|
Office/OutPatient Visit, Est 99211DSC
|
Professional
|
Both
|
$27.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3301471
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$30.64 |
| 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: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.25
|
| 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: Humana Commercial/EPO/HMO/POS/PPO |
$30.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.64
|
| 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: United Healthcare Medicaid |
$16.25
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
Office/OutPatient Visit, Est 99212DSC
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3301473
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.04 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$62.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.76
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$62.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.60
|
| Rate for Payer: Health EOS Commercial |
$60.06
|
| Rate for Payer: HFN Commercial |
$62.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$121.68
|
| Rate for Payer: Multiplan Commercial |
$52.80
|
| Rate for Payer: Preferred Network Access Commercial |
$62.70
|
| Rate for Payer: Quartz Beloit One Network |
$29.04
|
| Rate for Payer: Quartz Commercial |
$37.62
|
| Rate for Payer: The Alliance Commercial |
$33.00
|
| Rate for Payer: United Healthcare Medicaid |
$37.79
|
| Rate for Payer: WEA Trust Commercial |
$36.30
|
| Rate for Payer: WPS Commercial |
$48.89
|
|
|
Office/OutPatient Visit, Est 99213DSC
|
Professional
|
Both
|
$119.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3301475
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.36 |
| Max. Negotiated Rate |
$227.58 |
| Rate for Payer: Aetna Commercial |
$113.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$113.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.40
|
| Rate for Payer: Health EOS Commercial |
$108.29
|
| Rate for Payer: HFN Commercial |
$113.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.58
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: Preferred Network Access Commercial |
$113.05
|
| Rate for Payer: Quartz Beloit One Network |
$52.36
|
| Rate for Payer: Quartz Commercial |
$67.83
|
| Rate for Payer: The Alliance Commercial |
$59.50
|
| Rate for Payer: United Healthcare Medicaid |
$60.42
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: WPS Commercial |
$88.14
|
|
|
Office/OutPatient Visit, Est 99214DSC
|
Professional
|
Both
|
$216.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
3301477
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.58 |
| Max. Negotiated Rate |
$336.73 |
| 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: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$205.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$85.58
|
| 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 |
$336.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$336.73
|
| 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: United Healthcare Medicaid |
$85.58
|
| Rate for Payer: WEA Trust Commercial |
$118.80
|
| Rate for Payer: WPS Commercial |
$159.99
|
|
|
Office/OutPatient Visit, Est 99215DSC
|
Professional
|
Both
|
$332.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
3301479
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$119.97 |
| Max. Negotiated Rate |
$495.26 |
| Rate for Payer: Aetna Commercial |
$315.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$285.52
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$315.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$119.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.20
|
| Rate for Payer: Health EOS Commercial |
$302.12
|
| Rate for Payer: HFN Commercial |
$315.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$495.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$495.26
|
| Rate for Payer: Multiplan Commercial |
$265.60
|
| Rate for Payer: Preferred Network Access Commercial |
$315.40
|
| Rate for Payer: Quartz Beloit One Network |
$146.08
|
| Rate for Payer: Quartz Commercial |
$189.24
|
| Rate for Payer: The Alliance Commercial |
$166.00
|
| Rate for Payer: United Healthcare Medicaid |
$119.97
|
| Rate for Payer: WEA Trust Commercial |
$182.60
|
| Rate for Payer: WPS Commercial |
$245.91
|
|
|
Office/OutPatient Visit, Established 99211DSH
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
5500672
|
|
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, Established 99211DSH
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
5500672
|
|
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
|
|
|
Office/Outpatient Visit Level 1 Established
|
Professional
|
Both
|
$14.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
1122814
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$30.64 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12.04
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.40
|
| Rate for Payer: Health EOS Commercial |
$12.74
|
| Rate for Payer: HFN Commercial |
$13.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.64
|
| Rate for Payer: Multiplan Commercial |
