|
Leustatin 100 mg Charge
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
HCPCS J9065
|
| Hospital Charge Code |
2958946
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$43.15 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$7.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.47
|
| Rate for Payer: Anthem Medicare Advantage |
$7.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.72
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7.72
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7.72
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$11.58
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$25.01
|
| Rate for Payer: Quartz Medicare Advantage |
$7.72
|
| Rate for Payer: The Alliance Commercial |
$30.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.72
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: Wellcare Medicare |
$7.72
|
| Rate for Payer: WPS Commercial |
$43.15
|
|
|
Leustatin 100 mg Charge
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS J9065
|
| Hospital Charge Code |
2958946
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$43.15 |
| Rate for Payer: Aetna Commercial |
$36.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$7.72
|
| Rate for Payer: Anthem Medicare Advantage |
$7.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.72
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$36.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.26
|
| Rate for Payer: Health EOS Commercial |
$35.02
|
| Rate for Payer: HFN Commercial |
$36.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.72
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$11.58
|
| Rate for Payer: Preferred Network Access Commercial |
$36.56
|
| Rate for Payer: Quartz Beloit One Network |
$16.93
|
| Rate for Payer: Quartz Commercial |
$21.93
|
| Rate for Payer: Quartz Medicare Advantage |
$7.72
|
| Rate for Payer: The Alliance Commercial |
$21.22
|
| Rate for Payer: United Healthcare Medicaid |
$7.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.72
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$43.15
|
|
|
Leustatin 100 mg Charge
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
HCPCS J9065
|
| Hospital Charge Code |
2958946
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.86 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$23.09
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
LEVEEN SHUNT
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960373
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
LEVEEN SHUNT
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960373
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
Level 1 - 99281
|
Facility
|
OP
|
$381.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
5516683
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$88.74 |
| Max. Negotiated Rate |
$666.64 |
| Rate for Payer: Aetna Commercial |
$356.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$340.77
|
| Rate for Payer: Aetna Managed Medicare |
$88.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$666.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$477.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$453.44
|
| Rate for Payer: Anthem Medicare Advantage |
$88.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$88.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$88.74
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cigna Commercial |
$364.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$88.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$221.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$88.74
|
| Rate for Payer: Health EOS Commercial |
$352.65
|
| Rate for Payer: HFN Commercial |
$364.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$330.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$88.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$88.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$88.74
|
| Rate for Payer: Multiplan Commercial |
$316.99
|
| Rate for Payer: NAPHCARE Commercial |
$133.11
|
| Rate for Payer: Preferred Network Access Commercial |
$364.54
|
| Rate for Payer: Quartz Beloit One Network |
$194.16
|
| Rate for Payer: Quartz Commercial |
$257.56
|
| Rate for Payer: Quartz Medicare Advantage |
$88.74
|
| Rate for Payer: The Alliance Commercial |
$354.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$88.74
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$217.93
|
| Rate for Payer: Wellcare Medicare |
$88.74
|
| Rate for Payer: WPS Commercial |
$293.48
|
|
|
Level 1 - 99281
|
Facility
|
IP
|
$381.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
5516683
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$194.16 |
| Max. Negotiated Rate |
$364.54 |
| Rate for Payer: Aetna Commercial |
$356.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$340.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.01
