|
Consult, Extended
|
Facility
|
IP
|
$443.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040414
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$225.75 |
| Max. Negotiated Rate |
$423.86 |
| Rate for Payer: Aetna Commercial |
$414.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.18
|
| Rate for Payer: Cash Price |
$132.90
|
| Rate for Payer: Cigna Commercial |
$423.86
|
| Rate for Payer: Health EOS Commercial |
$410.04
|
| Rate for Payer: HFN Commercial |
$423.86
|
| Rate for Payer: Multiplan Commercial |
$368.58
|
| Rate for Payer: Preferred Network Access Commercial |
$423.86
|
| Rate for Payer: Quartz Beloit One Network |
$225.75
|
| Rate for Payer: Quartz Commercial |
$276.43
|
| Rate for Payer: WEA Trust Commercial |
$253.40
|
| Rate for Payer: WPS Commercial |
$341.24
|
|
|
Consult, Routine
|
Facility
|
OP
|
$367.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040413
|
|
Hospital Revenue Code
|
510
|
| 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: 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 |
$228.43
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
Consult, Routine
|
Facility
|
IP
|
$367.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040413
|
|
Hospital Revenue Code
|
510
|
| 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
|
|
|
CONTACT ISOLATION CART
|
Facility
|
OP
|
$1,364.00
|
|
| Hospital Charge Code |
3075873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$397.20 |
| Max. Negotiated Rate |
$1,305.08 |
| Rate for Payer: Aetna Commercial |
$1,276.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,219.96
|
| Rate for Payer: Aetna Managed Medicare |
$397.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$922.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$709.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$680.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$751.84
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna Commercial |
$1,305.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$793.85
|
| Rate for Payer: Health EOS Commercial |
$1,262.52
|
| Rate for Payer: HFN Commercial |
$1,305.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,063.92
|
| Rate for Payer: Multiplan Commercial |
$1,134.85
|
| Rate for Payer: NAPHCARE Commercial |
$851.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,305.08
|
| Rate for Payer: Quartz Beloit One Network |
$695.09
|
| Rate for Payer: Quartz Commercial |
$922.06
|
| Rate for Payer: Quartz Medicare Advantage |
$851.14
|
| Rate for Payer: The Alliance Commercial |
$709.28
|
| Rate for Payer: WEA Trust Commercial |
$780.21
|
| Rate for Payer: WPS Commercial |
$1,050.69
|
|
|
CONTACT ISOLATION CART
|
Facility
|
IP
|
$1,364.00
|
|
| Hospital Charge Code |
3075873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$695.09 |
| Max. Negotiated Rate |
$1,305.08 |
| Rate for Payer: Aetna Commercial |
$1,276.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,219.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$751.84
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna Commercial |
$1,305.08
|
| Rate for Payer: Health EOS Commercial |
$1,262.52
|
| Rate for Payer: HFN Commercial |
$1,305.08
|
| Rate for Payer: Multiplan Commercial |
$1,134.85
|
| Rate for Payer: Preferred Network Access Commercial |
$1,305.08
|
| Rate for Payer: Quartz Beloit One Network |
$695.09
|
| Rate for Payer: Quartz Commercial |
$851.14
|
| Rate for Payer: WEA Trust Commercial |
$780.21
|
| Rate for Payer: WPS Commercial |
$1,050.69
|
|
|
Contact - Isolation Required
|
Facility
|
IP
|
$1,364.00
|
|
| Hospital Charge Code |
3031396
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$695.09 |
| Max. Negotiated Rate |
$1,305.08 |
| Rate for Payer: Aetna Commercial |
$1,276.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,219.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$751.84
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna Commercial |
$1,305.08
|
| Rate for Payer: Health EOS Commercial |
$1,262.52
|
| Rate for Payer: HFN Commercial |
$1,305.08
|
| Rate for Payer: Multiplan Commercial |
$1,134.85
|
| Rate for Payer: Preferred Network Access Commercial |
$1,305.08
|
| Rate for Payer: Quartz Beloit One Network |
$695.09
|
| Rate for Payer: Quartz Commercial |
$851.14
|
| Rate for Payer: WEA Trust Commercial |
$780.21
|
| Rate for Payer: WPS Commercial |
$1,050.69
|
|
|
Contact - Isolation Required
