|
Special Ophthalmolgical Services: Fundus Photography With Interpretation
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
CPT 92250
|
| Hospital Charge Code |
1188928
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.91 |
| Max. Negotiated Rate |
$133.54 |
| Rate for Payer: Aetna Commercial |
$95.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.00
|
| Rate for Payer: Health EOS Commercial |
$91.00
|
| Rate for Payer: HFN Commercial |
$95.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$133.54
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: Preferred Network Access Commercial |
$95.00
|
| Rate for Payer: Quartz Beloit One Network |
$44.00
|
| Rate for Payer: Quartz Commercial |
$57.00
|
| Rate for Payer: The Alliance Commercial |
$50.00
|
| Rate for Payer: United Healthcare Medicaid |
$24.91
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
Special Ophthalmolgic Services: Extended Exam
|
Professional
|
Both
|
$162.00
|
|
|
Service Code
|
CPT 92083
|
| Hospital Charge Code |
1188925
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.93 |
| Max. Negotiated Rate |
$215.47 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$153.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.20
|
| Rate for Payer: Health EOS Commercial |
$147.42
|
| Rate for Payer: HFN Commercial |
$153.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$215.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$215.47
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: Preferred Network Access Commercial |
$153.90
|
| Rate for Payer: Quartz Beloit One Network |
$71.28
|
| Rate for Payer: Quartz Commercial |
$92.34
|
| Rate for Payer: The Alliance Commercial |
$81.00
|
| Rate for Payer: United Healthcare Medicaid |
$29.93
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
Special Ophthalmological Services: Determination of Refractive State
|
Professional
|
Both
|
$52.00
|
|
|
Service Code
|
CPT 92015
|
| Hospital Charge Code |
2634799
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$9.97 |
| Max. Negotiated Rate |
$66.82 |
| Rate for Payer: Aetna Commercial |
$49.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Anthem Commercial |
$20.00
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$49.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.20
|
| Rate for Payer: Health EOS Commercial |
$47.32
|
| Rate for Payer: HFN Commercial |
$49.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66.82
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: Preferred Network Access Commercial |
$49.40
|
| Rate for Payer: Quartz Beloit One Network |
$22.88
|
| Rate for Payer: Quartz Commercial |
$29.64
|
| Rate for Payer: The Alliance Commercial |
$26.00
|
| Rate for Payer: United Healthcare Medicaid |
$9.97
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Special Ophthalmological Services: Gonioscopy
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
CPT 92020
|
| Hospital Charge Code |
1188890
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.45 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Aetna Commercial |
$131.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$131.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$125.58
|
| Rate for Payer: HFN Commercial |
$131.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$70.32
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$131.10
|
| Rate for Payer: Quartz Beloit One Network |
$60.72
|
| Rate for Payer: Quartz Commercial |
$78.66
|
| Rate for Payer: The Alliance Commercial |
$69.00
|
| Rate for Payer: United Healthcare Medicaid |
$13.45
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Special Ophthalmological Services: Sensorimotor Examination
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
CPT 92060
|
| Hospital Charge Code |
1188891
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$216.85 |
| Rate for Payer: Aetna Commercial |
$80.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.10
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$80.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.00
|
| Rate for Payer: Health EOS Commercial |
$77.35
|
| Rate for Payer: HFN Commercial |
$80.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$216.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$216.85
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: Preferred Network Access Commercial |
$80.75
|
| Rate for Payer: Quartz Beloit One Network |
$37.40
|
| Rate for Payer: Quartz Commercial |
$48.45
|
| Rate for Payer: The Alliance Commercial |
$42.50
|
| Rate for Payer: United Healthcare Medicaid |
$47.82
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: WPS Commercial |
$62.96
|
|
|
Special Ophth Services Sensorimotor Exam 9206026
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
CPT 92060 26
|
| Hospital Charge Code |
4605871
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.96 |
| Max. Negotiated Rate |
$128.28 |
| Rate for Payer: Aetna Commercial |
$79.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$79.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.40
|
| Rate for Payer: Health EOS Commercial |
$76.44
|
| Rate for Payer: HFN Commercial |
$79.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$128.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Preferred Network Access Commercial |
