|
Level 3 - Labor Level
|
Facility
|
OP
|
$3,808.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3003933
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$228.43 |
| Max. Negotiated Rate |
$3,643.49 |
| Rate for Payer: Aetna Commercial |
$3,564.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,405.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,108.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,574.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,980.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,900.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,098.97
|
| Rate for Payer: Cash Price |
$1,142.40
|
| Rate for Payer: Cash Price |
$1,142.40
|
| Rate for Payer: Cigna Commercial |
$3,643.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,216.26
|
| Rate for Payer: Health EOS Commercial |
$3,524.68
|
| Rate for Payer: HFN Commercial |
$3,643.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,970.24
|
| Rate for Payer: Multiplan Commercial |
$3,168.26
|
| Rate for Payer: NAPHCARE Commercial |
$2,376.19
|
| Rate for Payer: Preferred Network Access Commercial |
$3,643.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,940.56
|
| Rate for Payer: Quartz Commercial |
$2,574.21
|
| Rate for Payer: Quartz Medicare Advantage |
$2,376.19
|
| Rate for Payer: The Alliance Commercial |
$228.43
|
| Rate for Payer: United Healthcare PPO |
$2,970.24
|
| Rate for Payer: WEA Trust Commercial |
$2,178.18
|
| Rate for Payer: WPS Commercial |
$2,933.30
|
|
|
Level 3 - Labor Level
|
Facility
|
IP
|
$3,808.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3003933
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,940.56 |
| Max. Negotiated Rate |
$3,643.49 |
| Rate for Payer: Aetna Commercial |
$3,564.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,405.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,098.97
|
| Rate for Payer: Cash Price |
$1,142.40
|
| Rate for Payer: Cigna Commercial |
$3,643.49
|
| Rate for Payer: Health EOS Commercial |
$3,524.68
|
| Rate for Payer: HFN Commercial |
$3,643.49
|
| Rate for Payer: Multiplan Commercial |
$3,168.26
|
| Rate for Payer: Preferred Network Access Commercial |
$3,643.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,940.56
|
| Rate for Payer: Quartz Commercial |
$2,376.19
|
| Rate for Payer: WEA Trust Commercial |
$2,178.18
|
| Rate for Payer: WPS Commercial |
$2,933.30
|
|
|
Level 3 New - 99203
|
Facility
|
OP
|
$374.00
|
|
| Hospital Charge Code |
5516697
|
| Min. Negotiated Rate |
$108.91 |
| Max. Negotiated Rate |
$357.84 |
| Rate for Payer: Aetna Commercial |
$350.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$334.51
|
| Rate for Payer: Aetna Managed Medicare |
$108.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$252.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$194.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$186.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.15
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$357.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.67
|
| Rate for Payer: Health EOS Commercial |
$346.17
|
| Rate for Payer: HFN Commercial |
$357.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$291.72
|
| Rate for Payer: Multiplan Commercial |
$311.17
|
| Rate for Payer: NAPHCARE Commercial |
$233.38
|
| Rate for Payer: Preferred Network Access Commercial |
$357.84
|
| Rate for Payer: Quartz Beloit One Network |
$190.59
|
| Rate for Payer: Quartz Commercial |
$252.82
|
| Rate for Payer: Quartz Medicare Advantage |
$233.38
|
| Rate for Payer: The Alliance Commercial |
$194.48
|
| Rate for Payer: WEA Trust Commercial |
$213.93
|
| Rate for Payer: WPS Commercial |
$288.09
|
|
|
Level 3 New - 99203
|
Facility
|
IP
|
$374.00
|
|
| Hospital Charge Code |
5516697
|
| Min. Negotiated Rate |
$190.59 |
| Max. Negotiated Rate |
$357.84 |
| Rate for Payer: Aetna Commercial |
$350.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$334.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.15
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$357.84
|
| Rate for Payer: Health EOS Commercial |
$346.17
|