|
Facility
|
OP
|
$1,364.00
|
|
| Hospital Charge Code |
3031396
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$397.20 |
| Max. Negotiated Rate |
$1,305.08 |
| Rate for Payer: Aetna Commercial |
$1,276.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,219.96
|
| Rate for Payer: Aetna Managed Medicare |
$397.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$922.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$709.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$680.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$751.84
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna Commercial |
$1,305.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$793.85
|
| Rate for Payer: Health EOS Commercial |
$1,262.52
|
| Rate for Payer: HFN Commercial |
$1,305.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,063.92
|
| Rate for Payer: Multiplan Commercial |
$1,134.85
|
| Rate for Payer: NAPHCARE Commercial |
$851.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,305.08
|
| Rate for Payer: Quartz Beloit One Network |
$695.09
|
| Rate for Payer: Quartz Commercial |
$922.06
|
| Rate for Payer: Quartz Medicare Advantage |
$851.14
|
| Rate for Payer: The Alliance Commercial |
$709.28
|
| Rate for Payer: WEA Trust Commercial |
$780.21
|
| Rate for Payer: WPS Commercial |
$1,050.69
|
|
|
Contact Lens Fitting 9231001
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
CPT 92310
|
| Hospital Charge Code |
3149554
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.71 |
| Max. Negotiated Rate |
$363.64 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$53.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.70
|
| Rate for Payer: Health EOS Commercial |
$51.11
|
| Rate for Payer: HFN Commercial |
$53.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$363.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$363.64
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$53.35
|
| Rate for Payer: Quartz Beloit One Network |
$24.71
|
| Rate for Payer: Quartz Commercial |
$32.01
|
| Rate for Payer: The Alliance Commercial |
$28.08
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Contact Lens Services: Corneal Lens for Aphakia, 1 eye
|
Professional
|
Both
|
$406.00
|
|
|
Service Code
|
CPT 92311
|
| Hospital Charge Code |
1122929
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.23 |
| Max. Negotiated Rate |
$401.13 |
| Rate for Payer: Aetna Commercial |
$401.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.13
|
| Rate for Payer: Aetna Managed Medicare |
$43.23
|
| Rate for Payer: Anthem Medicare Advantage |
$43.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.23
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$401.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$211.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.23
|
| Rate for Payer: Health EOS Commercial |
$384.24
|
| Rate for Payer: HFN Commercial |
$401.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$193.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$193.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.23
|
| Rate for Payer: Multiplan Commercial |
$337.79
|
| Rate for Payer: NAPHCARE Commercial |
$64.85
|
| Rate for Payer: Preferred Network Access Commercial |
$401.13
|
| Rate for Payer: Quartz Beloit One Network |
$185.79
|
| Rate for Payer: Quartz Commercial |
$240.68
|
| Rate for Payer: Quartz Medicare Advantage |
$43.23
|
| Rate for Payer: The Alliance Commercial |
$108.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.23
|
| Rate for Payer: WEA Trust Commercial |
$232.23
|
| Rate for Payer: WPS Commercial |
$172.93
|
|
|
CONTAINER BERKELEY SAFETOUCH TISSUE COLLECTION 003984-901
|
Facility
|
IP
|
$356.00
|
|
| Hospital Charge Code |
2965421
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$181.42 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$222.14
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
CONTAINER BERKELEY SAFETOUCH TISSUE COLLECTION 003984-901
|
Facility
|
OP
|
$356.00
|
|
| Hospital Charge Code |
2965421
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$103.67 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Aetna Managed Medicare |
$103.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$240.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.19
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.68
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$222.14
