|
Non-State Supplied - Rotateq Charge
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
3013482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.32 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna Commercial |
$103.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.28
|
| Rate for Payer: Aetna Managed Medicare |
$32.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$75.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.18
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$106.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.60
|
| Rate for Payer: Health EOS Commercial |
$102.74
|
| Rate for Payer: HFN Commercial |
$106.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.58
|
| Rate for Payer: Multiplan Commercial |
$92.35
|
| Rate for Payer: NAPHCARE Commercial |
$69.26
|
| Rate for Payer: Preferred Network Access Commercial |
$106.20
|
| Rate for Payer: Quartz Beloit One Network |
$56.57
|
| Rate for Payer: Quartz Commercial |
$75.04
|
| Rate for Payer: Quartz Medicare Advantage |
$69.26
|
| Rate for Payer: The Alliance Commercial |
$57.72
|
| Rate for Payer: WEA Trust Commercial |
$63.49
|
| Rate for Payer: WPS Commercial |
$85.50
|
|
|
Non-State Supplied - Rotateq Charge
|
Professional
|
Both
|
$111.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
3013482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.79 |
| Max. Negotiated Rate |
$151.90 |
| Rate for Payer: Aetna Commercial |
$109.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.28
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$109.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$106.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.26
|
| Rate for Payer: Health EOS Commercial |
$105.05
|
| Rate for Payer: HFN Commercial |
$109.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$151.90
|
| Rate for Payer: Multiplan Commercial |
$92.35
|
| Rate for Payer: Preferred Network Access Commercial |
$109.67
|
| Rate for Payer: Quartz Beloit One Network |
$50.79
|
| Rate for Payer: Quartz Commercial |
$65.80
|
| Rate for Payer: The Alliance Commercial |
$57.72
|
| Rate for Payer: United Healthcare Medicaid |
$106.85
|
| Rate for Payer: WEA Trust Commercial |
$63.49
|
| Rate for Payer: WPS Commercial |
$85.50
|
|
|
Non-State Supplied - TDaP Charge
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$167.61 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$28.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.78
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.44
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$61.15
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$66.25
|
| Rate for Payer: Quartz Medicare Advantage |
$61.15
|
| Rate for Payer: The Alliance Commercial |
$167.61
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$101.62
|
|
|
Non-State Supplied - TDaP Charge
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.65 |
| Max. Negotiated Rate |
$104.75 |
| Rate for Payer: Aetna Commercial |
$96.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$41.90
|
| Rate for Payer: Anthem Medicare Advantage |
$41.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.90
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$96.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.65
|
| Rate for Payer: Health EOS Commercial |
$92.75
|
| Rate for Payer: HFN Commercial |
$96.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.90
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$62.85
|
| Rate for Payer: Preferred Network Access Commercial |
$96.82
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$58.09
|
| Rate for Payer: Quartz Medicare Advantage |
$41.90
|
| Rate for Payer: The Alliance Commercial |
$104.75
|
| Rate for Payer: United Healthcare Medicaid |
$51.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.90
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$101.62
|
|
|
Non-State Supplied - TDaP Charge
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$61.15
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
Non-State Supplied - Td Charge
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.56 |
| Max. Negotiated Rate |
$55.49 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$36.19
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
Non-State Supplied - Td Charge
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.89 |
| Max. Negotiated Rate |
$169.15 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Aetna Managed Medicare |
$16.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.91
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.24
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: NAPHCARE Commercial |
$36.19
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$39.21
|
| Rate for Payer: Quartz Medicare Advantage |
$36.19
|
| Rate for Payer: The Alliance Commercial |
$169.15
