|
Ophthalmic Biometry 9213626
|
Professional
|
Both
|
$177.00
|
|
|
Service Code
|
CPT 92136 26
|
| Hospital Charge Code |
3137577
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.57 |
| Max. Negotiated Rate |
$174.88 |
| Rate for Payer: Aetna Commercial |
$174.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.31
|
| Rate for Payer: Aetna Managed Medicare |
$30.49
|
| Rate for Payer: Anthem Medicare Advantage |
$30.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.49
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$174.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.49
|
| Rate for Payer: Health EOS Commercial |
$167.51
|
| Rate for Payer: HFN Commercial |
$174.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$109.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.49
|
| Rate for Payer: Multiplan Commercial |
$147.26
|
| Rate for Payer: NAPHCARE Commercial |
$45.74
|
| Rate for Payer: Preferred Network Access Commercial |
$174.88
|
| Rate for Payer: Quartz Beloit One Network |
$81.00
|
| Rate for Payer: Quartz Commercial |
$104.93
|
| Rate for Payer: Quartz Medicare Advantage |
$30.49
|
| Rate for Payer: The Alliance Commercial |
$76.23
|
| Rate for Payer: United Healthcare Medicaid |
$28.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.49
|
| Rate for Payer: WEA Trust Commercial |
$101.24
|
| Rate for Payer: WPS Commercial |
$121.97
|
|
|
Ophthalmic Biometry, BILAT 9213650
|
Professional
|
Both
|
$353.00
|
|
|
Service Code
|
CPT 92136 50
|
| Hospital Charge Code |
6170142
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$77.17 |
| Max. Negotiated Rate |
$348.76 |
| Rate for Payer: Aetna Commercial |
$348.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$315.72
|
| Rate for Payer: Cash Price |
$105.90
|
| Rate for Payer: Cash Price |
$105.90
|
| Rate for Payer: Cash Price |
$105.90
|
| Rate for Payer: Cigna Commercial |
$348.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$77.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$220.27
|
| Rate for Payer: Health EOS Commercial |
$334.08
|
| Rate for Payer: HFN Commercial |
$348.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$194.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$194.21
|
| Rate for Payer: Multiplan Commercial |
$293.70
|
| Rate for Payer: Preferred Network Access Commercial |
$348.76
|
| Rate for Payer: Quartz Beloit One Network |
$161.53
|
| Rate for Payer: Quartz Commercial |
$209.26
|
| Rate for Payer: The Alliance Commercial |
$183.56
|
| Rate for Payer: United Healthcare Medicaid |
$77.17
|
| Rate for Payer: WEA Trust Commercial |
$201.92
|
| Rate for Payer: WPS Commercial |
$271.92
|
|
|
OPHTHALMIC BURR REUSABLE 8550850
|
Facility
|
OP
|
$200.00
|
|
| Hospital Charge Code |
2969656
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.24 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Aetna Managed Medicare |
$58.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$135.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$99.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$135.20
|
| Rate for Payer: Quartz Medicare Advantage |
$124.80
|
| Rate for Payer: The Alliance Commercial |
$104.00
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
OPHTHALMIC BURR REUSABLE 8550850
|
Facility
|
IP
|
$200.00
|
|
| Hospital Charge Code |
2969656
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
OPHTHALMIC US DX B-SCAN&QUAN A-SCAN SM PT ENCTR 76510
|
Professional
|
Both
|
$507.00
|
|
|
Service Code
|
CPT 76510
|
| Hospital Charge Code |
6187063
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$69.10 |
| Max. Negotiated Rate |
$500.92 |
| Rate for Payer: Aetna Commercial |
$500.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$453.46
|
| Rate for Payer: Aetna Managed Medicare |
$69.10
|
| Rate for Payer: Anthem Medicare Advantage |
$69.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.10
|
| Rate for Payer: Cash Price |
$152.10
|
| Rate for Payer: Cash Price |
$152.10
|
| Rate for Payer: Cash Price |
$152.10
|
| Rate for Payer: Cigna Commercial |
$500.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$263.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.10
|
| Rate for Payer: Health EOS Commercial |
$479.82
|
| Rate for Payer: HFN Commercial |
$500.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$260.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.10
|
| Rate for Payer: Multiplan Commercial |
$421.82
|
| Rate for Payer: NAPHCARE Commercial |
$103.65
|
| Rate for Payer: Preferred Network Access Commercial |
$500.92
|
| Rate for Payer: Quartz Beloit One Network |
$232.00
|
| Rate for Payer: Quartz Commercial |
$300.55
|
| Rate for Payer: Quartz Medicare Advantage |
$69.10
|
| Rate for Payer: The Alliance Commercial |
$262.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.10
|
| Rate for Payer: WEA Trust Commercial |
$290.00
|
| Rate for Payer: WPS Commercial |
