|
Level 2 - Labor Level
|
Facility
|
IP
|
$2,592.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3003934
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,270.08 |
| Max. Negotiated Rate |
$2,384.64 |
| Rate for Payer: Aetna Commercial |
$2,332.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,229.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,373.76
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna Commercial |
$2,384.64
|
| Rate for Payer: Health EOS Commercial |
$2,306.88
|
| Rate for Payer: HFN Commercial |
$2,384.64
|
| Rate for Payer: Multiplan Commercial |
$2,073.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,555.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,384.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,270.08
|
| Rate for Payer: Quartz Commercial |
$1,555.20
|
| Rate for Payer: WEA Trust Commercial |
$1,425.60
|
| Rate for Payer: WPS Commercial |
$1,919.89
|
|
|
Level 2 New - 99202
|
Facility
|
OP
|
$288.00
|
|
| Hospital Charge Code |
5516695
|
| Min. Negotiated Rate |
$80.64 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$259.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.68
|
| Rate for Payer: Aetna Managed Medicare |
$80.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$187.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$144.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$138.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.64
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$264.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.16
|
| Rate for Payer: Health EOS Commercial |
$256.32
|
| Rate for Payer: HFN Commercial |
$264.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$216.00
|
| Rate for Payer: Multiplan Commercial |
$230.40
|
| Rate for Payer: NAPHCARE Commercial |
$172.80
|
| Rate for Payer: Preferred Network Access Commercial |
$264.96
|
| Rate for Payer: Quartz Beloit One Network |
$141.12
|
| Rate for Payer: Quartz Commercial |
$187.20
|
| Rate for Payer: Quartz Medicare Advantage |
$172.80
|
| Rate for Payer: The Alliance Commercial |
$1,152.00
|
| Rate for Payer: WEA Trust Commercial |
$158.40
|
| Rate for Payer: WPS Commercial |
$213.32
|
|
|
Level 2 New - 99202
|
Facility
|
IP
|
$288.00
|
|
| Hospital Charge Code |
5516695
|
| Min. Negotiated Rate |
$141.12 |
| Max. Negotiated Rate |
$264.96 |
| Rate for Payer: Aetna Commercial |
$259.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.64
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$264.96
|
| Rate for Payer: Health EOS Commercial |
$256.32
|
| Rate for Payer: HFN Commercial |
$264.96
|
| Rate for Payer: Multiplan Commercial |
$230.40
|
| Rate for Payer: NAPHCARE Commercial |
$172.80
|
| Rate for Payer: Preferred Network Access Commercial |
$264.96
|
| Rate for Payer: Quartz Beloit One Network |
$141.12
|
| Rate for Payer: Quartz Commercial |
$172.80
|
| Rate for Payer: WEA Trust Commercial |
$158.40
|
| Rate for Payer: WPS Commercial |
$213.32
|
|
|
Level 3 - 99283
|
Facility
|
IP
|
$1,137.00
|
|
|
Service Code
|
CPT 99283
|
| Hospital Charge Code |
5516685
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$557.13 |
| Max. Negotiated Rate |
$1,046.04 |
| Rate for Payer: Aetna Commercial |
$1,023.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$977.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.61
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cigna Commercial |
$1,046.04
|
| Rate for Payer: Health EOS Commercial |
$1,011.93
|
| Rate for Payer: HFN Commercial |
$1,046.04
|
| Rate for Payer: Multiplan Commercial |
$909.60
|
| Rate for Payer: NAPHCARE Commercial |
$682.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.04
|
| Rate for Payer: Quartz Beloit One Network |
$557.13
|
| Rate for Payer: Quartz Commercial |
$682.20
|
| Rate for Payer: WEA Trust Commercial |
$625.35
|
| Rate for Payer: WPS Commercial |
$842.18
|
|
|
Level 3 - 99283
|
Facility
|
OP
|
$1,137.00
|
|
|
Service Code
|
CPT 99283
|
| Hospital Charge Code |
5516685
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$282.01 |
| Max. Negotiated Rate |
$1,458.00 |
| Rate for Payer: Aetna Commercial |
$1,023.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$977.82
|
| Rate for Payer: Aetna Managed Medicare |
