147.06
|
| Rate for Payer: The Alliance Commercial |
$129.00
|
| Rate for Payer: WEA Trust Commercial |
$141.90
|
| Rate for Payer: WPS Commercial |
$191.10
|
|
|
Norepinephrine Level
|
Facility
|
IP
|
$258.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5144622
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$126.42 |
| Max. Negotiated Rate |
$237.36 |
| Rate for Payer: Aetna Commercial |
$232.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.74
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$237.36
|
| Rate for Payer: Health EOS Commercial |
$229.62
|
| Rate for Payer: HFN Commercial |
$237.36
|
| Rate for Payer: Multiplan Commercial |
$206.40
|
| Rate for Payer: NAPHCARE Commercial |
$154.80
|
| Rate for Payer: Preferred Network Access Commercial |
$237.36
|
| Rate for Payer: Quartz Beloit One Network |
$126.42
|
| Rate for Payer: Quartz Commercial |
$154.80
|
| Rate for Payer: WEA Trust Commercial |
$141.90
|
| Rate for Payer: WPS Commercial |
$191.10
|
|
|
NORIAN 10CC BONE VOID FILLER
|
Facility
|
IP
|
$17,893.00
|
|
| Hospital Charge Code |
2966304
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,767.57 |
| Max. Negotiated Rate |
$16,461.56 |
| Rate for Payer: Aetna Commercial |
$16,103.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,387.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,483.29
|
| Rate for Payer: Cash Price |
$5,367.90
|
| Rate for Payer: Cigna Commercial |
$16,461.56
|
| Rate for Payer: Health EOS Commercial |
$15,924.77
|
| Rate for Payer: HFN Commercial |
$16,461.56
|
| Rate for Payer: Multiplan Commercial |
$14,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,735.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,461.56
|
| Rate for Payer: Quartz Beloit One Network |
$8,767.57
|
| Rate for Payer: Quartz Commercial |
$10,735.80
|
| Rate for Payer: WEA Trust Commercial |
$9,841.15
|
| Rate for Payer: WPS Commercial |
$13,253.35
|
|
|
NORIAN 10CC BONE VOID FILLER
|
Facility
|
OP
|
$17,893.00
|
|
| Hospital Charge Code |
2966304
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,010.04 |
| Max. Negotiated Rate |
$71,572.00 |
| Rate for Payer: Aetna Commercial |
$16,103.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,387.98
|
| Rate for Payer: Aetna Managed Medicare |
$5,010.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,630.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,946.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,588.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,483.29
|
| Rate for Payer: Cash Price |
$5,367.90
|
| Rate for Payer: Cigna Commercial |
$16,461.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,012.92
|
| Rate for Payer: Health EOS Commercial |
$15,924.77
|
| Rate for Payer: HFN Commercial |
$16,461.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,419.75
|
| Rate for Payer: Multiplan Commercial |
$14,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,735.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,461.56
|
| Rate for Payer: Quartz Beloit One Network |
$8,767.57
|
| Rate for Payer: Quartz Commercial |
$11,630.45
|
| Rate for Payer: Quartz Medicare Advantage |
$10,735.80
|
| Rate for Payer: The Alliance Commercial |
$71,572.00
|
| Rate for Payer: WEA Trust Commercial |
$9,841.15
|
| Rate for Payer: WPS Commercial |
$13,253.35
|
|
|
NORIAN 5CC BONE VOID FILLER
|
Facility
|
OP
|
$7,854.00
|
|
| Hospital Charge Code |
2966305
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,199.12 |
| Max. Negotiated Rate |
$31,416.00 |
| Rate for Payer: Aetna Commercial |
$7,068.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,754.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,199.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,105.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,927.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,769.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,162.62
|
| Rate for Payer: Cash Price |
$2,356.20
|
| Rate for Payer: Cigna Commercial |
$7,225.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,395.10
|
| Rate for Payer: Health EOS Commercial |
$6,990.06
|
| Rate for Payer: HFN Commercial |
$7,225.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,890.50
|
| Rate for Payer: Multiplan Commercial |
$6,283.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,712.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,225.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,848.46
|
| Rate for Payer: Quartz Commercial |
$5,105.10
|
| Rate for Payer: Quartz Medicare Advantage |
$4,712.40
|
| Rate for Payer: The Alliance Commercial |
$31,416.00
|
| Rate for Payer: WEA Trust Commercial |
$4,319.70
|
| Rate for Payer: WPS Commercial |
$5,817.46
|
|
|
NORIAN 5CC BONE VOID FILLER
|
Facility
|
IP
|
$7,854.00
|
|
| Hospital Charge Code |
2966305
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,848.46 |
| Max. Negotiated Rate |