$345.49
|
|
|
OPHTHALMIC US DX B-SCAN&QUAN A-SCAN SM PT ENCTR 7651026
|
Professional
|
Both
|
$507.00
|
|
|
Service Code
|
CPT 76510 26
|
| Hospital Charge Code |
6187064
|
|
Hospital Revenue Code
|
511
|
| Min. Negotiated Rate |
$39.03 |
| Max. Negotiated Rate |
$500.92 |
| Rate for Payer: Aetna Commercial |
$500.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$453.46
|
| Rate for Payer: Aetna Managed Medicare |
$39.03
|
| Rate for Payer: Anthem Medicare Advantage |
$39.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.03
|
| Rate for Payer: Cash Price |
$152.10
|
| Rate for Payer: Cash Price |
$152.10
|
| Rate for Payer: Cash Price |
$152.10
|
| Rate for Payer: Cigna Commercial |
$500.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$263.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.03
|
| Rate for Payer: Health EOS Commercial |
$479.82
|
| Rate for Payer: HFN Commercial |
$500.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$141.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.03
|
| Rate for Payer: Multiplan Commercial |
$421.82
|
| Rate for Payer: NAPHCARE Commercial |
$58.55
|
| Rate for Payer: Preferred Network Access Commercial |
$500.92
|
| Rate for Payer: Quartz Beloit One Network |
$232.00
|
| Rate for Payer: Quartz Commercial |
$300.55
|
| Rate for Payer: Quartz Medicare Advantage |
$39.03
|
| Rate for Payer: The Alliance Commercial |
$148.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.03
|
| Rate for Payer: WEA Trust Commercial |
$290.00
|
| Rate for Payer: WPS Commercial |
$195.16
|
|
|
OPHTHALMIC US DX B-SCAN&QUAN A-SCAN SM PT ENCTR, BILAT 7651050
|
Professional
|
Both
|
$1,014.00
|
|
|
Service Code
|
CPT 76510
|
| Hospital Charge Code |
6220020
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$69.10 |
| Max. Negotiated Rate |
$1,001.83 |
| Rate for Payer: Aetna Commercial |
$1,001.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$906.92
|
| Rate for Payer: Aetna Managed Medicare |
$69.10
|
| Rate for Payer: Anthem Medicare Advantage |
$69.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.10
|
| Rate for Payer: Cash Price |
$304.20
|
| Rate for Payer: Cash Price |
$304.20
|
| Rate for Payer: Cash Price |
$304.20
|
| Rate for Payer: Cigna Commercial |
$1,001.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$527.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.10
|
| Rate for Payer: Health EOS Commercial |
$959.65
|
| Rate for Payer: HFN Commercial |
$1,001.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$260.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.10
|
| Rate for Payer: Multiplan Commercial |
$843.65
|
| Rate for Payer: NAPHCARE Commercial |
$103.65
|
| Rate for Payer: Preferred Network Access Commercial |
$1,001.83
|
| Rate for Payer: Quartz Beloit One Network |
$464.01
|
| Rate for Payer: Quartz Commercial |
$601.10
|
| Rate for Payer: Quartz Medicare Advantage |
$69.10
|
| Rate for Payer: The Alliance Commercial |
$262.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.10
|
| Rate for Payer: WEA Trust Commercial |
$580.01
|
| Rate for Payer: WPS Commercial |
$345.49
|
|
|
Ophthalmological Services: Established Patient
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
CPT 92012
|
| Hospital Charge Code |
1122926
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.19 |
| Max. Negotiated Rate |
$182.12 |
| Rate for Payer: Aetna Commercial |
$85.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Aetna Managed Medicare |
$41.93
|
| Rate for Payer: Anthem Medicare Advantage |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.93
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$85.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.93
|
| Rate for Payer: Health EOS Commercial |
$82.34
|
| Rate for Payer: HFN Commercial |
$85.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$182.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.93
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: NAPHCARE Commercial |
$62.90
|
| Rate for Payer: Preferred Network Access Commercial |
$85.96
|
| Rate for Payer: Quartz Beloit One Network |
$39.81
|
| Rate for Payer: Quartz Commercial |
$51.57
|
| Rate for Payer: Quartz Medicare Advantage |
$41.93
|
| Rate for Payer: The Alliance Commercial |
$104.83
|
| Rate for Payer: United Healthcare Medicaid |
$31.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.93
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$167.73
|
|
|
Ophthalmological Services: Established Patient Comprehensive
|
Professional
|
Both
|
$189.00
|
|
|
Service Code
|
CPT 92014
|
| Hospital Charge Code |
1122927
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$46.32 |
| Max. Negotiated Rate |
$275.53 |
| Rate for Payer: Aetna Commercial |
$186.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Aetna Managed Medicare |
$63.07
|
| Rate for Payer: Anthem Medicare Advantage |