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$48.95
|
|
|
Non-State Supplied - Td Charge
|
Professional
|
Both
|
$58.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.58 |
| Max. Negotiated Rate |
$105.72 |
| Rate for Payer: Aetna Commercial |
$57.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Aetna Managed Medicare |
$42.29
|
| Rate for Payer: Anthem Medicare Advantage |
$42.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$42.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$42.29
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$57.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.58
|
| Rate for Payer: Health EOS Commercial |
$54.89
|
| Rate for Payer: HFN Commercial |
$57.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$38.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$42.29
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: NAPHCARE Commercial |
$63.43
|
| Rate for Payer: Preferred Network Access Commercial |
$57.30
|
| Rate for Payer: Quartz Beloit One Network |
$26.54
|
| Rate for Payer: Quartz Commercial |
$34.38
|
| Rate for Payer: Quartz Medicare Advantage |
$42.29
|
| Rate for Payer: The Alliance Commercial |
$105.72
|
| Rate for Payer: United Healthcare Medicaid |
$43.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42.29
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$48.95
|
|
|
Non-State Supplied - Varicella Charge
|
Professional
|
Both
|
$301.00
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
3013487
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.74 |
| Max. Negotiated Rate |
$297.39 |
| Rate for Payer: Aetna Commercial |
$297.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.21
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$297.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$156.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$187.82
|
| Rate for Payer: Health EOS Commercial |
$284.87
|
| Rate for Payer: HFN Commercial |
$297.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$246.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$246.41
|
| Rate for Payer: Multiplan Commercial |
$250.43
|
| Rate for Payer: Preferred Network Access Commercial |
$297.39
|
| Rate for Payer: Quartz Beloit One Network |
$137.74
|
| Rate for Payer: Quartz Commercial |
$178.43
|
| Rate for Payer: The Alliance Commercial |
$156.52
|
| Rate for Payer: WEA Trust Commercial |
$172.17
|
| Rate for Payer: WPS Commercial |
$231.86
|
|
|
Non-State Supplied - Varicella Charge
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
3013487
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$153.39 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$281.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.91
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$288.00
|
| Rate for Payer: Health EOS Commercial |
$278.61
|
| Rate for Payer: HFN Commercial |
$288.00
|
| Rate for Payer: Multiplan Commercial |
$250.43
|
| Rate for Payer: Preferred Network Access Commercial |
$288.00
|
| Rate for Payer: Quartz Beloit One Network |
$153.39
|
| Rate for Payer: Quartz Commercial |
$187.82
|
| Rate for Payer: WEA Trust Commercial |
$172.17
|
| Rate for Payer: WPS Commercial |
$231.86
|
|
|
Non-State Supplied - Varicella Charge
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
3013487
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.65 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$281.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.21
|
| Rate for Payer: Aetna Managed Medicare |
$87.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$203.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$156.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$150.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.91
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$288.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$175.18
|
| Rate for Payer: Health EOS Commercial |
$278.61
|
| Rate for Payer: HFN Commercial |
$288.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$234.78
|
| Rate for Payer: Multiplan Commercial |
$250.43
|
| Rate for Payer: NAPHCARE Commercial |
$187.82
|
| Rate for Payer: Preferred Network Access Commercial |
$288.00
|
| Rate for Payer: Quartz Beloit One Network |
$153.39
|
| Rate for Payer: Quartz Commercial |
$203.48
|
| Rate for Payer: Quartz Medicare Advantage |
$187.82
|
| Rate for Payer: The Alliance Commercial |
$156.52
|
| Rate for Payer: WEA Trust Commercial |
$172.17
|
| Rate for Payer: WPS Commercial |
$231.86
|
|
|
NONTRAUMATIC STUPOR AND COMA WITH MCC
|
Facility
|
IP
|
$61,402.64
|
|
|
Service Code
|
MSDRG 080
|
| Min. Negotiated Rate |
$14,368.12 |
| Max. Negotiated Rate |
$61,402.64 |
| Rate for Payer: Aetna Managed Medicare |
$14,368.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39,492.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30,270.87