$282.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,458.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$919.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$873.00
|
| Rate for Payer: Anthem Medicare Advantage |
$282.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$282.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$282.01
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cigna Commercial |
$1,046.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$282.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$282.01
|
| Rate for Payer: Health EOS Commercial |
$1,011.93
|
| Rate for Payer: HFN Commercial |
$1,046.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,049.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$282.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$282.01
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$282.01
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$282.01
|
| Rate for Payer: Multiplan Commercial |
$909.60
|
| Rate for Payer: NAPHCARE Commercial |
$423.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.04
|
| Rate for Payer: Quartz Beloit One Network |
$557.13
|
| Rate for Payer: Quartz Commercial |
$739.05
|
| Rate for Payer: Quartz Medicare Advantage |
$282.01
|
| Rate for Payer: The Alliance Commercial |
$1,128.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$282.01
|
| Rate for Payer: United Healthcare PPO |
$1,217.00
|
| Rate for Payer: WEA Trust Commercial |
$625.35
|
| Rate for Payer: Wellcare Medicare |
$282.01
|
| Rate for Payer: WPS Commercial |
$842.18
|
|
|
Level 3 Est - 99213
|
Facility
|
OP
|
$324.00
|
|
| Hospital Charge Code |
5516698
|
| Min. Negotiated Rate |
$90.72 |
| Max. Negotiated Rate |
$1,296.00 |
| Rate for Payer: Aetna Commercial |
$291.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$278.64
|
| Rate for Payer: Aetna Managed Medicare |
$90.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$210.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$162.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$155.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$171.72
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$298.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$181.31
|
| Rate for Payer: Health EOS Commercial |
$288.36
|
| Rate for Payer: HFN Commercial |
$298.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$243.00
|
| Rate for Payer: Multiplan Commercial |
$259.20
|
| Rate for Payer: NAPHCARE Commercial |
$194.40
|
| Rate for Payer: Preferred Network Access Commercial |
$298.08
|
| Rate for Payer: Quartz Beloit One Network |
$158.76
|
| Rate for Payer: Quartz Commercial |
$210.60
|
| Rate for Payer: Quartz Medicare Advantage |
$194.40
|
| Rate for Payer: The Alliance Commercial |
$1,296.00
|
| Rate for Payer: WEA Trust Commercial |
$178.20
|
| Rate for Payer: WPS Commercial |
$239.99
|
|
|
Level 3 Est - 99213
|
Facility
|
IP
|
$324.00
|
|
| Hospital Charge Code |
5516698
|
| Min. Negotiated Rate |
$158.76 |
| Max. Negotiated Rate |
$298.08 |
| Rate for Payer: Aetna Commercial |
$291.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$278.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$171.72
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$298.08
|
| Rate for Payer: Health EOS Commercial |
$288.36
|
| Rate for Payer: HFN Commercial |
$298.08
|
| Rate for Payer: Multiplan Commercial |
$259.20
|
| Rate for Payer: NAPHCARE Commercial |
$194.40
|
| Rate for Payer: Preferred Network Access Commercial |
$298.08
|
| Rate for Payer: Quartz Beloit One Network |
$158.76
|
| Rate for Payer: Quartz Commercial |
$194.40
|
| Rate for Payer: WEA Trust Commercial |
$178.20
|
| Rate for Payer: WPS Commercial |
$239.99
|
|
|
Level 3 - Labor Level
|
Facility
|
IP
|
$3,808.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3003933
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,865.92 |
| Max. Negotiated Rate |
$3,503.36 |
| Rate for Payer: Aetna Commercial |
$3,427.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,274.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,018.24
|
| Rate for Payer: Cash Price |
$1,142.40
|
| Rate for Payer: Cigna Commercial |
$3,503.36
|
| Rate for Payer: Health EOS Commercial |
$3,389.12
|
| Rate for Payer: HFN Commercial |
$3,503.36
