|
Occ Bld Stl, Imm
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 82274
|
| Hospital Charge Code |
979904
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.56 |
| Max. Negotiated Rate |
$139.69 |
| Rate for Payer: Aetna Commercial |
$136.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.58
|
| Rate for Payer: Aetna Managed Medicare |
$16.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.48
|
| Rate for Payer: Anthem Medicare Advantage |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.56
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$139.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.56
|
| Rate for Payer: Health EOS Commercial |
$135.14
|
| Rate for Payer: HFN Commercial |
$139.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.56
|
| Rate for Payer: Multiplan Commercial |
$121.47
|
| Rate for Payer: NAPHCARE Commercial |
$24.84
|
| Rate for Payer: Preferred Network Access Commercial |
$139.69
|
| Rate for Payer: Quartz Beloit One Network |
$74.40
|
| Rate for Payer: Quartz Commercial |
$98.70
|
| Rate for Payer: Quartz Medicare Advantage |
$16.56
|
| Rate for Payer: The Alliance Commercial |
$66.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.56
|
| Rate for Payer: United Healthcare PPO |
$113.88
|
| Rate for Payer: WEA Trust Commercial |
$83.51
|
| Rate for Payer: Wellcare Medicare |
$16.56
|
| Rate for Payer: WPS Commercial |
$112.46
|
|
|
Occ Bld Stl, Imm
|
Professional
|
Both
|
$146.00
|
|
|
Service Code
|
CPT 82274
|
| Hospital Charge Code |
979904
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.56 |
| Max. Negotiated Rate |
$144.25 |
| Rate for Payer: Aetna Commercial |
$144.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.58
|
| Rate for Payer: Aetna Managed Medicare |
$16.56
|
| Rate for Payer: Anthem Medicare Advantage |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.56
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$144.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.56
|
| Rate for Payer: Health EOS Commercial |
$138.17
|
| Rate for Payer: HFN Commercial |
$144.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$58.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.56
|
| Rate for Payer: Multiplan Commercial |
$121.47
|
| Rate for Payer: NAPHCARE Commercial |
$24.84
|
| Rate for Payer: Preferred Network Access Commercial |
$144.25
|
| Rate for Payer: Quartz Beloit One Network |
$66.81
|
| Rate for Payer: Quartz Commercial |
$86.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.56
|
| Rate for Payer: The Alliance Commercial |
$65.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.56
|
| Rate for Payer: WEA Trust Commercial |
$83.51
|
| Rate for Payer: WPS Commercial |
$72.85
|
|
|
OCCUPATIONAL THERAPY
|
Facility
|
OP
|
$55.06
|
|
|
Service Code
|
EAPG 00270
|
| Min. Negotiated Rate |
$52.94 |
| Max. Negotiated Rate |
$55.06 |
| Rate for Payer: Anthem Medicaid |
$52.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$52.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.94
|
| Rate for Payer: Dean Health Medicaid |
$52.94
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$52.94
|
| Rate for Payer: Managed Health Services Medicaid |
$55.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.94
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$52.94
|
| Rate for Payer: United Healthcare Medicaid |
$52.94
|
|
|
OCUCOAT CC065S
|
Facility
|
IP
|
$532.00
|
|
| Hospital Charge Code |
5415290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$271.11 |
| Max. Negotiated Rate |
$509.02 |
| Rate for Payer: Aetna Commercial |
$497.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.24
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$509.02
|
| Rate for Payer: Health EOS Commercial |
$492.42
|
| Rate for Payer: HFN Commercial |
$509.02
|
| Rate for Payer: Multiplan Commercial |
$442.62
|
| Rate for Payer: Preferred Network Access Commercial |
$509.02
|
| Rate for Payer: Quartz Beloit One Network |
$271.11
|
| Rate for Payer: Quartz Commercial |
$331.97
|
| Rate for Payer: WEA Trust Commercial |
$304.30
|
| Rate for Payer: WPS Commercial |
$409.80
|
|
|
OCUCOAT CC065S
|
Facility
|
OP
|
$532.00
|
|
| Hospital Charge Code |
5415290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$154.92 |
| Max. Negotiated Rate |
$509.02 |
| Rate for Payer: Aetna Commercial |
$497.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.82
|
| Rate for Payer: Aetna Managed Medicare |
$154.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$359.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$276.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$265.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.24