$63.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$63.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$63.07
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$186.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.07
|
| Rate for Payer: Health EOS Commercial |
$178.87
|
| Rate for Payer: HFN Commercial |
$186.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$275.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$275.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$63.07
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: NAPHCARE Commercial |
$94.60
|
| Rate for Payer: Preferred Network Access Commercial |
$186.73
|
| Rate for Payer: Quartz Beloit One Network |
$86.49
|
| Rate for Payer: Quartz Commercial |
$112.04
|
| Rate for Payer: Quartz Medicare Advantage |
$63.07
|
| Rate for Payer: The Alliance Commercial |
$157.66
|
| Rate for Payer: United Healthcare Medicaid |
$46.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$63.07
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: WPS Commercial |
$252.26
|
|
|
Ophthalmological Services: New Patient
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 92002
|
| Hospital Charge Code |
1122924
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$38.44 |
| Max. Negotiated Rate |
$167.34 |
| Rate for Payer: Aetna Commercial |
$118.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$38.44
|
| Rate for Payer: Anthem Medicare Advantage |
$38.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$38.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$38.44
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$118.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.44
|
| Rate for Payer: Health EOS Commercial |
$113.57
|
| Rate for Payer: HFN Commercial |
$118.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$167.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$167.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$38.44
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$57.66
|
| Rate for Payer: Preferred Network Access Commercial |
$118.56
|
| Rate for Payer: Quartz Beloit One Network |
$54.91
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: Quartz Medicare Advantage |
$38.44
|
| Rate for Payer: The Alliance Commercial |
$96.10
|
| Rate for Payer: United Healthcare Medicaid |
$38.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.44
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$153.75
|
|
|
Ophthalmological Services: New Patient Comprehensive
|
Professional
|
Both
|
$218.00
|
|
|
Service Code
|
CPT 92004
|
| Hospital Charge Code |
1122925
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$46.10 |
| Max. Negotiated Rate |
$343.63 |
| Rate for Payer: Aetna Commercial |
$215.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$194.98
|
| Rate for Payer: Aetna Managed Medicare |
$79.29
|
| Rate for Payer: Anthem Medicare Advantage |
$79.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$79.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$79.29
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$215.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79.29
|
| Rate for Payer: Health EOS Commercial |
$206.32
|
| Rate for Payer: HFN Commercial |
$215.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$343.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$343.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$79.29
|
| Rate for Payer: Multiplan Commercial |
$181.38
|
| Rate for Payer: NAPHCARE Commercial |
$118.93
|
| Rate for Payer: Preferred Network Access Commercial |
$215.38
|
| Rate for Payer: Quartz Beloit One Network |
$99.76
|
| Rate for Payer: Quartz Commercial |
$129.23
|
| Rate for Payer: Quartz Medicare Advantage |
$79.29
|
| Rate for Payer: The Alliance Commercial |
$198.22
|
| Rate for Payer: United Healthcare Medicaid |
$46.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$79.29
|
| Rate for Payer: WEA Trust Commercial |
$124.70
|
| Rate for Payer: WPS Commercial |
$317.16
|
|
|
OPHTHALMOLOGICAL TESTS AND PROCEDURES
|
Facility
|
OP
|
$140.20
|
|
|
Service Code
|
EAPG 00230
|
| Min. Negotiated Rate |
$134.81 |
| Max. Negotiated Rate |
$140.20 |
| Rate for Payer: Anthem Medicaid |
$134.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$134.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$134.81
|
| Rate for Payer: Dean Health Medicaid |
$134.81
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$134.81
|
| Rate for Payer: Managed Health Services Medicaid |
$140.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$134.81
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$134.81
|
| Rate for Payer: United Healthcare Medicaid |
$134.81
|
|
|
OPHTHSCPY EXTND OPTC NRV/MACULA I&R UNI/BI 92202
|
Professional
|
Both
|
$227.00
|
|
|
Service Code
|
CPT 92202
|
| Hospital Charge Code |
5561336
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.78 |