|
| Rate for Payer: Multiplan Commercial |
$3,046.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,284.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,503.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,865.92
|
| Rate for Payer: Quartz Commercial |
$2,284.80
|
| Rate for Payer: WEA Trust Commercial |
$2,094.40
|
| Rate for Payer: WPS Commercial |
$2,820.59
|
|
|
Level 3 - Labor Level
|
Facility
|
OP
|
$3,808.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3003933
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,066.24 |
| Max. Negotiated Rate |
$15,232.00 |
| Rate for Payer: Aetna Commercial |
$3,427.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,274.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,066.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,475.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,904.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,827.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,018.24
|
| Rate for Payer: Cash Price |
$1,142.40
|
| Rate for Payer: Cigna Commercial |
$3,503.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,130.96
|
| Rate for Payer: Health EOS Commercial |
$3,389.12
|
| Rate for Payer: HFN Commercial |
$3,503.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,856.00
|
| Rate for Payer: Multiplan Commercial |
$3,046.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,284.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,503.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,865.92
|
| Rate for Payer: Quartz Commercial |
$2,475.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,284.80
|
| Rate for Payer: The Alliance Commercial |
$15,232.00
|
| Rate for Payer: United Healthcare PPO |
$2,856.00
|
| Rate for Payer: WEA Trust Commercial |
$2,094.40
|
| Rate for Payer: WPS Commercial |
$2,820.59
|
|
|
Level 3 New - 99203
|
Facility
|
IP
|
$374.00
|
|
| Hospital Charge Code |
5516697
|
| Min. Negotiated Rate |
$183.26 |
| Max. Negotiated Rate |
$344.08 |
| Rate for Payer: Aetna Commercial |
$336.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.22
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$344.08
|
| Rate for Payer: Health EOS Commercial |
$332.86
|
| Rate for Payer: HFN Commercial |
$344.08
|
| Rate for Payer: Multiplan Commercial |
$299.20
|
| Rate for Payer: NAPHCARE Commercial |
$224.40
|
| Rate for Payer: Preferred Network Access Commercial |
$344.08
|
| Rate for Payer: Quartz Beloit One Network |
$183.26
|
| Rate for Payer: Quartz Commercial |
$224.40
|
| Rate for Payer: WEA Trust Commercial |
$205.70
|
| Rate for Payer: WPS Commercial |
$277.02
|
|
|
Level 3 New - 99203
|
Facility
|
OP
|
$374.00
|
|
| Hospital Charge Code |
5516697
|
| Min. Negotiated Rate |
$104.72 |
| Max. Negotiated Rate |
$1,496.00 |
| Rate for Payer: Aetna Commercial |
$336.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.64
|
| Rate for Payer: Aetna Managed Medicare |
$104.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$243.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$187.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$179.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.22
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$344.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$209.29
|
| Rate for Payer: Health EOS Commercial |
$332.86
|
| Rate for Payer: HFN Commercial |
$344.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$280.50
|
| Rate for Payer: Multiplan Commercial |
$299.20
|
| Rate for Payer: NAPHCARE Commercial |
$224.40
|
| Rate for Payer: Preferred Network Access Commercial |
$344.08
|
| Rate for Payer: Quartz Beloit One Network |
$183.26
|
| Rate for Payer: Quartz Commercial |
$243.10
|
| Rate for Payer: Quartz Medicare Advantage |
$224.40
|
| Rate for Payer: The Alliance Commercial |
$1,496.00
|
| Rate for Payer: WEA Trust Commercial |
$205.70
|
| Rate for Payer: WPS Commercial |
$277.02
|
|
|
Level 4 - 99284
|
Facility
|
IP
|
$1,793.00
|
|
|
Service Code
|
CPT 99284
|
| Hospital Charge Code |
5516686
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$878.57 |
| Max. Negotiated Rate |
$1,649.56 |
| Rate for Payer: Aetna Commercial |
$1,613.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$950.29