$11.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13.30
|
| Rate for Payer: Quartz Beloit One Network |
$6.16
|
| Rate for Payer: Quartz Commercial |
$7.98
|
| Rate for Payer: The Alliance Commercial |
$7.00
|
| Rate for Payer: United Healthcare Medicaid |
$16.25
|
| Rate for Payer: WEA Trust Commercial |
$7.70
|
| Rate for Payer: WPS Commercial |
$10.37
|
|
|
Office/OutPatient Visit Level 1 Est O2 Eval RT
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
4125577
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$59.29 |
| Max. Negotiated Rate |
$111.32 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$72.60
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$72.60
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$89.62
|
|
|
Office/OutPatient Visit Level 1 Est O2 Eval RT
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
4125577
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$33.88 |
| Max. Negotiated Rate |
$484.00 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Aetna Managed Medicare |
$33.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.71
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.75
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$72.60
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$78.65
|
| Rate for Payer: Quartz Medicare Advantage |
$72.60
|
| Rate for Payer: The Alliance Commercial |
$484.00
|
| Rate for Payer: United Healthcare PPO |
$90.75
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$89.62
|
|
|
Office/Outpatient Visit Level 2 Established
|
Professional
|
Both
|
$51.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
1122815
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.60
|
| Rate for Payer: Health EOS Commercial |
$46.41
|
| Rate for Payer: HFN Commercial |
$48.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$121.68
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.45
|
| Rate for Payer: Quartz Beloit One Network |
$22.44
|
| Rate for Payer: Quartz Commercial |
$29.07
|
| Rate for Payer: The Alliance Commercial |
$25.50
|
| Rate for Payer: United Healthcare Medicaid |
$37.79
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
Office/Outpatient Visit Level 2 Established 95199-99212
|
Professional
|
Both
|
$59.00
|
|
|
Service Code
|
CPT 95199
|
| Hospital Charge Code |
5322740
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.96 |
| Max. Negotiated Rate |
$56.05 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$53.69
|
| Rate for Payer: HFN Commercial |
$56.05
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: Preferred Network Access Commercial |
$56.05
|
| Rate for Payer: Quartz Beloit One Network |
$25.96
|
| Rate for Payer: Quartz Commercial |
$33.63
|
| Rate for Payer: The Alliance Commercial |
$29.50
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
Office/Outpatient Visit Level 2 New
|
Professional
|
Both
|
$129.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
1122810
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.35 |
| Max. Negotiated Rate |
$165.42 |
| Rate for Payer: Aetna Commercial |
$122.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$122.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.40
|
| Rate for Payer: Health EOS Commercial |
$117.39
|
| Rate for Payer: HFN Commercial |
$122.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$165.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$165.42
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$122.55
|
| Rate for Payer: Quartz Beloit One Network |
$56.76
|
| Rate for Payer: Quartz Commercial |
$73.53
|
| Rate for Payer: The Alliance Commercial |
$64.50
|
| Rate for Payer: United Healthcare Medicaid |
$49.35
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
Office/Outpatient Visit Level 3 Established
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
1122816
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$227.58 |
| Rate for Payer: Aetna Commercial |
$118.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$118.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.00
|
| Rate for Payer: Health EOS Commercial |
$113.75
|
| Rate for Payer: HFN Commercial |
$118.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.58
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: Preferred Network Access Commercial |
$118.75
|
| Rate for Payer: Quartz Beloit One Network |
$55.00
|
| Rate for Payer: Quartz Commercial |
$71.25
|
| Rate for Payer: The Alliance Commercial |
$62.50
|
| Rate for Payer: United Healthcare Medicaid |
$60.42
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
Office/Outpatient Visit Level 3 Established 99213SM
|
Professional
|
Both
|
$139.00
|
|
| Hospital Charge Code |
4596872
|
| Min. Negotiated Rate |
$61.16 |
| Max. Negotiated Rate |
$132.05 |
| Rate for Payer: Aetna Commercial |
$132.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$132.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.40
|
| Rate for Payer: Health EOS Commercial |
$126.49
|
| Rate for Payer: HFN Commercial |
$132.05
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: Preferred Network Access Commercial |
$132.05
|
| Rate for Payer: Quartz Beloit One Network |
$61.16
|
| Rate for Payer: Quartz Commercial |