| Rate for Payer: HFN Commercial |
$357.84
|
| Rate for Payer: Multiplan Commercial |
$311.17
|
| Rate for Payer: Preferred Network Access Commercial |
$357.84
|
| Rate for Payer: Quartz Beloit One Network |
$190.59
|
| Rate for Payer: Quartz Commercial |
$233.38
|
| Rate for Payer: WEA Trust Commercial |
$213.93
|
| Rate for Payer: WPS Commercial |
$288.09
|
|
|
Level 4 - 99284
|
Facility
|
OP
|
$1,793.00
|
|
|
Service Code
|
CPT 99284
|
| Hospital Charge Code |
5516686
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$439.12 |
| Max. Negotiated Rate |
$4,546.88 |
| Rate for Payer: Aetna Commercial |
$1,678.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,603.66
|
| Rate for Payer: Aetna Managed Medicare |
$439.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,546.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,434.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,263.52
|
| Rate for Payer: Anthem Medicare Advantage |
$439.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$988.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$439.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$439.12
|
| 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 |
$1,715.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$439.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,043.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$439.12
|
| Rate for Payer: Health EOS Commercial |
$1,659.60
|
| Rate for Payer: HFN Commercial |
$1,715.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,633.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$439.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$439.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$439.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$439.12
|
| Rate for Payer: Multiplan Commercial |
$1,491.78
|
| Rate for Payer: NAPHCARE Commercial |
$658.68
|
| Rate for Payer: Preferred Network Access Commercial |
$1,715.54
|
| Rate for Payer: Quartz Beloit One Network |
$913.71
|
| Rate for Payer: Quartz Commercial |
$1,212.07
|
| Rate for Payer: Quartz Medicare Advantage |
$439.12
|
| Rate for Payer: The Alliance Commercial |
$1,756.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$439.12
|
| Rate for Payer: United Healthcare PPO |
$1,352.00
|
| Rate for Payer: WEA Trust Commercial |
$1,025.60
|
| Rate for Payer: Wellcare Medicare |
$439.12
|
| Rate for Payer: WPS Commercial |
$1,381.15
|
|
|
Level 4 - 99284
|
Facility
|
IP
|
$1,793.00
|
|
|
Service Code
|
CPT 99284
|
| Hospital Charge Code |
5516686
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$913.71 |
| Max. Negotiated Rate |
$1,715.54 |
| Rate for Payer: Aetna Commercial |
$1,678.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,603.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$988.30
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cigna Commercial |
$1,715.54
|
| Rate for Payer: Health EOS Commercial |
$1,659.60
|
| Rate for Payer: HFN Commercial |
$1,715.54
|
| Rate for Payer: Multiplan Commercial |
$1,491.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,715.54
|
| Rate for Payer: Quartz Beloit One Network |
$913.71
|
| Rate for Payer: Quartz Commercial |
$1,118.83
|
| Rate for Payer: WEA Trust Commercial |
$1,025.60
|
| Rate for Payer: WPS Commercial |
$1,381.15
|
|
|
Level 4 Est - 99214
|
Facility
|
IP
|
$523.00
|
|
| Hospital Charge Code |
5516700
|
| Min. Negotiated Rate |
$266.52 |
| Max. Negotiated Rate |
$500.41 |
| Rate for Payer: Aetna Commercial |
$489.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$467.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$288.28
|
| Rate for Payer: Cash Price |
$156.90
|
| Rate for Payer: Cigna Commercial |
$500.41
|
| Rate for Payer: Health EOS Commercial |
$484.09
|
| Rate for Payer: HFN Commercial |
$500.41
|
| Rate for Payer: Multiplan Commercial |
$435.14
|
| Rate for Payer: Preferred Network Access Commercial |
$500.41
|
| Rate for Payer: Quartz Beloit One Network |
$266.52
|
| Rate for Payer: Quartz Commercial |
$326.35
|
| Rate for Payer: WEA Trust Commercial |
$299.16
|
| Rate for Payer: WPS Commercial |
$402.87
|
|
|
Level 4 Est - 99214
