|
OBTURATOR FLEXIBLE AR-2275
|
Facility
|
IP
|
$2,383.00
|
|
| Hospital Charge Code |
5591320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,167.67 |
| Max. Negotiated Rate |
$2,192.36 |
| Rate for Payer: Aetna Commercial |
$2,144.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,049.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,262.99
|
| Rate for Payer: Cash Price |
$714.90
|
| Rate for Payer: Cigna Commercial |
$2,192.36
|
| Rate for Payer: Health EOS Commercial |
$2,120.87
|
| Rate for Payer: HFN Commercial |
$2,192.36
|
| Rate for Payer: Multiplan Commercial |
$1,906.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,429.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,192.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,167.67
|
| Rate for Payer: Quartz Commercial |
$1,429.80
|
| Rate for Payer: WEA Trust Commercial |
$1,310.65
|
| Rate for Payer: WPS Commercial |
$1,765.09
|
|
|
OB Ultrasound-Simple - Individual Charges
|
Facility
|
IP
|
$456.00
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
3003920
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$223.44 |
| Max. Negotiated Rate |
$419.52 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$273.60
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
OB Ultrasound-Simple - Individual Charges
|
Facility
|
OP
|
$456.00
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
3003920
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$255.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$296.40
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
OB Urine Protein
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
CPT 81099
|
| Hospital Charge Code |
5184711
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Aetna Managed Medicare |
$7.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.11
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.25
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$17.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.20
|
| Rate for Payer: The Alliance Commercial |
$108.00
|
| Rate for Payer: United Healthcare PPO |
$20.25
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
OB Urine Protein
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
CPT 81099
|
| Hospital Charge Code |
5184711
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.23 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
OB Urine Protein
|
Professional
|
Both
|
$27.00
|
|
|
Service Code
|
CPT 81099
|
| Hospital Charge Code |
5184711
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Aetna Commercial |
$25.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.20
|
| Rate for Payer: Health EOS Commercial |
$24.57
|
| Rate for Payer: HFN Commercial |
$25.65
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$25.65
|
| Rate for Payer: Quartz Beloit One Network |
$11.88
|
| Rate for Payer: Quartz Commercial |
$15.39
|
| Rate for Payer: The Alliance Commercial |
$13.50
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
OB US, Limited, Fetus (S) 7681526
|
Professional
|
Both
|
$168.00
|
|
|
Service Code
|
CPT 76815 26
|
| Hospital Charge Code |
4221354
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.92 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Aetna Commercial |
$159.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.48
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$159.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$84.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.80
|
| Rate for Payer: Health EOS Commercial |
$152.88
|
| Rate for Payer: HFN Commercial |
$159.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$109.36
|
| Rate for Payer: Multiplan Commercial |
$134.40
|
| Rate for Payer: Preferred Network Access Commercial |
$159.60
|
| Rate for Payer: Quartz Beloit One Network |
$73.92
|
| Rate for Payer: Quartz Commercial |
$95.76
|
| Rate for Payer: The Alliance Commercial |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$92.40
|
| Rate for Payer: WPS Commercial |
$124.44
|
|
|
Occ Bld Stl, Imm
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 82274
|
| Hospital Charge Code |
979904
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$71.54 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$87.60
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
Occ Bld Stl, Imm
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 82274
|
| Hospital Charge Code |
979904
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.92 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Aetna Managed Medicare |
$15.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.86