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cigna Commercial |
$364.54
|
| Rate for Payer: Health EOS Commercial |
$352.65
|
| Rate for Payer: HFN Commercial |
$364.54
|
| Rate for Payer: Multiplan Commercial |
$316.99
|
| Rate for Payer: Preferred Network Access Commercial |
$364.54
|
| Rate for Payer: Quartz Beloit One Network |
$194.16
|
| Rate for Payer: Quartz Commercial |
$237.74
|
| Rate for Payer: WEA Trust Commercial |
$217.93
|
| Rate for Payer: WPS Commercial |
$293.48
|
|
|
Level 1 Est - 99211
|
Facility
|
IP
|
$165.00
|
|
| Hospital Charge Code |
5516694
|
| Min. Negotiated Rate |
$84.08 |
| Max. Negotiated Rate |
$157.87 |
| Rate for Payer: Aetna Commercial |
$154.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.95
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$157.87
|
| Rate for Payer: Health EOS Commercial |
$152.72
|
| Rate for Payer: HFN Commercial |
$157.87
|
| Rate for Payer: Multiplan Commercial |
$137.28
|
| Rate for Payer: Preferred Network Access Commercial |
$157.87
|
| Rate for Payer: Quartz Beloit One Network |
$84.08
|
| Rate for Payer: Quartz Commercial |
$102.96
|
| Rate for Payer: WEA Trust Commercial |
$94.38
|
| Rate for Payer: WPS Commercial |
$127.10
|
|
|
Level 1 Est - 99211
|
Facility
|
OP
|
$165.00
|
|
| Hospital Charge Code |
5516694
|
| Min. Negotiated Rate |
$48.05 |
| Max. Negotiated Rate |
$157.87 |
| Rate for Payer: Aetna Commercial |
$154.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.58
|
| Rate for Payer: Aetna Managed Medicare |
$48.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$85.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.95
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$157.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.03
|
| Rate for Payer: Health EOS Commercial |
$152.72
|
| Rate for Payer: HFN Commercial |
$157.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.70
|
| Rate for Payer: Multiplan Commercial |
$137.28
|
| Rate for Payer: NAPHCARE Commercial |
$102.96
|
| Rate for Payer: Preferred Network Access Commercial |
$157.87
|
| Rate for Payer: Quartz Beloit One Network |
$84.08
|
| Rate for Payer: Quartz Commercial |
$111.54
|
| Rate for Payer: Quartz Medicare Advantage |
$102.96
|
| Rate for Payer: The Alliance Commercial |
$85.80
|
| Rate for Payer: WEA Trust Commercial |
$94.38
|
| Rate for Payer: WPS Commercial |
$127.10
|
|
|
Level 1 IV Fluid Warmer
|
Facility
|
IP
|
$187.00
|
|
| Hospital Charge Code |
3101757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$95.30 |
| Max. Negotiated Rate |
$178.92 |
| Rate for Payer: Aetna Commercial |
$175.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.07
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$178.92
|
| Rate for Payer: Health EOS Commercial |
$173.09
|
| Rate for Payer: HFN Commercial |
$178.92
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: Preferred Network Access Commercial |
$178.92
|
| Rate for Payer: Quartz Beloit One Network |
$95.30
|
| Rate for Payer: Quartz Commercial |
$116.69
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
Level 1 IV Fluid Warmer
|
Facility
|
OP
|
$187.00
|
|
| Hospital Charge Code |
3101757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.45 |
| Max. Negotiated Rate |
$178.92 |
| Rate for Payer: Aetna Commercial |
$175.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Aetna Managed Medicare |
$54.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.07
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$178.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.83
|
| Rate for Payer: Health EOS Commercial |
$173.09
|
| Rate for Payer: HFN Commercial |
$178.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.86
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: NAPHCARE Commercial |
$116.69
|
| Rate for Payer: Preferred Network Access Commercial |
$178.92
|
| Rate for Payer: Quartz Beloit One Network |
$95.30
|
| Rate for Payer: Quartz Commercial |
$126.41
|
| Rate for Payer: Quartz Medicare Advantage |
$116.69
|
| Rate for Payer: The Alliance Commercial |
$97.24
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
Level 1 - Labor Level
|
Facility
|
IP
|
$1,788.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3003935
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$911.16 |
| Max. Negotiated Rate |
$1,710.76 |
| Rate for Payer: Aetna Commercial |
$1,673.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,599.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$985.55
|
| Rate for Payer: Cash Price |
$536.40
|
| Rate for Payer: Cigna Commercial |
$1,710.76
|
| Rate for Payer: Health EOS Commercial |
$1,654.97
|
| Rate for Payer: HFN Commercial |
$1,710.76
|
| Rate for Payer: Multiplan Commercial |
$1,487.62
|
| Rate for Payer: Preferred Network Access Commercial |
$1,710.76
|
| Rate for Payer: Quartz Beloit One Network |
$911.16
|
| Rate for Payer: Quartz Commercial |
$1,115.71
|