$79.80
|
| Rate for Payer: Quartz Beloit One Network |
$36.96
|
| Rate for Payer: Quartz Commercial |
$47.88
|
| Rate for Payer: The Alliance Commercial |
$42.00
|
| Rate for Payer: United Healthcare Medicaid |
$47.82
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Special Physics Consultation
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
CPT 77370
|
| Hospital Charge Code |
3040393
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$134.11 |
| Max. Negotiated Rate |
$1,418.64 |
| Rate for Payer: Aetna Commercial |
$1,387.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,326.12
|
| Rate for Payer: Aetna Managed Medicare |
$134.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$502.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$402.33
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$382.21
|
| Rate for Payer: Anthem Medicare Advantage |
$134.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$817.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$134.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$134.11
|
| Rate for Payer: Cash Price |
$462.60
|
| Rate for Payer: Cash Price |
$462.60
|
| Rate for Payer: Cigna Commercial |
$1,418.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$134.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$862.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$134.11
|
| Rate for Payer: Health EOS Commercial |
$1,372.38
|
| Rate for Payer: HFN Commercial |
$1,418.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$498.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$134.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$134.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$134.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$134.11
|
| Rate for Payer: Multiplan Commercial |
$1,233.60
|
| Rate for Payer: NAPHCARE Commercial |
$201.16
|
| Rate for Payer: Preferred Network Access Commercial |
$1,418.64
|
| Rate for Payer: Quartz Beloit One Network |
$755.58
|
| Rate for Payer: Quartz Commercial |
$1,002.30
|
| Rate for Payer: Quartz Medicare Advantage |
$134.11
|
| Rate for Payer: The Alliance Commercial |
$536.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$134.11
|
| Rate for Payer: United Healthcare PPO |
$1,156.50
|
| Rate for Payer: WEA Trust Commercial |
$848.10
|
| Rate for Payer: Wellcare Medicare |
$134.11
|
| Rate for Payer: WPS Commercial |
$1,142.16
|
|
|
Special Physics Consultation
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
CPT 77370
|
| Hospital Charge Code |
3040393
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$755.58 |
| Max. Negotiated Rate |
$1,418.64 |
| Rate for Payer: Aetna Commercial |
$1,387.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,326.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$817.26
|
| Rate for Payer: Cash Price |
$462.60
|
| Rate for Payer: Cigna Commercial |
$1,418.64
|
| Rate for Payer: Health EOS Commercial |
$1,372.38
|
| Rate for Payer: HFN Commercial |
$1,418.64
|
| Rate for Payer: Multiplan Commercial |
$1,233.60
|
| Rate for Payer: NAPHCARE Commercial |
$925.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,418.64
|
| Rate for Payer: Quartz Beloit One Network |
$755.58
|
| Rate for Payer: Quartz Commercial |
$925.20
|
| Rate for Payer: WEA Trust Commercial |
$848.10
|
| Rate for Payer: WPS Commercial |
$1,142.16
|
|
|
Special Stain For inclusion Bodies Or Parasites
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
CPT 87207
|
| Hospital Charge Code |
1188853
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Aetna Commercial |
$131.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Anthem Commercial |
$16.61
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$131.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$125.58
|
| Rate for Payer: HFN Commercial |
$131.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.14
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$131.10
|
| Rate for Payer: Quartz Beloit One Network |
$60.72
|
| Rate for Payer: Quartz Commercial |
$78.66
|
| Rate for Payer: The Alliance Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Special Stains 1
|
Professional
|
Both
|
$217.00
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
2778826
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.03 |
| Max. Negotiated Rate |
$271.63 |
| Rate for Payer: Aetna Commercial |
$206.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.62
|
| Rate for Payer: Anthem Commercial |
$11.03
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cigna Commercial |
$206.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$108.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.20
|
| Rate for Payer: Health EOS Commercial |
$197.47
|
| Rate for Payer: HFN Commercial |
$206.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$271.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$271.63
|
| Rate for Payer: Multiplan Commercial |
$173.60
|
| Rate for Payer: Preferred Network Access Commercial |
$206.15
|
| Rate for Payer: Quartz Beloit One Network |
$95.48
|
| Rate for Payer: Quartz Commercial |
$123.69
|
| Rate for Payer: The Alliance Commercial |
$108.50
|
| Rate for Payer: WEA Trust Commercial |
$119.35
|
| Rate for Payer: WPS Commercial |
$160.73
|
|
|
Special Stains 1
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