|
Facility
|
OP
|
$523.00
|
|
| Hospital Charge Code |
5516700
|
| Min. Negotiated Rate |
$152.30 |
| Max. Negotiated Rate |
$500.41 |
| Rate for Payer: Aetna Commercial |
$489.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$467.77
|
| Rate for Payer: Aetna Managed Medicare |
$152.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$353.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$271.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$261.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$288.28
|
| Rate for Payer: Cash Price |
$156.90
|
| Rate for Payer: Cigna Commercial |
$500.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$304.39
|
| Rate for Payer: Health EOS Commercial |
$484.09
|
| Rate for Payer: HFN Commercial |
$500.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$407.94
|
| Rate for Payer: Multiplan Commercial |
$435.14
|
| Rate for Payer: NAPHCARE Commercial |
$326.35
|
| Rate for Payer: Preferred Network Access Commercial |
$500.41
|
| Rate for Payer: Quartz Beloit One Network |
$266.52
|
| Rate for Payer: Quartz Commercial |
$353.55
|
| Rate for Payer: Quartz Medicare Advantage |
$326.35
|
| Rate for Payer: The Alliance Commercial |
$271.96
|
| Rate for Payer: WEA Trust Commercial |
$299.16
|
| Rate for Payer: WPS Commercial |
$402.87
|
|
|
Level 4 - Labor Level
|
Facility
|
IP
|
$4,712.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
3003932
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$2,401.24 |
| Max. Negotiated Rate |
$4,508.44 |
| Rate for Payer: Aetna Commercial |
$4,410.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,214.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,597.25
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Cigna Commercial |
$4,508.44
|
| Rate for Payer: Health EOS Commercial |
$4,361.43
|
| Rate for Payer: HFN Commercial |
$4,508.44
|
| Rate for Payer: Multiplan Commercial |
$3,920.38
|
| Rate for Payer: Preferred Network Access Commercial |
$4,508.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,401.24
|
| Rate for Payer: Quartz Commercial |
$2,940.29
|
| Rate for Payer: WEA Trust Commercial |
$2,695.26
|
| Rate for Payer: WPS Commercial |
$3,629.65
|
|
|
Level 4 - Labor Level
|
Facility
|
OP
|
$4,712.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
3003932
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$335.34 |
| Max. Negotiated Rate |
$4,508.44 |
| Rate for Payer: Aetna Commercial |
$4,410.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,214.41
|
| Rate for Payer: Aetna Managed Medicare |
$1,372.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,185.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,450.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,352.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,597.25
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Cigna Commercial |
$4,508.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,742.38
|
| Rate for Payer: Health EOS Commercial |
$4,361.43
|
| Rate for Payer: HFN Commercial |
$4,508.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,675.36
|
| Rate for Payer: Multiplan Commercial |
$3,920.38
|
| Rate for Payer: NAPHCARE Commercial |
$2,940.29
|
| Rate for Payer: Preferred Network Access Commercial |
$4,508.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,401.24
|
| Rate for Payer: Quartz Commercial |
$3,185.31
|
| Rate for Payer: Quartz Medicare Advantage |
$2,940.29
|
| Rate for Payer: The Alliance Commercial |
$335.34
|
| Rate for Payer: United Healthcare PPO |
$3,675.36
|
| Rate for Payer: WEA Trust Commercial |
$2,695.26
|
| Rate for Payer: WPS Commercial |
$3,629.65
|
|
|
Level 4 New - 99204
|
Facility
|
OP
|
$570.00
|
|
| Hospital Charge Code |
5516699
|
| Min. Negotiated Rate |
$165.98 |
| Max. Negotiated Rate |
$545.38 |
| Rate for Payer: Aetna Commercial |
$533.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$509.81
|
| Rate for Payer: Aetna Managed Medicare |
$165.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$385.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$296.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$284.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$314.18