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.43
|
| Rate for Payer: Anthem Medicaid |
$16.45
|
| Rate for Payer: Anthem Medicare Advantage |
$15.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.92
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.70
|
| Rate for Payer: Dean Health Medicaid |
$16.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.92
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.92
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.92
|
| Rate for Payer: Managed Health Services Medicaid |
$17.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.92
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.92
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$23.88
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.45
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$94.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.92
|
| Rate for Payer: The Alliance Commercial |
$63.68
|
| Rate for Payer: United Healthcare Medicaid |
$16.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.92
|
| Rate for Payer: United Healthcare PPO |
$109.50
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: Wellcare Medicare |
$15.92
|
| Rate for Payer: WMAP Medicaid |
$16.45
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
Occ Bld Stl, Imm
|
Professional
|
Both
|
$146.00
|
|
|
Service Code
|
CPT 82274
|
| Hospital Charge Code |
979904
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Aetna Commercial |
$138.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$138.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.60
|
| Rate for Payer: Health EOS Commercial |
$132.86
|
| Rate for Payer: HFN Commercial |
$138.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.20
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: Preferred Network Access Commercial |
$138.70
|
| Rate for Payer: Quartz Beloit One Network |
$64.24
|
| Rate for Payer: Quartz Commercial |
$83.22
|
| Rate for Payer: The Alliance Commercial |
$73.00
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
OCUCOAT CC065S
|
Facility
|
IP
|
$532.00
|
|
| Hospital Charge Code |
5415290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$260.68 |
| Max. Negotiated Rate |
$489.44 |
| Rate for Payer: Aetna Commercial |
$478.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$457.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.96
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$489.44
|
| Rate for Payer: Health EOS Commercial |
$473.48
|
| Rate for Payer: HFN Commercial |
$489.44
|
| Rate for Payer: Multiplan Commercial |
$425.60
|
| Rate for Payer: NAPHCARE Commercial |
$319.20
|
| Rate for Payer: Preferred Network Access Commercial |
$489.44
|
| Rate for Payer: Quartz Beloit One Network |
$260.68
|
| Rate for Payer: Quartz Commercial |
$319.20
|
| Rate for Payer: WEA Trust Commercial |
$292.60
|
| Rate for Payer: WPS Commercial |
$394.05
|
|
|
OCUCOAT CC065S
|
Facility
|
OP
|
$532.00
|
|
| Hospital Charge Code |
5415290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$148.96 |
| Max. Negotiated Rate |
$2,128.00 |
| Rate for Payer: Aetna Commercial |
$478.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$457.52
|
| Rate for Payer: Aetna Managed Medicare |
$148.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$345.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$266.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.96
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$489.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$297.71
|
| Rate for Payer: Health EOS Commercial |
$473.48
|
| Rate for Payer: HFN Commercial |
$489.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$399.00
|
| Rate for Payer: Multiplan Commercial |
$425.60
|
| Rate for Payer: NAPHCARE Commercial |
$319.20
|
| Rate for Payer: Preferred Network Access Commercial |
$489.44
|
| Rate for Payer: Quartz Beloit One Network |
$260.68
|
| Rate for Payer: Quartz Commercial |
$345.80
|
| Rate for Payer: Quartz Medicare Advantage |
$319.20
|
| Rate for Payer: The Alliance Commercial |
$2,128.00
|
| Rate for Payer: WEA Trust Commercial |
$292.60
|
| Rate for Payer: WPS Commercial |
$394.05
|
|
|
OCULAR SECUREFLEX HF LENS OSIG
|
Facility
|
OP
|
$448.00
|
|
| Hospital Charge Code |
5459397
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$125.44 |
| Max. Negotiated Rate |
$1,792.00 |
| Rate for Payer: Aetna Commercial |
$403.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$385.28
|
| Rate for Payer: Aetna Managed Medicare |