| Max. Negotiated Rate |
$224.28 |
| Rate for Payer: Aetna Commercial |
$224.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.03
|
| Rate for Payer: Aetna Managed Medicare |
$11.78
|
| Rate for Payer: Anthem Medicare Advantage |
$11.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.78
|
| Rate for Payer: Cash Price |
$68.10
|
| Rate for Payer: Cash Price |
$68.10
|
| Rate for Payer: Cash Price |
$68.10
|
| Rate for Payer: Cigna Commercial |
$224.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.78
|
| Rate for Payer: Health EOS Commercial |
$214.83
|
| Rate for Payer: HFN Commercial |
$224.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.78
|
| Rate for Payer: Multiplan Commercial |
$188.86
|
| Rate for Payer: NAPHCARE Commercial |
$17.67
|
| Rate for Payer: Preferred Network Access Commercial |
$224.28
|
| Rate for Payer: Quartz Beloit One Network |
$103.88
|
| Rate for Payer: Quartz Commercial |
$134.57
|
| Rate for Payer: Quartz Medicare Advantage |
$11.78
|
| Rate for Payer: The Alliance Commercial |
$29.46
|
| Rate for Payer: United Healthcare Medicaid |
$12.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.78
|
| Rate for Payer: WEA Trust Commercial |
$129.84
|
| Rate for Payer: WPS Commercial |
$47.13
|
|
|
OPHTHSCPY EXTND RTA DRAW & SCL DEPRESN I&R UNI/BI 92201
|
Professional
|
Both
|
$157.00
|
|
|
Service Code
|
CPT 92201
|
| Hospital Charge Code |
5561335
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$18.42 |
| Max. Negotiated Rate |
$155.12 |
| Rate for Payer: Aetna Commercial |
$155.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.42
|
| Rate for Payer: Aetna Managed Medicare |
$18.42
|
| Rate for Payer: Anthem Medicare Advantage |
$18.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.42
|
| Rate for Payer: Cash Price |
$47.10
|
| Rate for Payer: Cash Price |
$47.10
|
| Rate for Payer: Cash Price |
$47.10
|
| Rate for Payer: Cigna Commercial |
$155.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.42
|
| Rate for Payer: Health EOS Commercial |
$148.58
|
| Rate for Payer: HFN Commercial |
$155.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.42
|
| Rate for Payer: Multiplan Commercial |
$130.62
|
| Rate for Payer: NAPHCARE Commercial |
$27.63
|
| Rate for Payer: Preferred Network Access Commercial |
$155.12
|
| Rate for Payer: Quartz Beloit One Network |
$71.84
|
| Rate for Payer: Quartz Commercial |
$93.07
|
| Rate for Payer: Quartz Medicare Advantage |
$18.42
|
| Rate for Payer: The Alliance Commercial |
$46.05
|
| Rate for Payer: United Healthcare Medicaid |
$20.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.42
|
| Rate for Payer: WEA Trust Commercial |
$89.80
|
| Rate for Payer: WPS Commercial |
$73.67
|
|
|
Opiates Confirmation Urine
|
Professional
|
Both
|
$367.00
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
983347
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$362.60 |
| Rate for Payer: Aetna Commercial |
$362.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$362.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$190.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$229.01
|
| Rate for Payer: Health EOS Commercial |
$347.33
|
| Rate for Payer: HFN Commercial |
$362.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: Preferred Network Access Commercial |
$362.60
|
| Rate for Payer: Quartz Beloit One Network |
$167.94
|
| Rate for Payer: Quartz Commercial |
$217.56
|
| Rate for Payer: The Alliance Commercial |
$190.84
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
Opiates Confirmation Urine
|
Facility
|
IP
|
$367.00
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
983347
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$187.02 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$229.01
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
Opiates Confirmation Urine
|
Facility
|
OP
|
$367.00
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
983347
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$106.87 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Aetna Managed Medicare |
$106.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$248.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$190.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$183.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$213.59
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.26
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: NAPHCARE Commercial |
$229.01
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$248.09
|
| Rate for Payer: Quartz Medicare Advantage |
$229.01
|
| Rate for Payer: The Alliance Commercial |
$190.84
|
| Rate for Payer: United Healthcare PPO |
$286.26
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
Opiate Screen
|
Professional
|
Both
|
$48.00
|
|
| Hospital Charge Code |
2942893