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cigna Commercial |
$545.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$331.74
|
| Rate for Payer: Health EOS Commercial |
$527.59
|
| Rate for Payer: HFN Commercial |
$545.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$444.60
|
| Rate for Payer: Multiplan Commercial |
$474.24
|
| Rate for Payer: NAPHCARE Commercial |
$355.68
|
| Rate for Payer: Preferred Network Access Commercial |
$545.38
|
| Rate for Payer: Quartz Beloit One Network |
$290.47
|
| Rate for Payer: Quartz Commercial |
$385.32
|
| Rate for Payer: Quartz Medicare Advantage |
$355.68
|
| Rate for Payer: The Alliance Commercial |
$296.40
|
| Rate for Payer: WEA Trust Commercial |
$326.04
|
| Rate for Payer: WPS Commercial |
$439.07
|
|
|
Level 4 New - 99204
|
Facility
|
IP
|
$570.00
|
|
| Hospital Charge Code |
5516699
|
| Min. Negotiated Rate |
$290.47 |
| Max. Negotiated Rate |
$545.38 |
| Rate for Payer: Aetna Commercial |
$533.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$509.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$314.18
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cigna Commercial |
$545.38
|
| Rate for Payer: Health EOS Commercial |
$527.59
|
| Rate for Payer: HFN Commercial |
$545.38
|
| Rate for Payer: Multiplan Commercial |
$474.24
|
| Rate for Payer: Preferred Network Access Commercial |
$545.38
|
| Rate for Payer: Quartz Beloit One Network |
$290.47
|
| Rate for Payer: Quartz Commercial |
$355.68
|
| Rate for Payer: WEA Trust Commercial |
$326.04
|
| Rate for Payer: WPS Commercial |
$439.07
|
|
|
Level 5 - 99285
|
Facility
|
OP
|
$3,158.00
|
|
|
Service Code
|
CPT 99285
|
| Hospital Charge Code |
5516687
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$626.74 |
| Max. Negotiated Rate |
$4,546.88 |
| Rate for Payer: Aetna Commercial |
$2,955.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,824.52
|
| Rate for Payer: Aetna Managed Medicare |
$626.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,546.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,434.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,263.52
|
| Rate for Payer: Anthem Medicare Advantage |
$626.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,740.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$626.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$626.74
|
| 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 |
$3,021.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$626.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,837.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$626.74
|
| Rate for Payer: Health EOS Commercial |
$2,923.04
|
| Rate for Payer: HFN Commercial |
$3,021.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,331.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$626.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$626.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$626.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$626.74
|
| Rate for Payer: Multiplan Commercial |
$2,627.46
|
| Rate for Payer: NAPHCARE Commercial |
$940.10
|
| Rate for Payer: Preferred Network Access Commercial |
$3,021.57
|
| Rate for Payer: Quartz Beloit One Network |
$1,609.32
|
| Rate for Payer: Quartz Commercial |
$2,134.81
|
| Rate for Payer: Quartz Medicare Advantage |
$626.74
|
| Rate for Payer: The Alliance Commercial |
$2,506.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$626.74
|
| Rate for Payer: United Healthcare PPO |
$2,560.48
|
| Rate for Payer: WEA Trust Commercial |
$1,806.38
|
| Rate for Payer: Wellcare Medicare |
$626.74
|
| Rate for Payer: WPS Commercial |
$2,432.61
|
|
|
Level 5 - 99285
|
Facility
|
IP
|
$3,158.00
|
|
|
Service Code
|
CPT 99285
|
| Hospital Charge Code |
5516687
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,609.32 |
| Max. Negotiated Rate |
$3,021.57 |
| Rate for Payer: Aetna Commercial |
$2,955.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,824.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,740.69
|
| Rate for Payer: Cash Price |
$947.40