$7,225.68 |
| Rate for Payer: Aetna Commercial |
$7,068.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,754.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,162.62
|
| Rate for Payer: Cash Price |
$2,356.20
|
| Rate for Payer: Cigna Commercial |
$7,225.68
|
| Rate for Payer: Health EOS Commercial |
$6,990.06
|
| Rate for Payer: HFN Commercial |
$7,225.68
|
| Rate for Payer: Multiplan Commercial |
$6,283.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,712.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,225.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,848.46
|
| Rate for Payer: Quartz Commercial |
$4,712.40
|
| Rate for Payer: WEA Trust Commercial |
$4,319.70
|
| Rate for Payer: WPS Commercial |
$5,817.46
|
|
|
NORIAN DRILLABLE INJECTION 10CC 07.704.010S
|
Facility
|
OP
|
$16,013.00
|
|
| Hospital Charge Code |
3313487
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,483.64 |
| Max. Negotiated Rate |
$64,052.00 |
| Rate for Payer: Aetna Commercial |
$14,411.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,771.18
|
| Rate for Payer: Aetna Managed Medicare |
$4,483.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,408.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,006.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,686.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,486.89
|
| Rate for Payer: Cash Price |
$4,803.90
|
| Rate for Payer: Cigna Commercial |
$14,731.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,960.87
|
| Rate for Payer: Health EOS Commercial |
$14,251.57
|
| Rate for Payer: HFN Commercial |
$14,731.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,009.75
|
| Rate for Payer: Multiplan Commercial |
$12,810.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,607.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,731.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,846.37
|
| Rate for Payer: Quartz Commercial |
$10,408.45
|
| Rate for Payer: Quartz Medicare Advantage |
$9,607.80
|
| Rate for Payer: The Alliance Commercial |
$64,052.00
|
| Rate for Payer: WEA Trust Commercial |
$8,807.15
|
| Rate for Payer: WPS Commercial |
$11,860.83
|
|
|
NORIAN DRILLABLE INJECTION 10CC 07.704.010S
|
Facility
|
IP
|
$16,013.00
|
|
| Hospital Charge Code |
3313487
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,846.37 |
| Max. Negotiated Rate |
$14,731.96 |
| Rate for Payer: Aetna Commercial |
$14,411.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,771.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,486.89
|
| Rate for Payer: Cash Price |
$4,803.90
|
| Rate for Payer: Cigna Commercial |
$14,731.96
|
| Rate for Payer: Health EOS Commercial |
$14,251.57
|
| Rate for Payer: HFN Commercial |
$14,731.96
|
| Rate for Payer: Multiplan Commercial |
$12,810.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,607.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,731.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,846.37
|
| Rate for Payer: Quartz Commercial |
$9,607.80
|
| Rate for Payer: WEA Trust Commercial |
$8,807.15
|
| Rate for Payer: WPS Commercial |
$11,860.83
|
|
|
NORIAN DRILLABLE INJECTION 5CC 07.704.005S
|
Facility
|
OP
|
$8,564.00
|
|
| Hospital Charge Code |
3135469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,397.92 |
| Max. Negotiated Rate |
$34,256.00 |
| Rate for Payer: Aetna Commercial |
$7,707.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,365.04
|
| Rate for Payer: Aetna Managed Medicare |
$2,397.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,566.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,282.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,110.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,538.92
|
| Rate for Payer: Cash Price |
$2,569.20
|
| Rate for Payer: Cigna Commercial |
$7,878.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,792.41
|
| Rate for Payer: Health EOS Commercial |
$7,621.96
|
| Rate for Payer: HFN Commercial |
$7,878.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,423.00
|
| Rate for Payer: Multiplan Commercial |
$6,851.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,138.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,878.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,196.36
|
| Rate for Payer: Quartz Commercial |
$5,566.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5,138.40
|
| Rate for Payer: The Alliance Commercial |
$34,256.00
|
| Rate for Payer: WEA Trust Commercial |
$4,710.20
|
| Rate for Payer: WPS Commercial |
$6,343.35
|
|
|
NORIAN DRILLABLE INJECTION 5CC 07.704.005S
|
Facility
|
IP
|
$8,564.00
|
|
| Hospital Charge Code |
3135469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,196.36 |
| Max. Negotiated Rate |
$7,878.88 |
| Rate for Payer: Aetna Commercial |
$7,707.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,365.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,538.92
|