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$240.66
|
| Rate for Payer: Quartz Medicare Advantage |
$222.14
|
| Rate for Payer: The Alliance Commercial |
$185.12
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
CONTAINER SPECIMEN CONVERTOR
|
Facility
|
IP
|
$59.00
|
|
| Hospital Charge Code |
2963817
|
|
Hospital Revenue Code
|
271
|
| 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
|
|
|
CONTAINER SPECIMEN CONVERTOR
|
Facility
|
OP
|
$59.00
|
|
| Hospital Charge Code |
2963817
|
|
Hospital Revenue Code
|
271
|
| 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: WEA Trust Commercial |
$33.75
|
| Rate for Payer: WPS Commercial |
$45.45
|
|
|
CONTAINER STERILE SLUSH NACL 2B7231
|
Facility
|
IP
|
$795.00
|
|
| Hospital Charge Code |
2969354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$405.13 |
| Max. Negotiated Rate |
$760.66 |
| Rate for Payer: Aetna Commercial |
$744.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$711.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$438.20
|
| Rate for Payer: Cash Price |
$238.50
|
| Rate for Payer: Cigna Commercial |
$760.66
|
| Rate for Payer: Health EOS Commercial |
$735.85
|
| Rate for Payer: HFN Commercial |
$760.66
|
| Rate for Payer: Multiplan Commercial |
$661.44
|
| Rate for Payer: Preferred Network Access Commercial |
$760.66
|
| Rate for Payer: Quartz Beloit One Network |
$405.13
|
| Rate for Payer: Quartz Commercial |
$496.08
|
| Rate for Payer: WEA Trust Commercial |
$454.74
|
| Rate for Payer: WPS Commercial |
$612.39
|
|
|
CONTAINER STERILE SLUSH NACL 2B7231
|
Facility
|
OP
|
$795.00
|
|
| Hospital Charge Code |
2969354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$231.50 |
| Max. Negotiated Rate |
$760.66 |
| Rate for Payer: Aetna Commercial |
$744.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$711.05
|
| Rate for Payer: Aetna Managed Medicare |
$231.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$537.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$413.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$396.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$438.20
|
| Rate for Payer: Cash Price |
$238.50
|
| Rate for Payer: Cigna Commercial |
$760.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$462.69
|
| Rate for Payer: Health EOS Commercial |
$735.85
|
| Rate for Payer: HFN Commercial |
$760.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$620.10
|
| Rate for Payer: Multiplan Commercial |
$661.44
|
| Rate for Payer: NAPHCARE Commercial |
$496.08
|
| Rate for Payer: Preferred Network Access Commercial |
$760.66
|
| Rate for Payer: Quartz Beloit One Network |
$405.13
|
| Rate for Payer: Quartz Commercial |
$537.42
|
| Rate for Payer: Quartz Medicare Advantage |
$496.08
|
| Rate for Payer: The Alliance Commercial |
$413.40
|
| Rate for Payer: WEA Trust Commercial |
$454.74
|
| Rate for Payer: WPS Commercial |
$612.39
|
|
|
CONT GLUC MNTR PHYSICIAN/QHP PROVIDED EQUIPTMENT 95250
|
Facility
|
OP
|
$276.00
|
|
| Hospital Charge Code |
5959641
|
| Min. Negotiated Rate |
$80.37 |
| Max. Negotiated Rate |
$264.08 |
| Rate for Payer: Aetna Commercial |
$258.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.85
|
| Rate for Payer: Aetna Managed Medicare |
$80.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$186.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$143.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$137.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.13
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$264.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.63
|
| Rate for Payer: Health EOS Commercial |
$255.47
|
| Rate for Payer: HFN Commercial |
$264.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$229.63
|
| Rate for Payer: NAPHCARE Commercial |
$172.22
|
| Rate for Payer: Preferred Network Access Commercial |
$264.08
|
| Rate for Payer: Quartz Beloit One Network |
$140.65
|
| Rate for Payer: Quartz Commercial |
$186.58
|
| Rate for Payer: Quartz Medicare Advantage |
$172.22
|
| Rate for Payer: The Alliance Commercial |
$143.52
|
| Rate for Payer: WEA Trust Commercial |
$157.87
|
| Rate for Payer: WPS Commercial |
$212.60
|
|
|
CONT GLUC MNTR PHYSICIAN/QHP PROVIDED EQUIPTMENT 95250
|
Facility
|
IP
|
$276.00
|
|
| Hospital Charge Code |
5959641
|
| Min. Negotiated Rate |
$140.65 |
| Max. Negotiated Rate |
$264.08 |
| Rate for Payer: Aetna Commercial |