$79.23
|
| Rate for Payer: The Alliance Commercial |
$69.50
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
Office/Outpatient Visit Level 3 New
|
Professional
|
Both
|
$154.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
1122811
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.76 |
| Max. Negotiated Rate |
$280.28 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.44
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$146.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.40
|
| Rate for Payer: Health EOS Commercial |
$140.14
|
| Rate for Payer: HFN Commercial |
$146.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$280.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$280.28
|
| Rate for Payer: Multiplan Commercial |
$123.20
|
| Rate for Payer: Preferred Network Access Commercial |
$146.30
|
| Rate for Payer: Quartz Beloit One Network |
$67.76
|
| Rate for Payer: Quartz Commercial |
$87.78
|
| Rate for Payer: The Alliance Commercial |
$77.00
|
| Rate for Payer: United Healthcare Medicaid |
$74.38
|
| Rate for Payer: WEA Trust Commercial |
$84.70
|
| Rate for Payer: WPS Commercial |
$114.07
|
|
|
Office/Outpatient Visit Level 4 Established
|
Professional
|
Both
|
$178.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
1122817
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$78.32 |
| Max. Negotiated Rate |
$336.73 |
| Rate for Payer: Aetna Commercial |
$169.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$169.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$85.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$106.80
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$169.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$336.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$336.73
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.10
|
| Rate for Payer: Quartz Beloit One Network |
$78.32
|
| Rate for Payer: Quartz Commercial |
$101.46
|
| Rate for Payer: The Alliance Commercial |
$89.00
|
| Rate for Payer: United Healthcare Medicaid |
$85.58
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
Office/Outpatient Visit Level 4 Established 99214SM
|
Professional
|
Both
|
$266.00
|
|
| Hospital Charge Code |
4596873
|
| Min. Negotiated Rate |
$117.04 |
| Max. Negotiated Rate |
$252.70 |
| Rate for Payer: Aetna Commercial |
$252.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.76
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$252.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$133.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.60
|
| Rate for Payer: Health EOS Commercial |
$242.06
|
| Rate for Payer: HFN Commercial |
$252.70
|
| Rate for Payer: Multiplan Commercial |
$212.80
|
| Rate for Payer: Preferred Network Access Commercial |
$252.70
|
| Rate for Payer: Quartz Beloit One Network |
$117.04
|
| Rate for Payer: Quartz Commercial |
$151.62
|
| Rate for Payer: The Alliance Commercial |
$133.00
|
| Rate for Payer: WEA Trust Commercial |
$146.30
|
| Rate for Payer: WPS Commercial |
$197.03
|
|
|
Office/Outpatient Visit Level 4 New
|
Professional
|
Both
|
$182.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
1122812
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$80.08 |
| Max. Negotiated Rate |
$457.42 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$110.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.20
|
| Rate for Payer: Health EOS Commercial |
$165.62
|
| Rate for Payer: HFN Commercial |
$172.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$457.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$457.42
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: Preferred Network Access Commercial |
$172.90
|
| Rate for Payer: Quartz Beloit One Network |
$80.08
|
| Rate for Payer: Quartz Commercial |
$103.74
|
| Rate for Payer: The Alliance Commercial |
$91.00
|
| Rate for Payer: United Healthcare Medicaid |
$110.94
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.81
|
|
|
Office/Outpatient Visit Level 5 Established
|
Professional
|
Both
|
$496.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
1122818
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$119.97 |
| Max. Negotiated Rate |
$495.26 |
| Rate for Payer: Aetna Commercial |
$471.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.56
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$471.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$119.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$297.60
|
| Rate for Payer: Health EOS Commercial |
$451.36
|
| Rate for Payer: HFN Commercial |
$471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$495.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$495.26
|
| Rate for Payer: Multiplan Commercial |
$396.80
|
| Rate for Payer: Preferred Network Access Commercial |
$471.20
|
| Rate for Payer: Quartz Beloit One Network |
$218.24
|
| Rate for Payer: Quartz Commercial |
$282.72
|
| Rate for Payer: The Alliance Commercial |
$248.00
|
| Rate for Payer: United Healthcare Medicaid |
$119.97
|
| Rate for Payer: WEA Trust Commercial |
$272.80
|
| Rate for Payer: WPS Commercial |
$367.39
|
|
|
Office/Outpatient Visit Level 5 Established 99215SM
|
Professional
|
Both