|
| Rate for Payer: Cigna Commercial |
$3,021.57
|
| Rate for Payer: Health EOS Commercial |
$2,923.04
|
| Rate for Payer: HFN Commercial |
$3,021.57
|
| Rate for Payer: Multiplan Commercial |
$2,627.46
|
| Rate for Payer: Preferred Network Access Commercial |
$3,021.57
|
| Rate for Payer: Quartz Beloit One Network |
$1,609.32
|
| Rate for Payer: Quartz Commercial |
$1,970.59
|
| Rate for Payer: WEA Trust Commercial |
$1,806.38
|
| Rate for Payer: WPS Commercial |
$2,432.61
|
|
|
Level 5 Est - 99215
|
Facility
|
OP
|
$696.00
|
|
| Hospital Charge Code |
5516702
|
| Min. Negotiated Rate |
$202.68 |
| Max. Negotiated Rate |
$665.93 |
| Rate for Payer: Aetna Commercial |
$651.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$622.50
|
| Rate for Payer: Aetna Managed Medicare |
$202.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$470.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$361.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$347.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$383.64
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cigna Commercial |
$665.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$405.07
|
| Rate for Payer: Health EOS Commercial |
$644.22
|
| Rate for Payer: HFN Commercial |
$665.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$542.88
|
| Rate for Payer: Multiplan Commercial |
$579.07
|
| Rate for Payer: NAPHCARE Commercial |
$434.30
|
| Rate for Payer: Preferred Network Access Commercial |
$665.93
|
| Rate for Payer: Quartz Beloit One Network |
$354.68
|
| Rate for Payer: Quartz Commercial |
$470.50
|
| Rate for Payer: Quartz Medicare Advantage |
$434.30
|
| Rate for Payer: The Alliance Commercial |
$361.92
|
| Rate for Payer: WEA Trust Commercial |
$398.11
|
| Rate for Payer: WPS Commercial |
$536.13
|
|
|
Level 5 Est - 99215
|
Facility
|
IP
|
$696.00
|
|
| Hospital Charge Code |
5516702
|
| Min. Negotiated Rate |
$354.68 |
| Max. Negotiated Rate |
$665.93 |
| Rate for Payer: Aetna Commercial |
$651.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$622.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$383.64
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cigna Commercial |
$665.93
|
| Rate for Payer: Health EOS Commercial |
$644.22
|
| Rate for Payer: HFN Commercial |
$665.93
|
| Rate for Payer: Multiplan Commercial |
$579.07
|
| Rate for Payer: Preferred Network Access Commercial |
$665.93
|
| Rate for Payer: Quartz Beloit One Network |
$354.68
|
| Rate for Payer: Quartz Commercial |
$434.30
|
| Rate for Payer: WEA Trust Commercial |
$398.11
|
| Rate for Payer: WPS Commercial |
$536.13
|
|
|
Level 5 - Labor Level
|
Facility
|
OP
|
$12,009.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
3003931
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$497.87 |
| Max. Negotiated Rate |
$11,490.21 |
| Rate for Payer: Aetna Commercial |
$11,240.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,740.85
|
| Rate for Payer: Aetna Managed Medicare |
$3,497.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,118.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,244.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,994.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,619.36
|
| Rate for Payer: Cash Price |
$3,602.70
|
| Rate for Payer: Cash Price |
$3,602.70
|
| Rate for Payer: Cigna Commercial |
$11,490.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,989.24
|
| Rate for Payer: Health EOS Commercial |
$11,115.53
|
| Rate for Payer: HFN Commercial |
$11,490.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,367.02
|
| Rate for Payer: Multiplan Commercial |
$9,991.49
|
| Rate for Payer: NAPHCARE Commercial |
$7,493.62
|
| Rate for Payer: Preferred Network Access Commercial |
$11,490.21
|
| Rate for Payer: Quartz Beloit One Network |
$6,119.79
|
| Rate for Payer: Quartz Commercial |
$8,118.08
|
| Rate for Payer: Quartz Medicare Advantage |
$7,493.62
|
| Rate for Payer: The Alliance Commercial |
$497.87
|
| Rate for Payer: United Healthcare PPO |
$9,367.02
|
| Rate for Payer: WEA Trust Commercial |
$6,869.15
|
| Rate for Payer: WPS Commercial |
$9,250.53
|
|
|