| Rate for Payer: WEA Trust Commercial |
$1,022.74
|
| Rate for Payer: WPS Commercial |
$1,377.30
|
|
|
Level 1 - Labor Level
|
Facility
|
OP
|
$1,788.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3003935
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$30.74 |
| Max. Negotiated Rate |
$1,710.76 |
| Rate for Payer: Aetna Commercial |
$1,673.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,599.19
|
| Rate for Payer: Aetna Managed Medicare |
$520.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,208.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$929.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$892.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$985.55
|
| Rate for Payer: Cash Price |
$536.40
|
| Rate for Payer: Cash Price |
$536.40
|
| Rate for Payer: Cigna Commercial |
$1,710.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,040.62
|
| Rate for Payer: Health EOS Commercial |
$1,654.97
|
| Rate for Payer: HFN Commercial |
$1,710.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,394.64
|
| Rate for Payer: Multiplan Commercial |
$1,487.62
|
| Rate for Payer: NAPHCARE Commercial |
$1,115.71
|
| Rate for Payer: Preferred Network Access Commercial |
$1,710.76
|
| Rate for Payer: Quartz Beloit One Network |
$911.16
|
| Rate for Payer: Quartz Commercial |
$1,208.69
|
| Rate for Payer: Quartz Medicare Advantage |
$1,115.71
|
| Rate for Payer: The Alliance Commercial |
$30.74
|
| Rate for Payer: United Healthcare PPO |
$1,394.64
|
| Rate for Payer: WEA Trust Commercial |
$1,022.74
|
| Rate for Payer: WPS Commercial |
$1,377.30
|
|
|
Level 2 - 99282
|
Facility
|
IP
|
$684.00
|
|
|
Service Code
|
CPT 99282
|
| Hospital Charge Code |
5516684
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$348.57 |
| Max. Negotiated Rate |
$654.45 |
| Rate for Payer: Aetna Commercial |
$640.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$611.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$377.02
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$654.45
|
| Rate for Payer: Health EOS Commercial |
$633.11
|
| Rate for Payer: HFN Commercial |
$654.45
|
| Rate for Payer: Multiplan Commercial |
$569.09
|
| Rate for Payer: Preferred Network Access Commercial |
$654.45
|
| Rate for Payer: Quartz Beloit One Network |
$348.57
|
| Rate for Payer: Quartz Commercial |
$426.82
|
| Rate for Payer: WEA Trust Commercial |
$391.25
|
| Rate for Payer: WPS Commercial |
$526.89
|
|
|
Level 2 - 99282
|
Facility
|
OP
|
$684.00
|
|
|
Service Code
|
CPT 99282
|
| Hospital Charge Code |
5516684
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$161.58 |
| Max. Negotiated Rate |
$666.64 |
| Rate for Payer: Aetna Commercial |
$640.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$611.77
|
| Rate for Payer: Aetna Managed Medicare |
$161.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$666.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$477.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$453.44
|
| Rate for Payer: Anthem Medicare Advantage |
$161.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$377.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$161.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$161.58
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$654.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$161.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$398.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$161.58
|
| Rate for Payer: Health EOS Commercial |
$633.11
|
| Rate for Payer: HFN Commercial |
$654.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$601.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$161.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$161.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$161.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$161.58
|
| Rate for Payer: Multiplan Commercial |
$569.09
|
| Rate for Payer: NAPHCARE Commercial |
$242.38
|
| Rate for Payer: Preferred Network Access Commercial |
$654.45
|
| Rate for Payer: Quartz Beloit One Network |
$348.57
|
| Rate for Payer: Quartz Commercial |
$462.38
|
| Rate for Payer: Quartz Medicare Advantage |
$161.58
|
| Rate for Payer: The Alliance Commercial |
$646.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$161.58
|
| Rate for Payer: United Healthcare PPO |
$547.04
|
| Rate for Payer: WEA Trust Commercial |
$391.25
|
| Rate for Payer: Wellcare Medicare |
$161.58
|
| Rate for Payer: WPS Commercial |
$526.89
|
|
|
Level 2 Est - 99212
|
Facility
|
IP
|
$261.00
|
|
| Hospital Charge Code |
5516696
|
| Min. Negotiated Rate |
$133.01 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$162.86
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
Level 2 Est - 99212
|
Facility
|
OP
|
$261.00
|
|
| Hospital Charge Code |
5516696
|
| Min. Negotiated Rate |
$76.00 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Aetna Managed Medicare |