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,759.31
|
| Rate for Payer: Anthem Medicare Advantage |
$14,368.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,368.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,368.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,368.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,925.47
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,368.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44,792.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,368.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,368.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,368.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,368.12
|
| Rate for Payer: NAPHCARE Commercial |
$21,552.18
|
| Rate for Payer: Quartz Medicare Advantage |
$14,368.12
|
| Rate for Payer: The Alliance Commercial |
$61,402.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,368.12
|
| Rate for Payer: United Healthcare PPO |
$34,871.48
|
| Rate for Payer: Wellcare Medicare |
$14,368.12
|
|
|
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC
|
Facility
|
IP
|
$25,480.00
|
|
|
Service Code
|
MSDRG 081
|
| Min. Negotiated Rate |
$7,365.46 |
| Max. Negotiated Rate |
$25,480.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,365.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,541.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,978.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,230.30
|
| Rate for Payer: Anthem Medicare Advantage |
$7,365.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,365.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,365.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,365.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,796.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,365.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,444.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,365.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,365.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,365.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,365.46
|
| Rate for Payer: NAPHCARE Commercial |
$11,048.19
|
| Rate for Payer: Quartz Medicare Advantage |
$7,365.46
|
| Rate for Payer: The Alliance Commercial |
$25,480.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,365.46
|
| Rate for Payer: United Healthcare PPO |
$14,359.40
|
| Rate for Payer: Wellcare Medicare |
$7,365.46
|
|
|
NONTRAUMATIC STUPOR & COMA
|
Facility
|
OP
|
$39.39
|
|
|
Service Code
|
EAPG 00528
|
| Min. Negotiated Rate |
$37.88 |
| Max. Negotiated Rate |
$39.39 |
| Rate for Payer: Anthem Medicaid |
$37.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$37.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.88
|
| Rate for Payer: Dean Health Medicaid |
$37.88
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$37.88
|
| Rate for Payer: Managed Health Services Medicaid |
$39.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$37.88
|
| Rate for Payer: United Healthcare Medicaid |
$37.88
|
|
|
Norepinephrine Level
|
Facility
|
IP
|
$258.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5144622
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$131.48 |
| Max. Negotiated Rate |
$246.85 |
| Rate for Payer: Aetna Commercial |
$241.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.21
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$246.85
|
| Rate for Payer: Health EOS Commercial |
$238.80
|
| Rate for Payer: HFN Commercial |
$246.85
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: Preferred Network Access Commercial |
$246.85
|
| Rate for Payer: Quartz Beloit One Network |
$131.48
|
| Rate for Payer: Quartz Commercial |
$160.99
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: WPS Commercial |
$198.74
|
|
|
Norepinephrine Level
|
Professional
|
Both
|
$258.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5144622
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$254.90 |
| Rate for Payer: Aetna Commercial |
$254.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$254.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$134.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$244.17
|
| Rate for Payer: HFN Commercial |
$254.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$254.90
|
| Rate for Payer: Quartz Beloit One Network |
$118.06
|
| Rate for Payer: Quartz Commercial |
$152.94
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$98.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: WPS Commercial |
$110.24
|
|
|
Norepinephrine Level
|
Facility
|
OP
|
$258.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5144622
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$246.85 |
| Rate for Payer: Aetna Commercial |
$241.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.59
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$246.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$238.80