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cigna Commercial |
$1,649.56
|
| Rate for Payer: Health EOS Commercial |
$1,595.77
|
| Rate for Payer: HFN Commercial |
$1,649.56
|
| Rate for Payer: Multiplan Commercial |
$1,434.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,075.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,649.56
|
| Rate for Payer: Quartz Beloit One Network |
$878.57
|
| Rate for Payer: Quartz Commercial |
$1,075.80
|
| Rate for Payer: WEA Trust Commercial |
$986.15
|
| Rate for Payer: WPS Commercial |
$1,328.08
|
|
|
Level 4 - 99284
|
Facility
|
OP
|
$1,793.00
|
|
|
Service Code
|
CPT 99284
|
| Hospital Charge Code |
5516686
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$437.77 |
| Max. Negotiated Rate |
$4,372.00 |
| Rate for Payer: Aetna Commercial |
$1,613.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.98
|
| Rate for Payer: Aetna Managed Medicare |
$437.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,372.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,302.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,138.00
|
| Rate for Payer: Anthem Medicare Advantage |
$437.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$950.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$437.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$437.77
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cigna Commercial |
$1,649.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$437.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,003.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$437.77
|
| Rate for Payer: Health EOS Commercial |
$1,595.77
|
| Rate for Payer: HFN Commercial |
$1,649.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,628.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$437.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$437.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$437.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$437.77
|
| Rate for Payer: Multiplan Commercial |
$1,434.40
|
| Rate for Payer: NAPHCARE Commercial |
$656.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,649.56
|
| Rate for Payer: Quartz Beloit One Network |
$878.57
|
| Rate for Payer: Quartz Commercial |
$1,165.45
|
| Rate for Payer: Quartz Medicare Advantage |
$437.77
|
| Rate for Payer: The Alliance Commercial |
$1,751.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$437.77
|
| Rate for Payer: United Healthcare PPO |
$1,300.00
|
| Rate for Payer: WEA Trust Commercial |
$986.15
|
| Rate for Payer: Wellcare Medicare |
$437.77
|
| Rate for Payer: WPS Commercial |
$1,328.08
|
|
|
Level 4 Est - 99214
|
Facility
|
OP
|
$523.00
|
|
| Hospital Charge Code |
5516700
|
| Min. Negotiated Rate |
$146.44 |
| Max. Negotiated Rate |
$2,092.00 |
| Rate for Payer: Aetna Commercial |
$470.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$449.78
|
| Rate for Payer: Aetna Managed Medicare |
$146.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$339.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$261.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$251.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$277.19
|
| Rate for Payer: Cash Price |
$156.90
|
| Rate for Payer: Cigna Commercial |
$481.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$292.67
|
| Rate for Payer: Health EOS Commercial |
$465.47
|
| Rate for Payer: HFN Commercial |
$481.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$392.25
|
| Rate for Payer: Multiplan Commercial |
$418.40
|
| Rate for Payer: NAPHCARE Commercial |
$313.80
|
| Rate for Payer: Preferred Network Access Commercial |
$481.16
|
| Rate for Payer: Quartz Beloit One Network |
$256.27
|
| Rate for Payer: Quartz Commercial |
$339.95
|
| Rate for Payer: Quartz Medicare Advantage |
$313.80
|
| Rate for Payer: The Alliance Commercial |
$2,092.00
|
| Rate for Payer: WEA Trust Commercial |
$287.65
|
| Rate for Payer: WPS Commercial |
$387.39
|
|
|
Level 4 Est - 99214
|
Facility
|
IP
|
$523.00
|
|
| Hospital Charge Code |
5516700
|
| Min. Negotiated Rate |
$256.27 |
| Max. Negotiated Rate |
$481.16 |
| Rate for Payer: Aetna Commercial |
$470.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$449.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$277.19
|
| Rate for Payer: Cash Price |
$156.90
|