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$509.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$309.62
|
| Rate for Payer: Health EOS Commercial |
$492.42
|
| Rate for Payer: HFN Commercial |
$509.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$414.96
|
| Rate for Payer: Multiplan Commercial |
$442.62
|
| Rate for Payer: NAPHCARE Commercial |
$331.97
|
| Rate for Payer: Preferred Network Access Commercial |
$509.02
|
| Rate for Payer: Quartz Beloit One Network |
$271.11
|
| Rate for Payer: Quartz Commercial |
$359.63
|
| Rate for Payer: Quartz Medicare Advantage |
$331.97
|
| Rate for Payer: The Alliance Commercial |
$276.64
|
| Rate for Payer: WEA Trust Commercial |
$304.30
|
| Rate for Payer: WPS Commercial |
$409.80
|
|
|
OCULAR AND PERIOCULAR MALIGNANCY
|
Facility
|
OP
|
$34.03
|
|
|
Service Code
|
EAPG 00556
|
| Min. Negotiated Rate |
$32.72 |
| Max. Negotiated Rate |
$34.03 |
| Rate for Payer: Anthem Medicaid |
$32.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$32.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.72
|
| Rate for Payer: Dean Health Medicaid |
$32.72
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$32.72
|
| Rate for Payer: Managed Health Services Medicaid |
$34.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$32.72
|
| Rate for Payer: United Healthcare Medicaid |
$32.72
|
|
|
OCULAR IMAGING AND RELATED SERVICES
|
Facility
|
OP
|
$12.55
|
|
|
Service Code
|
EAPG 00156
|
| Min. Negotiated Rate |
$12.07 |
| Max. Negotiated Rate |
$12.55 |
| Rate for Payer: Anthem Medicaid |
$12.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.07
|
| Rate for Payer: Dean Health Medicaid |
$12.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.07
|
| Rate for Payer: Managed Health Services Medicaid |
$12.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.07
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.07
|
| Rate for Payer: United Healthcare Medicaid |
$12.07
|
|
|
OCULAR SECUREFLEX HF LENS OSIG
|
Facility
|
OP
|
$448.00
|
|
| Hospital Charge Code |
5459397
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$130.46 |
| Max. Negotiated Rate |
$428.65 |
| Rate for Payer: Aetna Commercial |
$419.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$400.69
|
| Rate for Payer: Aetna Managed Medicare |
$130.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$302.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$232.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$223.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.94
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cigna Commercial |
$428.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$260.74
|
| Rate for Payer: Health EOS Commercial |
$414.67
|
| Rate for Payer: HFN Commercial |
$428.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$349.44
|
| Rate for Payer: Multiplan Commercial |
$372.74
|
| Rate for Payer: NAPHCARE Commercial |
$279.55
|
| Rate for Payer: Preferred Network Access Commercial |
$428.65
|
| Rate for Payer: Quartz Beloit One Network |
$228.30
|
| Rate for Payer: Quartz Commercial |
$302.85
|
| Rate for Payer: Quartz Medicare Advantage |
$279.55
|
| Rate for Payer: The Alliance Commercial |
$232.96
|
| Rate for Payer: WEA Trust Commercial |
$256.26
|
| Rate for Payer: WPS Commercial |
$345.09
|
|
|
OCULAR SECUREFLEX HF LENS OSIG
|
Facility
|
IP
|
$448.00
|
|
| Hospital Charge Code |
5459397
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$228.30 |
| Max. Negotiated Rate |
$428.65 |
| Rate for Payer: Aetna Commercial |
$419.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$400.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.94
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cigna Commercial |
$428.65
|
| Rate for Payer: Health EOS Commercial |
$414.67
|
| Rate for Payer: HFN Commercial |
$428.65
|
| Rate for Payer: Multiplan Commercial |
$372.74
|
| Rate for Payer: Preferred Network Access Commercial |
$428.65
|
| Rate for Payer: Quartz Beloit One Network |
$228.30
|
| Rate for Payer: Quartz Commercial |
$279.55
|
| Rate for Payer: WEA Trust Commercial |
$256.26
|
| Rate for Payer: WPS Commercial |
$345.09
|
|
|
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 |
$80.04 |
| Max. Negotiated Rate |
$354.22 |
| Rate for Payer: Aetna Commercial |
$282.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.80
|
| Rate for Payer: Aetna Managed Medicare |
$88.56
|
| Rate for Payer: Anthem Medicare Advantage |
$88.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$88.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$88.56
|
| 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 |