2778826
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.46 |
| Max. Negotiated Rate |
$241.84 |
| Rate for Payer: Aetna Commercial |
$195.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.62
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$226.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$105.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$100.36
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cigna Commercial |
$199.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$193.13
|
| Rate for Payer: HFN Commercial |
$199.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$173.60
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$199.64
|
| Rate for Payer: Quartz Beloit One Network |
$106.33
|
| Rate for Payer: Quartz Commercial |
$141.05
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: The Alliance Commercial |
$241.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$162.75
|
| Rate for Payer: WEA Trust Commercial |
$119.35
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WPS Commercial |
$160.73
|
|
|
Special Stains 1
|
Facility
|
IP
|
$217.00
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
2778826
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$106.33 |
| Max. Negotiated Rate |
$199.64 |
| Rate for Payer: Aetna Commercial |
$195.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.01
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cigna Commercial |
$199.64
|
| Rate for Payer: Health EOS Commercial |
$193.13
|
| Rate for Payer: HFN Commercial |
$199.64
|
| Rate for Payer: Multiplan Commercial |
$173.60
|
| Rate for Payer: NAPHCARE Commercial |
$130.20
|
| Rate for Payer: Preferred Network Access Commercial |
$199.64
|
| Rate for Payer: Quartz Beloit One Network |
$106.33
|
| Rate for Payer: Quartz Commercial |
$130.20
|
| Rate for Payer: WEA Trust Commercial |
$119.35
|
| Rate for Payer: WPS Commercial |
$160.73
|
|
|
Special Stains 2
|
Professional
|
Both
|
$49.00
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
2778830
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.03 |
| Max. Negotiated Rate |
$271.63 |
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Anthem Commercial |
$11.03
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.40
|
| Rate for Payer: Health EOS Commercial |
$44.59
|
| Rate for Payer: HFN Commercial |
$46.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$271.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$271.63
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: Preferred Network Access Commercial |
$46.55
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$27.93
|
| Rate for Payer: The Alliance Commercial |
$24.50
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Special Stains 2
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
2778830
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.01 |
| Max. Negotiated Rate |
$241.84 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$226.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$105.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$100.36
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$31.85
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: The Alliance Commercial |
$241.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$36.75
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Special Stains 2
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
2778830
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.01 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$29.40
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Special Treatment Procedure
|
Facility
|
IP
|
$1,409.00
|
|
|
Service Code
|
CPT 77470
|
| Hospital Charge Code |
3040409
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$690.41 |
| Max. Negotiated Rate |
$1,296.28 |
| Rate for Payer: Aetna Commercial |
$1,268.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,211.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.77
|
| Rate for Payer: Cash Price |
$422.70
|
| Rate for Payer: Cigna Commercial |
$1,296.28
|
| Rate for Payer: Health EOS Commercial |
$1,254.01
|
| Rate for Payer: HFN Commercial |
$1,296.28
|
| Rate for Payer: Multiplan Commercial |
$1,127.20
|
| Rate for Payer: NAPHCARE Commercial |
$845.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,296.28
|
| Rate for Payer: Quartz Beloit One Network |
$690.41
|
| Rate for Payer: Quartz Commercial |
$845.40
|
| Rate for Payer: WEA Trust Commercial |
$774.95
|
| Rate for Payer: WPS Commercial |
$1,043.65
|
|
|
Special Treatment Procedure
|
Facility
|
OP
|
$1,409.00
|
|
|
Service Code
|
CPT 77470
|
| Hospital Charge Code |
3040409
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$581.84 |
| Max. Negotiated Rate |
$2,327.36 |
| Rate for Payer: Aetna Commercial |
$1,268.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,211.74
|
| Rate for Payer: Aetna Managed Medicare |
$581.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,181.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,745.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,658.24
|
| Rate for Payer: Anthem Medicare Advantage |
$581.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$581.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$581.84
|
| Rate for Payer: Cash Price |
$422.70
|
| Rate for Payer: Cash Price |