$258.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.13
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$264.08
|
| Rate for Payer: Health EOS Commercial |
$255.47
|
| Rate for Payer: HFN Commercial |
$264.08
|
| Rate for Payer: Multiplan Commercial |
$229.63
|
| Rate for Payer: Preferred Network Access Commercial |
$264.08
|
| Rate for Payer: Quartz Beloit One Network |
$140.65
|
| Rate for Payer: Quartz Commercial |
$172.22
|
| Rate for Payer: WEA Trust Commercial |
$157.87
|
| Rate for Payer: WPS Commercial |
$212.60
|
|
|
CONT GLUC MONITORING PATIENT PROVIDED EQUIPMENT 95249
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
CPT 95249
|
| Hospital Charge Code |
5949630
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$140.65 |
| Max. Negotiated Rate |
$264.08 |
| Rate for Payer: Aetna Commercial |
$258.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.13
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$264.08
|
| Rate for Payer: Health EOS Commercial |
$255.47
|
| Rate for Payer: HFN Commercial |
$264.08
|
| Rate for Payer: Multiplan Commercial |
$229.63
|
| Rate for Payer: Preferred Network Access Commercial |
$264.08
|
| Rate for Payer: Quartz Beloit One Network |
$140.65
|
| Rate for Payer: Quartz Commercial |
$172.22
|
| Rate for Payer: WEA Trust Commercial |
$157.87
|
| Rate for Payer: WPS Commercial |
$212.60
|
|
|
CONT GLUC MONITORING PATIENT PROVIDED EQUIPMENT 95249
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
CPT 95249
|
| Hospital Charge Code |
5949630
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$62.09 |
| Max. Negotiated Rate |
$264.08 |
| Rate for Payer: Aetna Commercial |
$258.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.85
|
| Rate for Payer: Aetna Managed Medicare |
$62.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$186.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$143.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$137.78
|
| Rate for Payer: Anthem Medicare Advantage |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.09
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$264.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$62.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.63
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$62.09
|
| Rate for Payer: Health EOS Commercial |
$255.47
|
| Rate for Payer: HFN Commercial |
$264.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$62.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$62.09
|
| Rate for Payer: Multiplan Commercial |
$229.63
|
| Rate for Payer: NAPHCARE Commercial |
$93.13
|
| Rate for Payer: Preferred Network Access Commercial |
$264.08
|
| Rate for Payer: Quartz Beloit One Network |
$140.65
|
| Rate for Payer: Quartz Commercial |
$186.58
|
| Rate for Payer: Quartz Medicare Advantage |
$62.09
|
| Rate for Payer: The Alliance Commercial |
$248.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.09
|
| Rate for Payer: United Healthcare PPO |
$215.28
|
| Rate for Payer: WEA Trust Commercial |
$157.87
|
| Rate for Payer: Wellcare Medicare |
$62.09
|
| Rate for Payer: WPS Commercial |
$212.60
|
|
|
CONT GLUC MONITORING PATIENT PROVIDED EQUIPMENT - 95249
|
Professional
|
Both
|
$276.00
|
|
|
Service Code
|
CPT 95249
|
| Hospital Charge Code |
6075628
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.17 |
| Max. Negotiated Rate |
$274.60 |
| Rate for Payer: Aetna Commercial |
$272.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.85
|
| Rate for Payer: Aetna Managed Medicare |
$68.65
|
| Rate for Payer: Anthem Medicare Advantage |
$68.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$68.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$68.65
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.65
|
| Rate for Payer: Health EOS Commercial |
$261.21
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$199.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$68.65
|
| Rate for Payer: Multiplan Commercial |
$229.63
|
| Rate for Payer: NAPHCARE Commercial |
$102.98
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$126.30
|
| Rate for Payer: Quartz Commercial |
$163.61
|
| Rate for Payer: Quartz Medicare Advantage |
$68.65
|
| Rate for Payer: The Alliance Commercial |
$171.63
|
| Rate for Payer: United Healthcare Medicaid |
$44.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$68.65
|
| Rate for Payer: WEA Trust Commercial |
$157.87
|
| Rate for Payer: WPS Commercial |