$282.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$80.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.56
|
| Rate for Payer: Health EOS Commercial |
$270.67
|
| Rate for Payer: HFN Commercial |
$282.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$310.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$310.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$88.56
|
| Rate for Payer: Multiplan Commercial |
$237.95
|
| Rate for Payer: NAPHCARE Commercial |
$132.83
|
| Rate for Payer: Preferred Network Access Commercial |
$282.57
|
| Rate for Payer: Quartz Beloit One Network |
$130.87
|
| Rate for Payer: Quartz Commercial |
$169.54
|
| Rate for Payer: Quartz Medicare Advantage |
$88.56
|
| Rate for Payer: The Alliance Commercial |
$221.39
|
| Rate for Payer: United Healthcare Medicaid |
$80.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$88.56
|
| Rate for Payer: WEA Trust Commercial |
$163.59
|
| Rate for Payer: WPS Commercial |
$354.22
|
|
|
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 |
$39.43 |
| Max. Negotiated Rate |
$282.57 |
| Rate for Payer: Aetna Commercial |
$282.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.80
|
| Rate for Payer: Aetna Managed Medicare |
$45.85
|
| Rate for Payer: Anthem Medicare Advantage |
$45.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$45.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$45.85
|
| 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 |
$282.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.85
|
| Rate for Payer: Health EOS Commercial |
$270.67
|
| Rate for Payer: HFN Commercial |
$282.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$164.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$164.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$45.85
|
| Rate for Payer: Multiplan Commercial |
$237.95
|
| Rate for Payer: NAPHCARE Commercial |
$68.78
|
| Rate for Payer: Preferred Network Access Commercial |
$282.57
|
| Rate for Payer: Quartz Beloit One Network |
$130.87
|
| Rate for Payer: Quartz Commercial |
$169.54
|
| Rate for Payer: Quartz Medicare Advantage |
$45.85
|
| Rate for Payer: The Alliance Commercial |
$114.63
|
| Rate for Payer: United Healthcare Medicaid |
$39.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.85
|
| Rate for Payer: WEA Trust Commercial |
$163.59
|
| Rate for Payer: WPS Commercial |
$183.41
|
|
|
Office Consultation Level 1
|
Professional
|
Both
|
$216.00
|
|
|
Service Code
|
CPT 99241
|
| Hospital Charge Code |
1122834
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$98.84 |
| Max. Negotiated Rate |
$213.41 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.19
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$213.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$112.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.78
|
| Rate for Payer: Health EOS Commercial |
$204.42
|
| Rate for Payer: HFN Commercial |
$213.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.85
|
| Rate for Payer: Multiplan Commercial |
$179.71
|
| Rate for Payer: Preferred Network Access Commercial |
$213.41
|
| Rate for Payer: Quartz Beloit One Network |
$98.84
|
| Rate for Payer: Quartz Commercial |
$128.04
|
| Rate for Payer: The Alliance Commercial |
$112.32
|
| Rate for Payer: WEA Trust Commercial |
$123.55
|
| Rate for Payer: WPS Commercial |
$166.38
|
|
|
Office Consultation Level 2
|
Professional
|
Both
|
$315.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
1122835
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.47 |
| Max. Negotiated Rate |
$311.22 |
| Rate for Payer: Aetna Commercial |
$311.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.74
|
| 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 |
$311.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$64.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$196.56
|
| Rate for Payer: Health EOS Commercial |
$298.12
|
| Rate for Payer: HFN Commercial |
$311.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$237.38
|
| Rate for Payer: Multiplan Commercial |
$262.08
|
| Rate for Payer: Preferred Network Access Commercial |
$311.22
|
| Rate for Payer: Quartz Beloit One Network |
$144.14
|
| Rate for Payer: Quartz Commercial |
$186.73
|
| Rate for Payer: The Alliance Commercial |
$163.80
|
| Rate for Payer: United Healthcare Medicaid |
$64.47
|
| Rate for Payer: WEA Trust Commercial |
$180.18
|
| Rate for Payer: WPS Commercial |
$242.64
|
|
|
Office Consultation Level 3
|
Professional
|
Both
|
$490.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
1122836
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.94 |
| Max. Negotiated Rate |