| Rate for Payer: Cigna Commercial |
$481.16
|
| Rate for Payer: Health EOS Commercial |
$465.47
|
| Rate for Payer: HFN Commercial |
$481.16
|
| Rate for Payer: Multiplan Commercial |
$418.40
|
| Rate for Payer: NAPHCARE Commercial |
$313.80
|
| Rate for Payer: Preferred Network Access Commercial |
$481.16
|
| Rate for Payer: Quartz Beloit One Network |
$256.27
|
| Rate for Payer: Quartz Commercial |
$313.80
|
| Rate for Payer: WEA Trust Commercial |
$287.65
|
| Rate for Payer: WPS Commercial |
$387.39
|
|
|
Level 4 - Labor Level
|
Facility
|
OP
|
$4,712.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
3003932
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,319.36 |
| Max. Negotiated Rate |
$18,848.00 |
| Rate for Payer: Aetna Commercial |
$4,240.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,052.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,319.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,062.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,356.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,261.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,497.36
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Cigna Commercial |
$4,335.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,636.84
|
| Rate for Payer: Health EOS Commercial |
$4,193.68
|
| Rate for Payer: HFN Commercial |
$4,335.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,534.00
|
| Rate for Payer: Multiplan Commercial |
$3,769.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,827.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,335.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,308.88
|
| Rate for Payer: Quartz Commercial |
$3,062.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,827.20
|
| Rate for Payer: The Alliance Commercial |
$18,848.00
|
| Rate for Payer: United Healthcare PPO |
$3,534.00
|
| Rate for Payer: WEA Trust Commercial |
$2,591.60
|
| Rate for Payer: WPS Commercial |
$3,490.18
|
|
|
Level 4 - Labor Level
|
Facility
|
IP
|
$4,712.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
3003932
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$2,308.88 |
| Max. Negotiated Rate |
$4,335.04 |
| Rate for Payer: Aetna Commercial |
$4,240.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,052.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,497.36
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Cigna Commercial |
$4,335.04
|
| Rate for Payer: Health EOS Commercial |
$4,193.68
|
| Rate for Payer: HFN Commercial |
$4,335.04
|
| Rate for Payer: Multiplan Commercial |
$3,769.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,827.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,335.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,308.88
|
| Rate for Payer: Quartz Commercial |
$2,827.20
|
| Rate for Payer: WEA Trust Commercial |
$2,591.60
|
| Rate for Payer: WPS Commercial |
$3,490.18
|
|
|
Level 4 New - 99204
|
Facility
|
OP
|
$570.00
|
|
| Hospital Charge Code |
5516699
|
| Min. Negotiated Rate |
$159.60 |
| Max. Negotiated Rate |
$2,280.00 |
| Rate for Payer: Aetna Commercial |
$513.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$490.20
|
| Rate for Payer: Aetna Managed Medicare |
$159.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$370.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$285.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$273.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$302.10
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cigna Commercial |
$524.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$318.97
|
| Rate for Payer: Health EOS Commercial |
$507.30
|
| Rate for Payer: HFN Commercial |
$524.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$427.50
|
| Rate for Payer: Multiplan Commercial |
$456.00
|
| Rate for Payer: NAPHCARE Commercial |
$342.00
|
| Rate for Payer: Preferred Network Access Commercial |
$524.40
|
| Rate for Payer: Quartz Beloit One Network |
$279.30
|
| Rate for Payer: Quartz Commercial |
$370.50
|
| Rate for Payer: Quartz Medicare Advantage |
$342.00
|
| Rate for Payer: The Alliance Commercial |
$2,280.00
|
| Rate for Payer: WEA Trust Commercial |
$313.50
|
| Rate for Payer: WPS Commercial |
$422.20
|
|
|
Level 4 New - 99204
|
Facility
|
IP
|
$570.00