$125.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$291.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$224.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$215.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.44
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cigna Commercial |
$412.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.70
|
| Rate for Payer: Health EOS Commercial |
$398.72
|
| Rate for Payer: HFN Commercial |
$412.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$336.00
|
| Rate for Payer: Multiplan Commercial |
$358.40
|
| Rate for Payer: NAPHCARE Commercial |
$268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$412.16
|
| Rate for Payer: Quartz Beloit One Network |
$219.52
|
| Rate for Payer: Quartz Commercial |
$291.20
|
| Rate for Payer: Quartz Medicare Advantage |
$268.80
|
| Rate for Payer: The Alliance Commercial |
$1,792.00
|
| Rate for Payer: WEA Trust Commercial |
$246.40
|
| Rate for Payer: WPS Commercial |
$331.83
|
|
|
OCULAR SECUREFLEX HF LENS OSIG
|
Facility
|
IP
|
$448.00
|
|
| Hospital Charge Code |
5459397
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$219.52 |
| Max. Negotiated Rate |
$412.16 |
| Rate for Payer: Aetna Commercial |
$403.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$385.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.44
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cigna Commercial |
$412.16
|
| Rate for Payer: Health EOS Commercial |
$398.72
|
| Rate for Payer: HFN Commercial |
$412.16
|
| Rate for Payer: Multiplan Commercial |
$358.40
|
| Rate for Payer: NAPHCARE Commercial |
$268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$412.16
|
| Rate for Payer: Quartz Beloit One Network |
$219.52
|
| Rate for Payer: Quartz Commercial |
$268.80
|
| Rate for Payer: WEA Trust Commercial |
$246.40
|
| Rate for Payer: WPS Commercial |
$331.83
|
|
|
Oculoelectromyography 1 or Both Eye 92265
|
Professional
|
Both
|
$286.00
|
|
|
Service Code
|
CPT 92265
|
| Hospital Charge Code |
5072635
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$76.96 |
| Max. Negotiated Rate |
$298.92 |
| Rate for Payer: Aetna Commercial |
$271.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$271.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.60
|
| Rate for Payer: Health EOS Commercial |
$260.26
|
| Rate for Payer: HFN Commercial |
$271.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$298.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$298.92
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: Preferred Network Access Commercial |
$271.70
|
| Rate for Payer: Quartz Beloit One Network |
$125.84
|
| Rate for Payer: Quartz Commercial |
$163.02
|
| Rate for Payer: The Alliance Commercial |
$143.00
|
| Rate for Payer: United Healthcare Medicaid |
$76.96
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
Oculoelectromyography 1 or Both Eye 9226526
|
Professional
|
Both
|
$286.00
|
|
|
Service Code
|
CPT 92265 26
|
| Hospital Charge Code |
5072666
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$76.96 |
| Max. Negotiated Rate |
$271.70 |
| Rate for Payer: Aetna Commercial |
$271.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$271.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.60
|
| Rate for Payer: Health EOS Commercial |
$260.26
|
| Rate for Payer: HFN Commercial |
$271.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$158.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$158.14
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: Preferred Network Access Commercial |
$271.70
|
| Rate for Payer: Quartz Beloit One Network |
$125.84
|
| Rate for Payer: Quartz Commercial |
$163.02
|
| Rate for Payer: The Alliance Commercial |
$143.00
|
| Rate for Payer: United Healthcare Medicaid |
$76.96
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
Office Consultation Level 1
|
Professional
|
Both
|
$216.00
|
|
|
Service Code
|
CPT 99241
|
| Hospital Charge Code |
1122834
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$95.04 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.76
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$205.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$108.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.60
|
| Rate for Payer: Health EOS Commercial |
$196.56
|
| Rate for Payer: HFN Commercial |
$205.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.51
|
| Rate for Payer: Multiplan Commercial |
$172.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.20
|
| Rate for Payer: Quartz Beloit One Network |
$95.04
|
| Rate for Payer: Quartz Commercial |
$123.12
|
| Rate for Payer: The Alliance Commercial |