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.96 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$47.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$47.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.95
|
| Rate for Payer: Health EOS Commercial |
$45.43
|
| Rate for Payer: HFN Commercial |
$47.42
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: Preferred Network Access Commercial |
$47.42
|
| Rate for Payer: Quartz Beloit One Network |
$21.96
|
| Rate for Payer: Quartz Commercial |
$28.45
|
| Rate for Payer: The Alliance Commercial |
$24.96
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
Opiate Screen
|
Facility
|
OP
|
$48.00
|
|
| Hospital Charge Code |
2942893
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$45.93 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Aetna Managed Medicare |
$13.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.94
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.44
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: NAPHCARE Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$32.45
|
| Rate for Payer: Quartz Medicare Advantage |
$29.95
|
| Rate for Payer: The Alliance Commercial |
$24.96
|
| Rate for Payer: United Healthcare PPO |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
Opiate Screen
|
Facility
|
IP
|
$48.00
|
|
| Hospital Charge Code |
2942893
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$45.93 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$29.95
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
Opiates Meconium
|
Professional
|
Both
|
$38.00
|
|
| Hospital Charge Code |
2942889
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.39 |
| Max. Negotiated Rate |
$37.54 |
| Rate for Payer: Aetna Commercial |
$37.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$37.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.71
|
| Rate for Payer: Health EOS Commercial |
$35.96
|
| Rate for Payer: HFN Commercial |
$37.54
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: Preferred Network Access Commercial |
$37.54
|
| Rate for Payer: Quartz Beloit One Network |
$17.39
|
| Rate for Payer: Quartz Commercial |
$22.53
|
| Rate for Payer: The Alliance Commercial |
$19.76
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
Opiates Meconium
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
2942889
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.36 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$23.71
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
Opiates Meconium
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
2942889
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Aetna Managed Medicare |
$11.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.12
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.64
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: NAPHCARE Commercial |
$23.71
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$25.69
|
| Rate for Payer: Quartz Medicare Advantage |
$23.71
|
| Rate for Payer: The Alliance Commercial |
$19.76
|
| Rate for Payer: United Healthcare PPO |
$29.64
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
Opiates serum
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
5144621
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.07 |
| Max. Negotiated Rate |
$56.45 |
| Rate for Payer: Aetna Commercial |
$55.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.52
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.45
|
| Rate for Payer: Health EOS Commercial |
$54.61
|
| Rate for Payer: HFN Commercial |
$56.45
|
| Rate for Payer: Multiplan Commercial |
$49.09
|
| Rate for Payer: Preferred Network Access Commercial |
$56.45
|
| Rate for Payer: Quartz Beloit One Network |
$30.07
|
| Rate for Payer: Quartz Commercial |
$36.82
|
| Rate for Payer: WEA Trust Commercial |
$33.75
|
| Rate for Payer: WPS Commercial |
$45.45
|
|
|
Opiates serum
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
5144621
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.18 |
| Max. Negotiated Rate |
$56.45 |
| Rate for Payer: Aetna Commercial |
$55.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.77
|
| Rate for Payer: Aetna Managed Medicare |
$17.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.52
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.34
|
| Rate for Payer: Health EOS Commercial |
$54.61
|
| Rate for Payer: HFN Commercial |
$56.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.02
|
| Rate for Payer: Multiplan Commercial |
$49.09
|
| Rate for Payer: NAPHCARE Commercial |
$36.82
|
| Rate for Payer: Preferred Network Access Commercial |
$56.45
|
| Rate for Payer: Quartz Beloit One Network |
$30.07
|
| Rate for Payer: Quartz Commercial |
$39.88
|
| Rate for Payer: Quartz Medicare Advantage |
$36.82
|
| Rate for Payer: The Alliance Commercial |
$30.68
|
| Rate for Payer: United Healthcare PPO |
$46.02
|
| Rate for Payer: WEA Trust Commercial |
$33.75
|
| Rate for Payer: WPS Commercial |
$45.45
|
|