|
|
| Hospital Charge Code |
5516699
|
| Min. Negotiated Rate |
$279.30 |
| Max. Negotiated Rate |
$524.40 |
| Rate for Payer: Aetna Commercial |
$513.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$490.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$302.10
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cigna Commercial |
$524.40
|
| Rate for Payer: Health EOS Commercial |
$507.30
|
| Rate for Payer: HFN Commercial |
$524.40
|
| Rate for Payer: Multiplan Commercial |
$456.00
|
| Rate for Payer: NAPHCARE Commercial |
$342.00
|
| Rate for Payer: Preferred Network Access Commercial |
$524.40
|
| Rate for Payer: Quartz Beloit One Network |
$279.30
|
| Rate for Payer: Quartz Commercial |
$342.00
|
| Rate for Payer: WEA Trust Commercial |
$313.50
|
| Rate for Payer: WPS Commercial |
$422.20
|
|
|
Level 5 - 99285
|
Facility
|
IP
|
$3,158.00
|
|
|
Service Code
|
CPT 99285
|
| Hospital Charge Code |
5516687
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,547.42 |
| Max. Negotiated Rate |
$2,905.36 |
| Rate for Payer: Aetna Commercial |
$2,842.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,715.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,673.74
|
| Rate for Payer: Cash Price |
$947.40
|
| Rate for Payer: Cigna Commercial |
$2,905.36
|
| Rate for Payer: Health EOS Commercial |
$2,810.62
|
| Rate for Payer: HFN Commercial |
$2,905.36
|
| Rate for Payer: Multiplan Commercial |
$2,526.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,894.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,905.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,547.42
|
| Rate for Payer: Quartz Commercial |
$1,894.80
|
| Rate for Payer: WEA Trust Commercial |
$1,736.90
|
| Rate for Payer: WPS Commercial |
$2,339.13
|
|
|
Level 5 - 99285
|
Facility
|
OP
|
$3,158.00
|
|
|
Service Code
|
CPT 99285
|
| Hospital Charge Code |
5516687
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$634.87 |
| Max. Negotiated Rate |
$4,372.00 |
| Rate for Payer: Aetna Commercial |
$2,842.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,715.88
|
| Rate for Payer: Aetna Managed Medicare |
$634.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,372.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,302.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,138.00
|
| Rate for Payer: Anthem Medicare Advantage |
$634.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,673.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$634.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$634.87
|
| Rate for Payer: Cash Price |
$947.40
|
| Rate for Payer: Cash Price |
$947.40
|
| Rate for Payer: Cash Price |
$947.40
|
| Rate for Payer: Cigna Commercial |
$2,905.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$634.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,767.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$634.87
|
| Rate for Payer: Health EOS Commercial |
$2,810.62
|
| Rate for Payer: HFN Commercial |
$2,905.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,361.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$634.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$634.87
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$634.87
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$634.87
|
| Rate for Payer: Multiplan Commercial |
$2,526.40
|
| Rate for Payer: NAPHCARE Commercial |
$952.30
|
| Rate for Payer: Preferred Network Access Commercial |
$2,905.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,547.42
|
| Rate for Payer: Quartz Commercial |
$2,052.70
|
| Rate for Payer: Quartz Medicare Advantage |
$634.87
|
| Rate for Payer: The Alliance Commercial |
$2,539.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$634.87
|
| Rate for Payer: United Healthcare PPO |
$2,462.00
|
| Rate for Payer: WEA Trust Commercial |
$1,736.90
|
| Rate for Payer: Wellcare Medicare |
$634.87
|
| Rate for Payer: WPS Commercial |
$2,339.13
|
|
|
Level 5 Est - 99215
|
Facility
|
IP
|
$696.00
|
|
| Hospital Charge Code |
5516702
|
| Min. Negotiated Rate |
$341.04 |
| Max. Negotiated Rate |
$640.32 |
| Rate for Payer: Aetna Commercial |
$626.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$598.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$368.88