$76.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.90
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$203.58
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: NAPHCARE Commercial |
$162.86
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$176.44
|
| Rate for Payer: Quartz Medicare Advantage |
$162.86
|
| Rate for Payer: The Alliance Commercial |
$135.72
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
Level 2 - Labor Level
|
Facility
|
OP
|
$2,592.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3003934
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$122.47 |
| Max. Negotiated Rate |
$2,480.03 |
| Rate for Payer: Aetna Commercial |
$2,426.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,318.28
|
| Rate for Payer: Aetna Managed Medicare |
$754.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,752.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,347.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,293.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,428.71
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna Commercial |
$2,480.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,508.54
|
| Rate for Payer: Health EOS Commercial |
$2,399.16
|
| Rate for Payer: HFN Commercial |
$2,480.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,021.76
|
| Rate for Payer: Multiplan Commercial |
$2,156.54
|
| Rate for Payer: NAPHCARE Commercial |
$1,617.41
|
| Rate for Payer: Preferred Network Access Commercial |
$2,480.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,320.88
|
| Rate for Payer: Quartz Commercial |
$1,752.19
|
| Rate for Payer: Quartz Medicare Advantage |
$1,617.41
|
| Rate for Payer: The Alliance Commercial |
$122.47
|
| Rate for Payer: United Healthcare PPO |
$2,021.76
|
| Rate for Payer: WEA Trust Commercial |
$1,482.62
|
| Rate for Payer: WPS Commercial |
$1,996.62
|
|
|
Level 2 - Labor Level
|
Facility
|
IP
|
$2,592.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3003934
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,320.88 |
| Max. Negotiated Rate |
$2,480.03 |
| Rate for Payer: Aetna Commercial |
$2,426.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,318.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,428.71
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna Commercial |
$2,480.03
|
| Rate for Payer: Health EOS Commercial |
$2,399.16
|
| Rate for Payer: HFN Commercial |
$2,480.03
|
| Rate for Payer: Multiplan Commercial |
$2,156.54
|
| Rate for Payer: Preferred Network Access Commercial |
$2,480.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,320.88
|
| Rate for Payer: Quartz Commercial |
$1,617.41
|
| Rate for Payer: WEA Trust Commercial |
$1,482.62
|
| Rate for Payer: WPS Commercial |
$1,996.62
|
|
|
Level 2 New - 99202
|
Facility
|
OP
|
$288.00
|
|
| Hospital Charge Code |
5516695
|
| Min. Negotiated Rate |
$83.87 |
| Max. Negotiated Rate |
$275.56 |
| Rate for Payer: Aetna Commercial |
$269.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$257.59
|
| Rate for Payer: Aetna Managed Medicare |
$83.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$194.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$149.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$143.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$158.75
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$275.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$167.62
|
| Rate for Payer: Health EOS Commercial |
$266.57
|
| Rate for Payer: HFN Commercial |
$275.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.64
|
| Rate for Payer: Multiplan Commercial |
$239.62
|
| Rate for Payer: NAPHCARE Commercial |
$179.71
|
| Rate for Payer: Preferred Network Access Commercial |
$275.56
|
| Rate for Payer: Quartz Beloit One Network |
$146.76
|
| Rate for Payer: Quartz Commercial |
$194.69
|
| Rate for Payer: Quartz Medicare Advantage |
$179.71
|
| Rate for Payer: The Alliance Commercial |
$149.76
|
| Rate for Payer: WEA Trust Commercial |
$164.74
|
| Rate for Payer: WPS Commercial |
$221.85
|
|
|
Level 2 New - 99202
|
Facility
|
IP
|
$288.00
|
|
| Hospital Charge Code |
5516695
|
| Min. Negotiated Rate |
$146.76 |
| Max. Negotiated Rate |
$275.56 |
| Rate for Payer: Aetna Commercial |
$269.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$257.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$158.75
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$275.56
|
| Rate for Payer: Health EOS Commercial |
$266.57
|
| Rate for Payer: HFN Commercial |
$275.56
|
| Rate for Payer: Multiplan Commercial |
$239.62
|
| Rate for Payer: Preferred Network Access Commercial |
$275.56
|
| Rate for Payer: Quartz Beloit One Network |
$146.76
|
| Rate for Payer: Quartz Commercial |
$179.71
|
| Rate for Payer: WEA Trust Commercial |
$164.74
|
| Rate for Payer: WPS Commercial |
$221.85
|
|
|
Level 3 - 99283
|
Facility
|
IP
|
$1,137.00
|
|
|