$484.12 |
| Rate for Payer: Aetna Commercial |
$484.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$438.26
|
| 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 |
$484.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$305.76
|
| Rate for Payer: Health EOS Commercial |
$463.74
|
| Rate for Payer: HFN Commercial |
$484.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$332.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$332.21
|
| Rate for Payer: Multiplan Commercial |
$407.68
|
| Rate for Payer: Preferred Network Access Commercial |
$484.12
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$290.47
|
| Rate for Payer: The Alliance Commercial |
$254.80
|
| Rate for Payer: United Healthcare Medicaid |
$87.94
|
| Rate for Payer: WEA Trust Commercial |
$280.28
|
| Rate for Payer: WPS Commercial |
$377.45
|
|
|
Office Consultation Level 4
|
Professional
|
Both
|
$685.00
|
|
|
Service Code
|
CPT 99244
|
| Hospital Charge Code |
1122837
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$113.61 |
| Max. Negotiated Rate |
$676.78 |
| Rate for Payer: Aetna Commercial |
$676.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$612.66
|
| 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 |
$676.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$113.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$427.44
|
| Rate for Payer: Health EOS Commercial |
$648.28
|
| Rate for Payer: HFN Commercial |
$676.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$533.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$533.90
|
| Rate for Payer: Multiplan Commercial |
$569.92
|
| Rate for Payer: Preferred Network Access Commercial |
$676.78
|
| Rate for Payer: Quartz Beloit One Network |
$313.46
|
| Rate for Payer: Quartz Commercial |
$406.07
|
| Rate for Payer: The Alliance Commercial |
$356.20
|
| Rate for Payer: United Healthcare Medicaid |
$113.61
|
| Rate for Payer: WEA Trust Commercial |
$391.82
|
| Rate for Payer: WPS Commercial |
$527.66
|
|
|
Office Consultation Level 5
|
Professional
|
Both
|
$857.00
|
|
|
Service Code
|
CPT 99245
|
| Hospital Charge Code |
1122838
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$148.12 |
| Max. Negotiated Rate |
$846.72 |
| Rate for Payer: Aetna Commercial |
$846.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$766.50
|
| 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 |
$846.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$534.77
|
| Rate for Payer: Health EOS Commercial |
$811.06
|
| Rate for Payer: HFN Commercial |
$846.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$660.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$660.86
|
| Rate for Payer: Multiplan Commercial |
$713.02
|
| Rate for Payer: Preferred Network Access Commercial |
$846.72
|
| Rate for Payer: Quartz Beloit One Network |
$392.16
|
| Rate for Payer: Quartz Commercial |
$508.03
|
| Rate for Payer: The Alliance Commercial |
$445.64
|
| Rate for Payer: United Healthcare Medicaid |
$148.12
|
| Rate for Payer: WEA Trust Commercial |
$490.20
|
| Rate for Payer: WPS Commercial |
$660.15
|
|
|
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 |
$64.47 |
| Max. Negotiated Rate |
$341.85 |
| Rate for Payer: Aetna Commercial |
$341.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.46
|
| 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 |
$341.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$64.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.90
|
| Rate for Payer: Health EOS Commercial |
$327.45
|
| Rate for Payer: HFN Commercial |
$341.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$237.38
|
| Rate for Payer: Multiplan Commercial |
$287.87
|
| Rate for Payer: Preferred Network Access Commercial |
$341.85
|
| Rate for Payer: Quartz Beloit One Network |
$158.33
|
| Rate for Payer: Quartz Commercial |
$205.11
|
| Rate for Payer: The Alliance Commercial |
$179.92
|
| Rate for Payer: United Healthcare Medicaid |
$64.47
|
| Rate for Payer: WEA Trust Commercial |
$197.91
|
| Rate for Payer: WPS Commercial |
$266.52
|
|
|
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 |
$212.78 |
| Max. Negotiated Rate |
$459.42 |
| Rate for Payer: Aetna Commercial |
$459.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$415.90
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$459.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$241.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$290.16
|
| Rate for Payer: Health EOS Commercial |
$440.08
|
| Rate for Payer: HFN Commercial |
$459.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$422.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$422.41