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cigna Commercial |
$640.32
|
| Rate for Payer: Health EOS Commercial |
$619.44
|
| Rate for Payer: HFN Commercial |
$640.32
|
| Rate for Payer: Multiplan Commercial |
$556.80
|
| Rate for Payer: NAPHCARE Commercial |
$417.60
|
| Rate for Payer: Preferred Network Access Commercial |
$640.32
|
| Rate for Payer: Quartz Beloit One Network |
$341.04
|
| Rate for Payer: Quartz Commercial |
$417.60
|
| Rate for Payer: WEA Trust Commercial |
$382.80
|
| Rate for Payer: WPS Commercial |
$515.53
|
|
|
Level 5 Est - 99215
|
Facility
|
OP
|
$696.00
|
|
| Hospital Charge Code |
5516702
|
| Min. Negotiated Rate |
$194.88 |
| Max. Negotiated Rate |
$2,784.00 |
| Rate for Payer: Aetna Commercial |
$626.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$598.56
|
| Rate for Payer: Aetna Managed Medicare |
$194.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$452.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$348.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$334.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$368.88
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cigna Commercial |
$640.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$389.48
|
| Rate for Payer: Health EOS Commercial |
$619.44
|
| Rate for Payer: HFN Commercial |
$640.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$522.00
|
| Rate for Payer: Multiplan Commercial |
$556.80
|
| Rate for Payer: NAPHCARE Commercial |
$417.60
|
| Rate for Payer: Preferred Network Access Commercial |
$640.32
|
| Rate for Payer: Quartz Beloit One Network |
$341.04
|
| Rate for Payer: Quartz Commercial |
$452.40
|
| Rate for Payer: Quartz Medicare Advantage |
$417.60
|
| Rate for Payer: The Alliance Commercial |
$2,784.00
|
| Rate for Payer: WEA Trust Commercial |
$382.80
|
| Rate for Payer: WPS Commercial |
$515.53
|
|
|
Level 5 - Labor Level
|
Facility
|
OP
|
$12,009.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
3003931
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$3,362.52 |
| Max. Negotiated Rate |
$48,036.00 |
| Rate for Payer: Aetna Commercial |
$10,808.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,327.74
|
| Rate for Payer: Aetna Managed Medicare |
$3,362.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,805.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,004.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,764.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,364.77
|
| Rate for Payer: Cash Price |
$3,602.70
|
| Rate for Payer: Cigna Commercial |
$11,048.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,720.24
|
| Rate for Payer: Health EOS Commercial |
$10,688.01
|
| Rate for Payer: HFN Commercial |
$11,048.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,006.75
|
| Rate for Payer: Multiplan Commercial |
$9,607.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,205.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,048.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,884.41
|
| Rate for Payer: Quartz Commercial |
$7,805.85
|
| Rate for Payer: Quartz Medicare Advantage |
$7,205.40
|
| Rate for Payer: The Alliance Commercial |
$48,036.00
|
| Rate for Payer: United Healthcare PPO |
$9,006.75
|
| Rate for Payer: WEA Trust Commercial |
$6,604.95
|
| Rate for Payer: WPS Commercial |
$8,895.07
|
|
|
Level 5 - Labor Level
|
Facility
|
IP
|
$12,009.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
3003931
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$5,884.41 |
| Max. Negotiated Rate |
$11,048.28 |
| Rate for Payer: Aetna Commercial |
$10,808.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,327.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,364.77
|
| Rate for Payer: Cash Price |
$3,602.70
|
| Rate for Payer: Cigna Commercial |
$11,048.28
|
| Rate for Payer: Health EOS Commercial |
$10,688.01
|
| Rate for Payer: HFN Commercial |
$11,048.28
|
| Rate for Payer: Multiplan Commercial |
$9,607.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,205.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,048.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,884.41
|
| Rate for Payer: Quartz Commercial |
$7,205.40
|
| Rate for Payer: WEA Trust Commercial |
$6,604.95
|
| Rate for Payer: WPS Commercial |
$8,895.07
|
|