$422.70
|
| Rate for Payer: Cigna Commercial |
$1,296.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$581.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$788.48
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$581.84
|
| Rate for Payer: Health EOS Commercial |
$1,254.01
|
| Rate for Payer: HFN Commercial |
$1,296.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,164.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$581.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$581.84
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$581.84
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$581.84
|
| Rate for Payer: Multiplan Commercial |
$1,127.20
|
| Rate for Payer: NAPHCARE Commercial |
$872.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,296.28
|
| Rate for Payer: Quartz Beloit One Network |
$690.41
|
| Rate for Payer: Quartz Commercial |
$915.85
|
| Rate for Payer: Quartz Medicare Advantage |
$581.84
|
| Rate for Payer: The Alliance Commercial |
$2,327.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$581.84
|
| Rate for Payer: United Healthcare PPO |
$1,056.75
|
| Rate for Payer: WEA Trust Commercial |
$774.95
|
| Rate for Payer: Wellcare Medicare |
$581.84
|
| Rate for Payer: WPS Commercial |
$1,043.65
|
|
|
Special Treatment Procedure 77470
|
Professional
|
Both
|
$505.00
|
|
|
Service Code
|
CPT 77470
|
| Hospital Charge Code |
5516739
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.20 |
| Max. Negotiated Rate |
$479.75 |
| Rate for Payer: Aetna Commercial |
$479.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$434.30
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cigna Commercial |
$479.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$252.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$303.00
|
| Rate for Payer: Health EOS Commercial |
$459.55
|
| Rate for Payer: HFN Commercial |
$479.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$454.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$454.42
|
| Rate for Payer: Multiplan Commercial |
$404.00
|
| Rate for Payer: Preferred Network Access Commercial |
$479.75
|
| Rate for Payer: Quartz Beloit One Network |
$222.20
|
| Rate for Payer: Quartz Commercial |
$287.85
|
| Rate for Payer: The Alliance Commercial |
$252.50
|
| Rate for Payer: WEA Trust Commercial |
$277.75
|
| Rate for Payer: WPS Commercial |
$374.05
|
|
|
Specialty bed: Bariatric - Devices and Equipment
|
Facility
|
OP
|
$1,792.00
|
|
| Hospital Charge Code |
3031054
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$501.76 |
| Max. Negotiated Rate |
$7,168.00 |
| Rate for Payer: Aetna Commercial |
$1,612.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.12
|
| Rate for Payer: Aetna Managed Medicare |
$501.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,164.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$896.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$860.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$949.76
|
| Rate for Payer: Cash Price |
$537.60
|
| Rate for Payer: Cigna Commercial |
$1,648.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,002.80
|
| Rate for Payer: Health EOS Commercial |
$1,594.88
|
| Rate for Payer: HFN Commercial |
$1,648.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,344.00
|
| Rate for Payer: Multiplan Commercial |
$1,433.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,075.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,648.64
|
| Rate for Payer: Quartz Beloit One Network |
$878.08
|
| Rate for Payer: Quartz Commercial |
$1,164.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,075.20
|
| Rate for Payer: The Alliance Commercial |
$7,168.00
|
| Rate for Payer: WEA Trust Commercial |
$985.60
|
| Rate for Payer: WPS Commercial |
$1,327.33
|
|
|
Specialty bed: Bariatric - Devices and Equipment
|
Facility
|
IP
|
$1,792.00
|
|
| Hospital Charge Code |
3031054
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$878.08 |
| Max. Negotiated Rate |
$1,648.64 |
| Rate for Payer: Aetna Commercial |
$1,612.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$949.76
|
| Rate for Payer: Cash Price |
$537.60
|
| Rate for Payer: Cigna Commercial |
$1,648.64
|
| Rate for Payer: Health EOS Commercial |
$1,594.88
|
| Rate for Payer: HFN Commercial |
$1,648.64
|
| Rate for Payer: Multiplan Commercial |
$1,433.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,075.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,648.64
|
| Rate for Payer: Quartz Beloit One Network |
$878.08
|
| Rate for Payer: Quartz Commercial |
$1,075.20
|
| Rate for Payer: WEA Trust Commercial |
$985.60
|
| Rate for Payer: WPS Commercial |
$1,327.33
|
|
|
Specialty bed: Bariatric w/ Turn Assist - Devices and Equipment
|
Facility
|
IP
|
$1,164.00
|
|
| Hospital Charge Code |
3031053
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$570.36 |
| Max. Negotiated Rate |
$1,070.88 |
| Rate for Payer: Aetna Commercial |
$1,047.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,001.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.92
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$1,070.88
|
| Rate for Payer: Health EOS Commercial |
$1,035.96
|
| Rate for Payer: HFN Commercial |
$1,070.88
|
| Rate for Payer: Multiplan Commercial |
$931.20
|
| Rate for Payer: NAPHCARE Commercial |