|
| Rate for Payer: HFN Commercial |
$246.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$246.85
|
| Rate for Payer: Quartz Beloit One Network |
$131.48
|
| Rate for Payer: Quartz Commercial |
$174.41
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$100.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: United Healthcare PPO |
$201.24
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: Wellcare Medicare |
$25.05
|
| Rate for Payer: WPS Commercial |
$198.74
|
|
|
NORIAN 10CC BONE VOID FILLER
|
Facility
|
IP
|
$17,893.00
|
|
| Hospital Charge Code |
2966304
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,118.27 |
| Max. Negotiated Rate |
$17,120.02 |
| Rate for Payer: Aetna Commercial |
$16,747.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,003.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,862.62
|
| Rate for Payer: Cash Price |
$5,367.90
|
| Rate for Payer: Cigna Commercial |
$17,120.02
|
| Rate for Payer: Health EOS Commercial |
$16,561.76
|
| Rate for Payer: HFN Commercial |
$17,120.02
|
| Rate for Payer: Multiplan Commercial |
$14,886.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17,120.02
|
| Rate for Payer: Quartz Beloit One Network |
$9,118.27
|
| Rate for Payer: Quartz Commercial |
$11,165.23
|
| Rate for Payer: WEA Trust Commercial |
$10,234.80
|
| Rate for Payer: WPS Commercial |
$13,782.98
|
|
|
NORIAN 10CC BONE VOID FILLER
|
Facility
|
OP
|
$17,893.00
|
|
| Hospital Charge Code |
2966304
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,210.44 |
| Max. Negotiated Rate |
$17,120.02 |
| Rate for Payer: Aetna Commercial |
$16,747.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,003.50
|
| Rate for Payer: Aetna Managed Medicare |
$5,210.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,095.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,304.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,932.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,862.62
|
| Rate for Payer: Cash Price |
$5,367.90
|
| Rate for Payer: Cigna Commercial |
$17,120.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,413.73
|
| Rate for Payer: Health EOS Commercial |
$16,561.76
|
| Rate for Payer: HFN Commercial |
$17,120.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,956.54
|
| Rate for Payer: Multiplan Commercial |
$14,886.98
|
| Rate for Payer: NAPHCARE Commercial |
$11,165.23
|
| Rate for Payer: Preferred Network Access Commercial |
$17,120.02
|
| Rate for Payer: Quartz Beloit One Network |
$9,118.27
|
| Rate for Payer: Quartz Commercial |
$12,095.67
|
| Rate for Payer: Quartz Medicare Advantage |
$11,165.23
|
| Rate for Payer: The Alliance Commercial |
$9,304.36
|
| Rate for Payer: WEA Trust Commercial |
$10,234.80
|
| Rate for Payer: WPS Commercial |
$13,782.98
|
|
|
NORIAN 5CC BONE VOID FILLER
|
Facility
|
OP
|
$7,854.00
|
|
| Hospital Charge Code |
2966305
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,287.08 |
| Max. Negotiated Rate |
$7,514.71 |
| Rate for Payer: Aetna Commercial |
$7,351.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,024.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,287.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,309.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,084.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,920.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,329.12
|
| Rate for Payer: Cash Price |
$2,356.20
|
| Rate for Payer: Cigna Commercial |
$7,514.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,571.03
|
| Rate for Payer: Health EOS Commercial |
$7,269.66
|
| Rate for Payer: HFN Commercial |
$7,514.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,126.12
|
| Rate for Payer: Multiplan Commercial |
$6,534.53
|
| Rate for Payer: NAPHCARE Commercial |
$4,900.90
|
| Rate for Payer: Preferred Network Access Commercial |
$7,514.71
|
| Rate for Payer: Quartz Beloit One Network |
$4,002.40
|
| Rate for Payer: Quartz Commercial |
$5,309.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,900.90
|
| Rate for Payer: The Alliance Commercial |
$4,084.08
|
| Rate for Payer: WEA Trust Commercial |
$4,492.49
|
| Rate for Payer: WPS Commercial |
$6,049.94
|
|
|
NORIAN 5CC BONE VOID FILLER
|
Facility
|
IP
|
$7,854.00
|
|
| Hospital Charge Code |
2966305
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,002.40 |
| Max. Negotiated Rate |
$7,514.71 |
| Rate for Payer: Aetna Commercial |
$7,351.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,024.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,329.12
|
| Rate for Payer: Cash Price |
$2,356.20
|
| Rate for Payer: Cigna Commercial |
$7,514.71
|
| Rate for Payer: Health EOS Commercial |
$7,269.66
|
| Rate for Payer: HFN Commercial |
$7,514.71
|
| Rate for Payer: Multiplan Commercial |
$6,534.53
|
| Rate for Payer: Preferred Network Access Commercial |