Level 5 - Labor Level
|
Facility
|
IP
|
$12,009.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
3003931
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$6,119.79 |
| Max. Negotiated Rate |
$11,490.21 |
| Rate for Payer: Aetna Commercial |
$11,240.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,740.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,619.36
|
| Rate for Payer: Cash Price |
$3,602.70
|
| Rate for Payer: Cigna Commercial |
$11,490.21
|
| Rate for Payer: Health EOS Commercial |
$11,115.53
|
| Rate for Payer: HFN Commercial |
$11,490.21
|
| Rate for Payer: Multiplan Commercial |
$9,991.49
|
| Rate for Payer: Preferred Network Access Commercial |
$11,490.21
|
| Rate for Payer: Quartz Beloit One Network |
$6,119.79
|
| Rate for Payer: Quartz Commercial |
$7,493.62
|
| Rate for Payer: WEA Trust Commercial |
$6,869.15
|
| Rate for Payer: WPS Commercial |
$9,250.53
|
|
|
Level 5 New - 99205
|
Facility
|
OP
|
$727.00
|
|
| Hospital Charge Code |
5516701
|
| Min. Negotiated Rate |
$211.70 |
| Max. Negotiated Rate |
$695.59 |
| Rate for Payer: Aetna Commercial |
$680.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$650.23
|
| Rate for Payer: Aetna Managed Medicare |
$211.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$491.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$378.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$362.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$400.72
|
| Rate for Payer: Cash Price |
$218.10
|
| Rate for Payer: Cigna Commercial |
$695.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$423.11
|
| Rate for Payer: Health EOS Commercial |
$672.91
|
| Rate for Payer: HFN Commercial |
$695.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$567.06
|
| Rate for Payer: Multiplan Commercial |
$604.86
|
| Rate for Payer: NAPHCARE Commercial |
$453.65
|
| Rate for Payer: Preferred Network Access Commercial |
$695.59
|
| Rate for Payer: Quartz Beloit One Network |
$370.48
|
| Rate for Payer: Quartz Commercial |
$491.45
|
| Rate for Payer: Quartz Medicare Advantage |
$453.65
|
| Rate for Payer: The Alliance Commercial |
$378.04
|
| Rate for Payer: WEA Trust Commercial |
$415.84
|
| Rate for Payer: WPS Commercial |
$560.01
|
|
|
Level 5 New - 99205
|
Facility
|
IP
|
$727.00
|
|
| Hospital Charge Code |
5516701
|
| Min. Negotiated Rate |
$370.48 |
| Max. Negotiated Rate |
$695.59 |
| Rate for Payer: Aetna Commercial |
$680.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$650.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$400.72
|
| Rate for Payer: Cash Price |
$218.10
|
| Rate for Payer: Cigna Commercial |
$695.59
|
| Rate for Payer: Health EOS Commercial |
$672.91
|
| Rate for Payer: HFN Commercial |
$695.59
|
| Rate for Payer: Multiplan Commercial |
$604.86
|
| Rate for Payer: Preferred Network Access Commercial |
$695.59
|
| Rate for Payer: Quartz Beloit One Network |
$370.48
|
| Rate for Payer: Quartz Commercial |
$453.65
|
| Rate for Payer: WEA Trust Commercial |
$415.84
|
| Rate for Payer: WPS Commercial |
$560.01
|
|
|
Level 6 - Labor Level
|
Facility
|
OP
|
$15,062.00
|
|
| Hospital Charge Code |
3003930
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$4,386.05 |
| Max. Negotiated Rate |
$14,411.32 |
| Rate for Payer: Aetna Commercial |
$14,098.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,471.45
|
| Rate for Payer: Aetna Managed Medicare |
$4,386.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,181.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,832.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,518.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,302.17
|
| Rate for Payer: Cash Price |
$4,518.60
|
| Rate for Payer: Cigna Commercial |
$14,411.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,766.08
|
| Rate for Payer: Health EOS Commercial |
$13,941.39
|
| Rate for Payer: HFN Commercial |
$14,411.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,748.36
|
| Rate for Payer: Multiplan Commercial |
$12,531.58
|
| Rate for Payer: NAPHCARE Commercial |
$9,398.69
|
| Rate for Payer: Preferred Network Access Commercial |
$14,411.32
|