Service Code
|
CPT 99283
|
| Hospital Charge Code |
5516685
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$579.42 |
| Max. Negotiated Rate |
$1,087.88 |
| Rate for Payer: Aetna Commercial |
$1,064.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$626.71
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cigna Commercial |
$1,087.88
|
| Rate for Payer: Health EOS Commercial |
$1,052.41
|
| Rate for Payer: HFN Commercial |
$1,087.88
|
| Rate for Payer: Multiplan Commercial |
$945.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,087.88
|
| Rate for Payer: Quartz Beloit One Network |
$579.42
|
| Rate for Payer: Quartz Commercial |
$709.49
|
| Rate for Payer: WEA Trust Commercial |
$650.36
|
| Rate for Payer: WPS Commercial |
$875.83
|
|
|
Level 3 - 99283
|
Facility
|
OP
|
$1,137.00
|
|
|
Service Code
|
CPT 99283
|
| Hospital Charge Code |
5516685
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$287.28 |
| Max. Negotiated Rate |
$1,516.32 |
| Rate for Payer: Aetna Commercial |
$1,064.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.93
|
| Rate for Payer: Aetna Managed Medicare |
$287.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,516.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$955.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$907.92
|
| Rate for Payer: Anthem Medicare Advantage |
$287.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$626.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$287.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$287.28
|
| 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 |
$1,087.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$287.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$661.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$287.28
|
| Rate for Payer: Health EOS Commercial |
$1,052.41
|
| Rate for Payer: HFN Commercial |
$1,087.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,068.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$287.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$287.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$287.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$287.28
|
| Rate for Payer: Multiplan Commercial |
$945.98
|
| Rate for Payer: NAPHCARE Commercial |
$430.92
|
| Rate for Payer: Preferred Network Access Commercial |
$1,087.88
|
| Rate for Payer: Quartz Beloit One Network |
$579.42
|
| Rate for Payer: Quartz Commercial |
$768.61
|
| Rate for Payer: Quartz Medicare Advantage |
$287.28
|
| Rate for Payer: The Alliance Commercial |
$1,149.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$287.28
|
| Rate for Payer: United Healthcare PPO |
$1,265.68
|
| Rate for Payer: WEA Trust Commercial |
$650.36
|
| Rate for Payer: Wellcare Medicare |
$287.28
|
| Rate for Payer: WPS Commercial |
$875.83
|
|
|
Level 3 Est - 99213
|
Facility
|
OP
|
$324.00
|
|
| Hospital Charge Code |
5516698
|
| Min. Negotiated Rate |
$94.35 |
| Max. Negotiated Rate |
$310.00 |
| Rate for Payer: Aetna Commercial |
$303.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$289.79
|
| Rate for Payer: Aetna Managed Medicare |
$94.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$219.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$168.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$161.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$178.59
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$310.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$188.57
|
| Rate for Payer: Health EOS Commercial |
$299.89
|
| Rate for Payer: HFN Commercial |
$310.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$252.72
|
| Rate for Payer: Multiplan Commercial |
$269.57
|
| Rate for Payer: NAPHCARE Commercial |
$202.18
|
| Rate for Payer: Preferred Network Access Commercial |
$310.00
|
| Rate for Payer: Quartz Beloit One Network |
$165.11
|
| Rate for Payer: Quartz Commercial |
$219.02
|
| Rate for Payer: Quartz Medicare Advantage |
$202.18
|
| Rate for Payer: The Alliance Commercial |
$168.48
|
| Rate for Payer: WEA Trust Commercial |
$185.33
|
| Rate for Payer: WPS Commercial |
$249.58
|
|
|
Level 3 Est - 99213
|
Facility
|
IP
|
$324.00
|
|
| Hospital Charge Code |
5516698
|
| Min. Negotiated Rate |
$165.11 |
| Max. Negotiated Rate |
$310.00 |
| Rate for Payer: Aetna Commercial |
$303.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$289.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$178.59
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$310.00
|
| Rate for Payer: Health EOS Commercial |
$299.89
|
| Rate for Payer: HFN Commercial |
$310.00
|
| Rate for Payer: Multiplan Commercial |
$269.57
|
| Rate for Payer: Preferred Network Access Commercial |
$310.00
|
| Rate for Payer: Quartz Beloit One Network |
$165.11
|
| Rate for Payer: Quartz Commercial |
$202.18
|
| Rate for Payer: WEA Trust Commercial |
$185.33
|
| Rate for Payer: WPS Commercial |
$249.58
|
|