|
| Rate for Payer: Multiplan Commercial |
$386.88
|
| Rate for Payer: Preferred Network Access Commercial |
$459.42
|
| Rate for Payer: Quartz Beloit One Network |
$212.78
|
| Rate for Payer: Quartz Commercial |
$275.65
|
| Rate for Payer: The Alliance Commercial |
$241.80
|
| Rate for Payer: WEA Trust Commercial |
$265.98
|
| Rate for Payer: WPS Commercial |
$358.19
|
|
|
Office/OutPatient Visit, Est 99211
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3705546
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.74 |
| Max. Negotiated Rate |
$134.91 |
| Rate for Payer: Aetna Commercial |
$131.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Aetna Managed Medicare |
$41.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.72
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$134.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.06
|
| Rate for Payer: Health EOS Commercial |
$130.51
|
| Rate for Payer: HFN Commercial |
$134.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.98
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: NAPHCARE Commercial |
$87.98
|
| Rate for Payer: Preferred Network Access Commercial |
$134.91
|
| Rate for Payer: Quartz Beloit One Network |
$71.85
|
| Rate for Payer: Quartz Commercial |
$95.32
|
| Rate for Payer: Quartz Medicare Advantage |
$87.98
|
| Rate for Payer: The Alliance Commercial |
$30.74
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: WPS Commercial |
$108.61
|
|
|
Office/OutPatient Visit, Est 99211
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3705546
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.85 |
| Max. Negotiated Rate |
$134.91 |
| Rate for Payer: Aetna Commercial |
$131.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.72
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$134.91
|
| Rate for Payer: Health EOS Commercial |
$130.51
|
| Rate for Payer: HFN Commercial |
$134.91
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: Preferred Network Access Commercial |
$134.91
|
| Rate for Payer: Quartz Beloit One Network |
$71.85
|
| Rate for Payer: Quartz Commercial |
$87.98
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: WPS Commercial |
$108.61
|
|
|
Office/OutPatient Visit, Est 99211DSC
|
Professional
|
Both
|
$27.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3301471
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$7.69 |
| Max. Negotiated Rate |
$31.87 |
| Rate for Payer: Aetna Commercial |
$26.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Aetna Managed Medicare |
$7.69
|
| Rate for Payer: Anthem Medicare Advantage |
$7.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.69
|
| 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 |
$26.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.69
|
| Rate for Payer: Health EOS Commercial |
$25.55
|
| Rate for Payer: HFN Commercial |
$26.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.69
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: NAPHCARE Commercial |
$11.53
|
| Rate for Payer: Preferred Network Access Commercial |
$26.68
|
| Rate for Payer: Quartz Beloit One Network |
$12.36
|
| Rate for Payer: Quartz Commercial |
$16.01
|
| Rate for Payer: Quartz Medicare Advantage |
$7.69
|
| Rate for Payer: The Alliance Commercial |
$18.45
|
| Rate for Payer: United Healthcare Medicaid |
$16.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.69
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$16.14
|
|
|
Office/OutPatient Visit, Est 99212DSC
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3301473
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.20 |
| Max. Negotiated Rate |
$126.55 |
| Rate for Payer: Aetna Commercial |
$65.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Aetna Managed Medicare |
$30.62
|
| Rate for Payer: Anthem Medicare Advantage |
$30.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.62
|
| 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 |
$65.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.62
|
| Rate for Payer: Health EOS Commercial |
$62.46
|
| Rate for Payer: HFN Commercial |
$65.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$126.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.62
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: NAPHCARE Commercial |
$45.93
|
| Rate for Payer: Preferred Network Access Commercial |
$65.21
|
| Rate for Payer: Quartz Beloit One Network |
$30.20
|
| Rate for Payer: Quartz Commercial |
$39.12
|
| Rate for Payer: Quartz Medicare Advantage |
$30.62
|
| Rate for Payer: The Alliance Commercial |
$73.48
|
| Rate for Payer: United Healthcare Medicaid |