$108.00
|
| Rate for Payer: WEA Trust Commercial |
$118.80
|
| Rate for Payer: WPS Commercial |
$159.99
|
|
|
Office Consultation Level 2
|
Professional
|
Both
|
$315.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
1122835
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.99 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Aetna Commercial |
$299.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$270.90
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna Commercial |
$299.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.00
|
| Rate for Payer: Health EOS Commercial |
$286.65
|
| Rate for Payer: HFN Commercial |
$299.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$228.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$228.25
|
| Rate for Payer: Multiplan Commercial |
$252.00
|
| Rate for Payer: Preferred Network Access Commercial |
$299.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.60
|
| Rate for Payer: Quartz Commercial |
$179.55
|
| Rate for Payer: The Alliance Commercial |
$157.50
|
| Rate for Payer: United Healthcare Medicaid |
$61.99
|
| Rate for Payer: WEA Trust Commercial |
$173.25
|
| Rate for Payer: WPS Commercial |
$233.32
|
|
|
Office Consultation Level 3
|
Professional
|
Both
|
$490.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
1122836
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$84.56 |
| Max. Negotiated Rate |
$465.50 |
| Rate for Payer: Aetna Commercial |
$465.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$421.40
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$465.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$84.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$294.00
|
| Rate for Payer: Health EOS Commercial |
$445.90
|
| Rate for Payer: HFN Commercial |
$465.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$319.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$319.43
|
| Rate for Payer: Multiplan Commercial |
$392.00
|
| Rate for Payer: Preferred Network Access Commercial |
$465.50
|
| Rate for Payer: Quartz Beloit One Network |
$215.60
|
| Rate for Payer: Quartz Commercial |
$279.30
|
| Rate for Payer: The Alliance Commercial |
$245.00
|
| Rate for Payer: United Healthcare Medicaid |
$84.56
|
| Rate for Payer: WEA Trust Commercial |
$269.50
|
| Rate for Payer: WPS Commercial |
$362.94
|
|
|
Office Consultation Level 4
|
Professional
|
Both
|
$685.00
|
|
|
Service Code
|
CPT 99244
|
| Hospital Charge Code |
1122837
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$109.24 |
| Max. Negotiated Rate |
$650.75 |
| Rate for Payer: Aetna Commercial |
$650.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$589.10
|
| Rate for Payer: Cash Price |
$205.50
|
| Rate for Payer: Cash Price |
$205.50
|
| Rate for Payer: Cash Price |
$205.50
|
| Rate for Payer: Cigna Commercial |
$650.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$109.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$411.00
|
| Rate for Payer: Health EOS Commercial |
$623.35
|
| Rate for Payer: HFN Commercial |
$650.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$513.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$513.37
|
| Rate for Payer: Multiplan Commercial |
$548.00
|
| Rate for Payer: Preferred Network Access Commercial |
$650.75
|
| Rate for Payer: Quartz Beloit One Network |
$301.40
|
| Rate for Payer: Quartz Commercial |
$390.45
|
| Rate for Payer: The Alliance Commercial |
$342.50
|
| Rate for Payer: United Healthcare Medicaid |
$109.24
|
| Rate for Payer: WEA Trust Commercial |
$376.75
|
| Rate for Payer: WPS Commercial |
$507.38
|
|
|
Office Consultation Level 5
|
Professional
|
Both
|
$857.00
|
|
|
Service Code
|
CPT 99245
|
| Hospital Charge Code |
1122838
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$142.42 |
| Max. Negotiated Rate |
$814.15 |
| Rate for Payer: Aetna Commercial |
$814.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$737.02
|
| Rate for Payer: Cash Price |
$257.10
|
| Rate for Payer: Cash Price |
$257.10
|
| Rate for Payer: Cash Price |
$257.10
|
| Rate for Payer: Cigna Commercial |
$814.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$142.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$514.20
|
| Rate for Payer: Health EOS Commercial |
$779.87
|
| Rate for Payer: HFN Commercial |
$814.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$635.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$635.44
|
| Rate for Payer: Multiplan Commercial |
$685.60
|
| Rate for Payer: Preferred Network Access Commercial |
$814.15
|
| Rate for Payer: Quartz Beloit One Network |