$698.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,070.88
|
| Rate for Payer: Quartz Beloit One Network |
$570.36
|
| Rate for Payer: Quartz Commercial |
$698.40
|
| Rate for Payer: WEA Trust Commercial |
$640.20
|
| Rate for Payer: WPS Commercial |
$862.17
|
|
|
Specialty bed: Bariatric w/ Turn Assist - Devices and Equipment
|
Facility
|
OP
|
$1,164.00
|
|
| Hospital Charge Code |
3031053
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$325.92 |
| Max. Negotiated Rate |
$4,656.00 |
| Rate for Payer: Aetna Commercial |
$1,047.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,001.04
|
| Rate for Payer: Aetna Managed Medicare |
$325.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$756.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$582.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$558.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.92
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$1,070.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$651.37
|
| Rate for Payer: Health EOS Commercial |
$1,035.96
|
| Rate for Payer: HFN Commercial |
$1,070.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$873.00
|
| Rate for Payer: Multiplan Commercial |
$931.20
|
| Rate for Payer: NAPHCARE Commercial |
$698.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,070.88
|
| Rate for Payer: Quartz Beloit One Network |
$570.36
|
| Rate for Payer: Quartz Commercial |
$756.60
|
| Rate for Payer: Quartz Medicare Advantage |
$698.40
|
| Rate for Payer: The Alliance Commercial |
$4,656.00
|
| Rate for Payer: WEA Trust Commercial |
$640.20
|
| Rate for Payer: WPS Commercial |
$862.17
|
|
|
Specialty bed: Critical Care - Devices and Equipment
|
Facility
|
IP
|
$2,478.00
|
|
| Hospital Charge Code |
3031052
|
| Min. Negotiated Rate |
$1,214.22 |
| Max. Negotiated Rate |
$2,279.76 |
| Rate for Payer: Aetna Commercial |
$2,230.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,131.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,313.34
|
| Rate for Payer: Cash Price |
$743.40
|
| Rate for Payer: Cigna Commercial |
$2,279.76
|
| Rate for Payer: Health EOS Commercial |
$2,205.42
|
| Rate for Payer: HFN Commercial |
$2,279.76
|
| Rate for Payer: Multiplan Commercial |
$1,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,486.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,279.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,214.22
|
| Rate for Payer: Quartz Commercial |
$1,486.80
|
| Rate for Payer: WEA Trust Commercial |
$1,362.90
|
| Rate for Payer: WPS Commercial |
$1,835.45
|
|
|
Specialty bed: Critical Care - Devices and Equipment
|
Facility
|
OP
|
$2,478.00
|
|
| Hospital Charge Code |
3031052
|
| Min. Negotiated Rate |
$693.84 |
| Max. Negotiated Rate |
$9,912.00 |
| Rate for Payer: Aetna Commercial |
$2,230.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,131.08
|
| Rate for Payer: Aetna Managed Medicare |
$693.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,610.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,239.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,189.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,313.34
|
| Rate for Payer: Cash Price |
$743.40
|
| Rate for Payer: Cigna Commercial |
$2,279.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,386.69
|
| Rate for Payer: Health EOS Commercial |
$2,205.42
|
| Rate for Payer: HFN Commercial |
$2,279.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,858.50
|
| Rate for Payer: Multiplan Commercial |
$1,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,486.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,279.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,214.22
|
| Rate for Payer: Quartz Commercial |
$1,610.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,486.80
|
| Rate for Payer: The Alliance Commercial |
$9,912.00
|
| Rate for Payer: WEA Trust Commercial |
$1,362.90
|
| Rate for Payer: WPS Commercial |
$1,835.45
|
|
|
Specialty bed: Fluid air bed - Devices and Equipment
|
Facility
|
OP
|
$1,793.00
|
|
| Hospital Charge Code |
3031051
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$502.04 |
| Max. Negotiated Rate |
$7,172.00 |
| Rate for Payer: Aetna Commercial |
$1,613.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.98
|
| Rate for Payer: Aetna Managed Medicare |
$502.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,165.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$896.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$860.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$950.29
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cigna Commercial |
$1,649.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,003.36
|
| Rate for Payer: Health EOS Commercial |
$1,595.77
|
| Rate for Payer: HFN Commercial |
$1,649.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,344.75
|
| Rate for Payer: Multiplan Commercial |
$1,434.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,075.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,649.56
|
| Rate for Payer: Quartz Beloit One Network |
$878.57
|
| Rate for Payer: Quartz Commercial |
$1,165.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,075.80
|
| Rate for Payer: The Alliance Commercial |
$7,172.00
|
| Rate for Payer: WEA Trust Commercial |
$986.15
|
| Rate for Payer: WPS Commercial |
$1,328.08
|
|