$39.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.62
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$64.30
|
|
|
Office/OutPatient Visit, Est 99213DSC
|
Professional
|
Both
|
$119.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3301475
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.45 |
| Max. Negotiated Rate |
$236.68 |
| Rate for Payer: Aetna Commercial |
$117.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.43
|
| Rate for Payer: Aetna Managed Medicare |
$57.11
|
| Rate for Payer: Anthem Medicare Advantage |
$57.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$57.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$57.11
|
| 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 |
$117.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.11
|
| Rate for Payer: Health EOS Commercial |
$112.62
|
| Rate for Payer: HFN Commercial |
$117.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$236.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$236.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$57.11
|
| Rate for Payer: Multiplan Commercial |
$99.01
|
| Rate for Payer: NAPHCARE Commercial |
$85.66
|
| Rate for Payer: Preferred Network Access Commercial |
$117.57
|
| Rate for Payer: Quartz Beloit One Network |
$54.45
|
| Rate for Payer: Quartz Commercial |
$70.54
|
| Rate for Payer: Quartz Medicare Advantage |
$57.11
|
| Rate for Payer: The Alliance Commercial |
$137.06
|
| Rate for Payer: United Healthcare Medicaid |
$62.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$57.11
|
| Rate for Payer: WEA Trust Commercial |
$68.07
|
| Rate for Payer: WPS Commercial |
$119.92
|
|
|
Office/OutPatient Visit, Est 99214DSC
|
Professional
|
Both
|
$216.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
3301477
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$83.83 |
| Max. Negotiated Rate |
$350.20 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.19
|
| Rate for Payer: Aetna Managed Medicare |
$83.83
|
| Rate for Payer: Anthem Medicare Advantage |
$83.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$83.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$83.83
|
| 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 |
$213.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.83
|
| Rate for Payer: Health EOS Commercial |
$204.42
|
| Rate for Payer: HFN Commercial |
$213.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$350.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$350.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$83.83
|
| Rate for Payer: Multiplan Commercial |
$179.71
|
| Rate for Payer: NAPHCARE Commercial |
$125.75
|
| Rate for Payer: Preferred Network Access Commercial |
$213.41
|
| Rate for Payer: Quartz Beloit One Network |
$98.84
|
| Rate for Payer: Quartz Commercial |
$128.04
|
| Rate for Payer: Quartz Medicare Advantage |
$83.83
|
| Rate for Payer: The Alliance Commercial |
$201.20
|
| Rate for Payer: United Healthcare Medicaid |
$89.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$83.83
|
| Rate for Payer: WEA Trust Commercial |
$123.55
|
| Rate for Payer: WPS Commercial |
$176.05
|
|
|
Office/OutPatient Visit, Est 99215DSC
|
Professional
|
Both
|
$332.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
3301479
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$124.47 |
| Max. Negotiated Rate |
$515.07 |
| Rate for Payer: Aetna Commercial |
$328.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Aetna Managed Medicare |
$124.47
|
| Rate for Payer: Anthem Medicare Advantage |
$124.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$124.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$124.47
|
| 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 |
$328.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$124.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.47
|
| Rate for Payer: Health EOS Commercial |
$314.20
|
| Rate for Payer: HFN Commercial |
$328.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$515.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$515.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$124.47
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: NAPHCARE Commercial |
$186.70
|
| Rate for Payer: Preferred Network Access Commercial |
$328.02
|
| Rate for Payer: Quartz Beloit One Network |
$151.92
|
| Rate for Payer: Quartz Commercial |
$196.81
|
| Rate for Payer: Quartz Medicare Advantage |
$124.47
|
| Rate for Payer: The Alliance Commercial |
$298.72
|
| Rate for Payer: United Healthcare Medicaid |
$124.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$124.47
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: WPS Commercial |
$261.38
|
|