$377.08
|
| Rate for Payer: Quartz Commercial |
$488.49
|
| Rate for Payer: The Alliance Commercial |
$428.50
|
| Rate for Payer: United Healthcare Medicaid |
$142.42
|
| Rate for Payer: WEA Trust Commercial |
$471.35
|
| Rate for Payer: WPS Commercial |
$634.78
|
|
|
Office consultation new or est patient; criteria for Pre-employment physical
|
Professional
|
Both
|
$346.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
1122883
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.99 |
| Max. Negotiated Rate |
$328.70 |
| Rate for Payer: Aetna Commercial |
$328.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$297.56
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$328.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.60
|
| Rate for Payer: Health EOS Commercial |
$314.86
|
| Rate for Payer: HFN Commercial |
$328.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$228.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$228.25
|
| Rate for Payer: Multiplan Commercial |
$276.80
|
| Rate for Payer: Preferred Network Access Commercial |
$328.70
|
| Rate for Payer: Quartz Beloit One Network |
$152.24
|
| Rate for Payer: Quartz Commercial |
$197.22
|
| Rate for Payer: The Alliance Commercial |
$173.00
|
| Rate for Payer: United Healthcare Medicaid |
$61.99
|
| Rate for Payer: WEA Trust Commercial |
$190.30
|
| Rate for Payer: WPS Commercial |
$256.28
|
|
|
Office Or Home Visit 1st Hour
|
Professional
|
Both
|
$465.00
|
|
|
Service Code
|
CPT 99354
|
| Hospital Charge Code |
1122864
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$204.60 |
| Max. Negotiated Rate |
$441.75 |
| Rate for Payer: Aetna Commercial |
$441.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$399.90
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$441.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$232.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$279.00
|
| Rate for Payer: Health EOS Commercial |
$423.15
|
| Rate for Payer: HFN Commercial |
$441.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$406.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$406.16
|
| Rate for Payer: Multiplan Commercial |
$372.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.75
|
| Rate for Payer: Quartz Beloit One Network |
$204.60
|
| Rate for Payer: Quartz Commercial |
$265.05
|
| Rate for Payer: The Alliance Commercial |
$232.50
|
| Rate for Payer: WEA Trust Commercial |
$255.75
|
| Rate for Payer: WPS Commercial |
$344.43
|
|
|
Office/OutPatient Visit, Est 99211
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3705546
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$69.09 |
| Max. Negotiated Rate |
$129.72 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$121.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.73
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$129.72
|
| Rate for Payer: Health EOS Commercial |
$125.49
|
| Rate for Payer: HFN Commercial |
$129.72
|
| Rate for Payer: Multiplan Commercial |
$112.80
|
| Rate for Payer: NAPHCARE Commercial |
$84.60
|
| Rate for Payer: Preferred Network Access Commercial |
$129.72
|
| Rate for Payer: Quartz Beloit One Network |
$69.09
|
| Rate for Payer: Quartz Commercial |
$84.60
|
| Rate for Payer: WEA Trust Commercial |
$77.55
|
| Rate for Payer: WPS Commercial |
$104.44
|
|
|
Office/OutPatient Visit, Est 99211
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3705546
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$39.48 |
| Max. Negotiated Rate |
$564.00 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$121.26
|
| Rate for Payer: Aetna Managed Medicare |
$39.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$91.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$70.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$67.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.73
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$129.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.90
|
| Rate for Payer: Health EOS Commercial |
$125.49
|
| Rate for Payer: HFN Commercial |
$129.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.75
|
| Rate for Payer: Multiplan Commercial |
$112.80
|
| Rate for Payer: NAPHCARE Commercial |
$84.60
|
| Rate for Payer: Preferred Network Access Commercial |
$129.72
|
| Rate for Payer: Quartz Beloit One Network |
$69.09
|
| Rate for Payer: Quartz Commercial |
$91.65
|
| Rate for Payer: Quartz Medicare Advantage |
$84.60
|
| Rate for Payer: The Alliance Commercial |
$564.00
|
| Rate for Payer: WEA Trust Commercial |
$77.55
|
| Rate for Payer: WPS Commercial |
$104.44
|
|