$7,514.71
|
| Rate for Payer: Quartz Beloit One Network |
$4,002.40
|
| Rate for Payer: Quartz Commercial |
$4,900.90
|
| Rate for Payer: WEA Trust Commercial |
$4,492.49
|
| Rate for Payer: WPS Commercial |
$6,049.94
|
|
|
NORIAN DRILLABLE INJECTION 10CC 07.704.010S
|
Facility
|
IP
|
$16,013.00
|
|
| Hospital Charge Code |
3313487
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,160.22 |
| Max. Negotiated Rate |
$15,321.24 |
| Rate for Payer: Aetna Commercial |
$14,988.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,322.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,826.37
|
| Rate for Payer: Cash Price |
$4,803.90
|
| Rate for Payer: Cigna Commercial |
$15,321.24
|
| Rate for Payer: Health EOS Commercial |
$14,821.63
|
| Rate for Payer: HFN Commercial |
$15,321.24
|
| Rate for Payer: Multiplan Commercial |
$13,322.82
|
| Rate for Payer: Preferred Network Access Commercial |
$15,321.24
|
| Rate for Payer: Quartz Beloit One Network |
$8,160.22
|
| Rate for Payer: Quartz Commercial |
$9,992.11
|
| Rate for Payer: WEA Trust Commercial |
$9,159.44
|
| Rate for Payer: WPS Commercial |
$12,334.81
|
|
|
NORIAN DRILLABLE INJECTION 10CC 07.704.010S
|
Facility
|
OP
|
$16,013.00
|
|
| Hospital Charge Code |
3313487
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,662.99 |
| Max. Negotiated Rate |
$15,321.24 |
| Rate for Payer: Aetna Commercial |
$14,988.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,322.03
|
| Rate for Payer: Aetna Managed Medicare |
$4,662.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,824.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,326.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,993.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,826.37
|
| Rate for Payer: Cash Price |
$4,803.90
|
| Rate for Payer: Cigna Commercial |
$15,321.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,319.57
|
| Rate for Payer: Health EOS Commercial |
$14,821.63
|
| Rate for Payer: HFN Commercial |
$15,321.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,490.14
|
| Rate for Payer: Multiplan Commercial |
$13,322.82
|
| Rate for Payer: NAPHCARE Commercial |
$9,992.11
|
| Rate for Payer: Preferred Network Access Commercial |
$15,321.24
|
| Rate for Payer: Quartz Beloit One Network |
$8,160.22
|
| Rate for Payer: Quartz Commercial |
$10,824.79
|
| Rate for Payer: Quartz Medicare Advantage |
$9,992.11
|
| Rate for Payer: The Alliance Commercial |
$8,326.76
|
| Rate for Payer: WEA Trust Commercial |
$9,159.44
|
| Rate for Payer: WPS Commercial |
$12,334.81
|
|
|
NORIAN DRILLABLE INJECTION 5CC 07.704.005S
|
Facility
|
IP
|
$8,564.00
|
|
| Hospital Charge Code |
3135469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,364.21 |
| Max. Negotiated Rate |
$8,194.04 |
| Rate for Payer: Aetna Commercial |
$8,015.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,659.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,720.48
|
| Rate for Payer: Cash Price |
$2,569.20
|
| Rate for Payer: Cigna Commercial |
$8,194.04
|
| Rate for Payer: Health EOS Commercial |
$7,926.84
|
| Rate for Payer: HFN Commercial |
$8,194.04
|
| Rate for Payer: Multiplan Commercial |
$7,125.25
|
| Rate for Payer: Preferred Network Access Commercial |
$8,194.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,364.21
|
| Rate for Payer: Quartz Commercial |
$5,343.94
|
| Rate for Payer: WEA Trust Commercial |
$4,898.61
|
| Rate for Payer: WPS Commercial |
$6,596.85
|
|
|
NORIAN DRILLABLE INJECTION 5CC 07.704.005S
|
Facility
|
OP
|
$8,564.00
|
|
| Hospital Charge Code |
3135469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,493.84 |
| Max. Negotiated Rate |
$8,194.04 |
| Rate for Payer: Aetna Commercial |
$8,015.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,659.64
|
| Rate for Payer: Aetna Managed Medicare |
$2,493.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,789.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,453.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,275.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,720.48
|
| Rate for Payer: Cash Price |
$2,569.20
|
| Rate for Payer: Cigna Commercial |
$8,194.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,984.25
|
| Rate for Payer: Health EOS Commercial |
$7,926.84
|
| Rate for Payer: HFN Commercial |
$8,194.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,679.92
|
| Rate for Payer: Multiplan Commercial |
$7,125.25
|
| Rate for Payer: NAPHCARE Commercial |
$5,343.94
|
| Rate for Payer: Preferred Network Access Commercial |
$8,194.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,364.21
|
| Rate for Payer: Quartz Commercial |
$5,789.26
|
| Rate for Payer: Quartz Medicare Advantage |
$5,343.94
|
| Rate for Payer: The Alliance Commercial |
$4,453.28
|
| Rate for Payer: WEA Trust Commercial |
$4,898.61
|
| Rate for Payer: WPS Commercial |
$6,596.85
|
|