| Rate for Payer: Cash Price |
$2,569.20
|
| Rate for Payer: Cigna Commercial |
$7,878.88
|
| Rate for Payer: Health EOS Commercial |
$7,621.96
|
| Rate for Payer: HFN Commercial |
$7,878.88
|
| Rate for Payer: Multiplan Commercial |
$6,851.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,138.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,878.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,196.36
|
| Rate for Payer: Quartz Commercial |
$5,138.40
|
| Rate for Payer: WEA Trust Commercial |
$4,710.20
|
| Rate for Payer: WPS Commercial |
$6,343.35
|
|
|
NORMAL NEWBORN
|
Facility
|
IP
|
$5,683.00
|
|
|
Service Code
|
MSDRG 795
|
| Min. Negotiated Rate |
$1,101.00 |
| Max. Negotiated Rate |
$5,683.00 |
| Rate for Payer: Aetna Managed Medicare |
$2,044.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,723.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$2,044.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,044.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,044.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,044.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,392.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,044.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,933.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,044.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,044.19
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,044.19
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,044.19
|
| Rate for Payer: NAPHCARE Commercial |
$3,066.28
|
| Rate for Payer: Quartz Medicare Advantage |
$2,044.19
|
| Rate for Payer: The Alliance Commercial |
$5,683.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,044.19
|
| Rate for Payer: United Healthcare PPO |
$1,101.00
|
| Rate for Payer: Wellcare Medicare |
$2,044.19
|
|
|
Normal Saline 1000 mg Charge
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
2958856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.02 |
| Max. Negotiated Rate |
$90.16 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$58.80
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
Normal Saline 1000 mg Charge
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
2958856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$93.10 |
| Rate for Payer: Aetna Commercial |
$93.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.61
|
| Rate for Payer: Health EOS Commercial |
$89.18
|
| Rate for Payer: HFN Commercial |
$93.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.07
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: Preferred Network Access Commercial |
$93.10
|
| Rate for Payer: Quartz Beloit One Network |
$43.12
|
| Rate for Payer: Quartz Commercial |
$55.86
|
| Rate for Payer: The Alliance Commercial |
$49.00
|
| Rate for Payer: United Healthcare Medicaid |
$2.61
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$6.52
|
|
|
Normal Saline 1000 mg Charge
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
2958856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Aetna Managed Medicare |
$27.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.45
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.50
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$63.70
|
| Rate for Payer: Quartz Medicare Advantage |
$58.80
|
| Rate for Payer: The Alliance Commercial |
$392.00
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$6.52
|
|
|
Normal Saline Solution 100mL
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
3040287
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Aetna Managed Medicare |
$0.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.68
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1.80
|
| Rate for Payer: The Alliance Commercial |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
Normal Saline Solution 100mL
|
Facility
|
IP
|
$3.00
|
|
| Hospital Charge Code |
3040287
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.80
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
Normal saline solution infus J7030
|
Professional
|
Both
|
$5.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
3600901
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$6.52 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.61
|
| Rate for Payer: Health EOS Commercial |
$4.55
|
| Rate for Payer: HFN Commercial |
$4.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.07
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.75
|
| Rate for Payer: Quartz Beloit One Network |
$2.20
|
| Rate for Payer: Quartz Commercial |
$2.85
|
| Rate for Payer: The Alliance Commercial |
$2.50
|
| Rate for Payer: United Healthcare Medicaid |
$2.61
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$6.52
|
|
|
Normal saline solution infus J7030
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
3600901
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.45
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