| Rate for Payer: Quartz Beloit One Network |
$7,675.60
|
| Rate for Payer: Quartz Commercial |
$10,181.91
|
| Rate for Payer: Quartz Medicare Advantage |
$9,398.69
|
| Rate for Payer: The Alliance Commercial |
$7,832.24
|
| Rate for Payer: United Healthcare PPO |
$11,748.36
|
| Rate for Payer: WEA Trust Commercial |
$8,615.46
|
| Rate for Payer: WPS Commercial |
$11,602.26
|
|
|
Level 6 - Labor Level
|
Facility
|
IP
|
$15,062.00
|
|
| Hospital Charge Code |
3003930
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$7,675.60 |
| Max. Negotiated Rate |
$14,411.32 |
| Rate for Payer: Aetna Commercial |
$14,098.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,471.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,302.17
|
| Rate for Payer: Cash Price |
$4,518.60
|
| Rate for Payer: Cigna Commercial |
$14,411.32
|
| Rate for Payer: Health EOS Commercial |
$13,941.39
|
| Rate for Payer: HFN Commercial |
$14,411.32
|
| Rate for Payer: Multiplan Commercial |
$12,531.58
|
| Rate for Payer: Preferred Network Access Commercial |
$14,411.32
|
| Rate for Payer: Quartz Beloit One Network |
$7,675.60
|
| Rate for Payer: Quartz Commercial |
$9,398.69
|
| Rate for Payer: WEA Trust Commercial |
$8,615.46
|
| Rate for Payer: WPS Commercial |
$11,602.26
|
|
|
Level I
|
Facility
|
IP
|
$3,566.00
|
|
| Hospital Charge Code |
3000366
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,817.23 |
| Max. Negotiated Rate |
$3,411.95 |
| Rate for Payer: Aetna Commercial |
$3,337.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,189.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,965.58
|
| Rate for Payer: Cash Price |
$1,069.80
|
| Rate for Payer: Cigna Commercial |
$3,411.95
|
| Rate for Payer: Health EOS Commercial |
$3,300.69
|
| Rate for Payer: HFN Commercial |
$3,411.95
|
| Rate for Payer: Multiplan Commercial |
$2,966.91
|
| Rate for Payer: Preferred Network Access Commercial |
$3,411.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,817.23
|
| Rate for Payer: Quartz Commercial |
$2,225.18
|
| Rate for Payer: WEA Trust Commercial |
$2,039.75
|
| Rate for Payer: WPS Commercial |
$2,746.89
|
|
|
Level I
|
Facility
|
OP
|
$3,566.00
|
|
| Hospital Charge Code |
3000366
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$3,411.95 |
| Rate for Payer: Aetna Commercial |
$3,337.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,189.43
|
| Rate for Payer: Aetna Managed Medicare |
$1,038.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,410.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,854.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,780.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,965.58
|
| Rate for Payer: Cash Price |
$1,069.80
|
| Rate for Payer: Cash Price |
$1,069.80
|
| Rate for Payer: Cigna Commercial |
$3,411.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,075.41
|
| Rate for Payer: Health EOS Commercial |
$3,300.69
|
| Rate for Payer: HFN Commercial |
$3,411.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,781.48
|
| Rate for Payer: Multiplan Commercial |
$2,966.91
|
| Rate for Payer: NAPHCARE Commercial |
$2,225.18
|
| Rate for Payer: Preferred Network Access Commercial |
$3,411.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,817.23
|
| Rate for Payer: Quartz Commercial |
$2,410.62
|
| Rate for Payer: Quartz Medicare Advantage |
$2,225.18
|
| Rate for Payer: The Alliance Commercial |
$1,854.32
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$2,039.75
|
| Rate for Payer: WPS Commercial |
$2,746.89
|
|
|
LEVEL I ADJUNCTIVE GENERAL DENTAL SERVICES
|
Facility
|
OP
|
$60.27
|
|
|
Service Code
|
EAPG 00350
|
| Min. Negotiated Rate |
$57.96 |
| Max. Negotiated Rate |
$60.27 |
| Rate for Payer: Anthem Medicaid |
$57.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$57.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.96
|
| Rate for Payer: Dean Health Medicaid |
$57.96
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$57.96
|
| Rate for Payer: Managed Health Services Medicaid |
$60.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$57.96
|
| Rate for Payer: United Healthcare Medicaid |
$57.96
|
|