|
$512.00
|
|
| Hospital Charge Code |
4596874
|
| Min. Negotiated Rate |
$225.28 |
| Max. Negotiated Rate |
$486.40 |
| Rate for Payer: Aetna Commercial |
$486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$440.32
|
| Rate for Payer: Cash Price |
$153.60
|
| Rate for Payer: Cigna Commercial |
$486.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$256.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$307.20
|
| Rate for Payer: Health EOS Commercial |
$465.92
|
| Rate for Payer: HFN Commercial |
$486.40
|
| Rate for Payer: Multiplan Commercial |
$409.60
|
| Rate for Payer: Preferred Network Access Commercial |
$486.40
|
| Rate for Payer: Quartz Beloit One Network |
$225.28
|
| Rate for Payer: Quartz Commercial |
$291.84
|
| Rate for Payer: The Alliance Commercial |
$256.00
|
| Rate for Payer: WEA Trust Commercial |
$281.60
|
| Rate for Payer: WPS Commercial |
$379.24
|
|
|
Office/Outpatient Visit Level 5 New
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
1122813
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$146.41 |
| Max. Negotiated Rate |
$621.10 |
| Rate for Payer: Aetna Commercial |
$522.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$473.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna Commercial |
$522.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$146.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$330.00
|
| Rate for Payer: Health EOS Commercial |
$500.50
|
| Rate for Payer: HFN Commercial |
$522.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$621.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$621.10
|
| Rate for Payer: Multiplan Commercial |
$440.00
|
| Rate for Payer: Preferred Network Access Commercial |
$522.50
|
| Rate for Payer: Quartz Beloit One Network |
$242.00
|
| Rate for Payer: Quartz Commercial |
$313.50
|
| Rate for Payer: The Alliance Commercial |
$275.00
|
| Rate for Payer: United Healthcare Medicaid |
$146.41
|
| Rate for Payer: WEA Trust Commercial |
$302.50
|
| Rate for Payer: WPS Commercial |
$407.38
|
|
|
Office/Outpatient Visit Level New 99205HS
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
5510885
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$146.41 |
| Max. Negotiated Rate |
$621.10 |
| Rate for Payer: Aetna Commercial |
$522.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$473.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna Commercial |
$522.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$146.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$330.00
|
| Rate for Payer: Health EOS Commercial |
$500.50
|
| Rate for Payer: HFN Commercial |
$522.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$621.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$621.10
|
| Rate for Payer: Multiplan Commercial |
$440.00
|
| Rate for Payer: Preferred Network Access Commercial |
$522.50
|
| Rate for Payer: Quartz Beloit One Network |
$242.00
|
| Rate for Payer: Quartz Commercial |
$313.50
|
| Rate for Payer: The Alliance Commercial |
$275.00
|
| Rate for Payer: United Healthcare Medicaid |
$146.41
|
| Rate for Payer: WEA Trust Commercial |
$302.50
|
| Rate for Payer: WPS Commercial |
$407.38
|
|
|
Office/OutPatient Visit, New 99202DSC
|
Professional
|
Both
|
$128.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
3301483
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.35 |
| Max. Negotiated Rate |
$165.42 |
| Rate for Payer: Aetna Commercial |
$121.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$121.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.80
|
| Rate for Payer: Health EOS Commercial |
$116.48
|
| Rate for Payer: HFN Commercial |
$121.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$165.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$165.42
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: Preferred Network Access Commercial |
$121.60
|
| Rate for Payer: Quartz Beloit One Network |
$56.32
|
| Rate for Payer: Quartz Commercial |
$72.96
|
| Rate for Payer: The Alliance Commercial |
$64.00
|
| Rate for Payer: United Healthcare Medicaid |
$49.35
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Office/OutPatient Visit, New 99203DSC
|
Professional
|
Both
|
$165.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
3301485
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.60 |
| Max. Negotiated Rate |
$280.28 |
| Rate for Payer: Aetna Commercial |
$156.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.90
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$156.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$99.00
|
| Rate for Payer: Health EOS Commercial |
$150.15
|
| Rate for Payer: HFN Commercial |
$156.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$280.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$280.28
|
| Rate for Payer: Multiplan Commercial |
$132.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.75
|
| Rate for Payer: Quartz Beloit One Network |
$72.60
|
| Rate for Payer: Quartz Commercial |
$94.05
|
| Rate for Payer: The Alliance Commercial |
$82.50
|
| Rate for Payer: United Healthcare Medicaid |
$74.38
|
| Rate for Payer: WEA Trust Commercial |
$90.75
|
| Rate for Payer: WPS Commercial |
$122.22
|
|