$274.60
|
|
|
Continuous Glucose Monitoring Sensor 72 hour minimum; Interpretation
|
Professional
|
Both
|
$317.00
|
|
|
Service Code
|
CPT 95251
|
| Hospital Charge Code |
1188986
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.28 |
| Max. Negotiated Rate |
$313.20 |
| Rate for Payer: Aetna Commercial |
$313.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Aetna Managed Medicare |
$34.81
|
| Rate for Payer: Anthem Medicare Advantage |
$34.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$34.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$34.81
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$313.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.81
|
| Rate for Payer: Health EOS Commercial |
$300.01
|
| Rate for Payer: HFN Commercial |
$313.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$124.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$124.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$34.81
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: NAPHCARE Commercial |
$52.21
|
| Rate for Payer: Preferred Network Access Commercial |
$313.20
|
| Rate for Payer: Quartz Beloit One Network |
$145.06
|
| Rate for Payer: Quartz Commercial |
$187.92
|
| Rate for Payer: Quartz Medicare Advantage |
$34.81
|
| Rate for Payer: The Alliance Commercial |
$87.02
|
| Rate for Payer: United Healthcare Medicaid |
$24.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34.81
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$139.24
|
|
|
Continuous Nebulizer Initial setup - Continuous Nebulizer Charge
|
Facility
|
OP
|
$1,475.00
|
|
|
Service Code
|
CPT 94644
|
| Hospital Charge Code |
3576169
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$140.02 |
| Max. Negotiated Rate |
$1,411.28 |
| Rate for Payer: Aetna Commercial |
$1,380.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,319.24
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$997.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$767.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$736.32
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$813.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cigna Commercial |
$1,411.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$858.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$1,365.26
|
| Rate for Payer: HFN Commercial |
$1,411.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$1,227.20
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,411.28
|
| Rate for Payer: Quartz Beloit One Network |
$751.66
|
| Rate for Payer: Quartz Commercial |
$997.10
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$1,150.50
|
| Rate for Payer: WEA Trust Commercial |
$843.70
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$1,136.19
|
|
|
Continuous Nebulizer Initial setup - Continuous Nebulizer Charge
|
Facility
|
IP
|
$1,475.00
|
|
|
Service Code
|
CPT 94644
|
| Hospital Charge Code |
3576169
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$751.66 |
| Max. Negotiated Rate |
$1,411.28 |
| Rate for Payer: Aetna Commercial |
$1,380.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,319.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$813.02
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cigna Commercial |
$1,411.28
|
| Rate for Payer: Health EOS Commercial |
$1,365.26
|
| Rate for Payer: HFN Commercial |
$1,411.28
|
| Rate for Payer: Multiplan Commercial |
$1,227.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,411.28
|
| Rate for Payer: Quartz Beloit One Network |
$751.66
|
| Rate for Payer: Quartz Commercial |
$920.40
|
| Rate for Payer: WEA Trust Commercial |
$843.70
|
| Rate for Payer: WPS Commercial |
$1,136.19
|
|
|
Continuous Positive Airway Pressure Initiation And Management 94660
|
Professional
|
Both
|
$641.00
|
|
|
Service Code
|
CPT 94660
|
| Hospital Charge Code |
1188804
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$633.31 |
| Rate for Payer: Aetna Commercial |
$633.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$573.31
|
| Rate for Payer: Aetna Managed Medicare |
$32.00
|
| Rate for Payer: Anthem Medicare Advantage |
$32.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32.00
|
| Rate for Payer: Cash Price |
$192.30
|
| Rate for Payer: Cash Price |
$192.30
|
| Rate for Payer: Cigna Commercial |
$633.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.00
|
| Rate for Payer: Health EOS Commercial |
$606.64
|
| Rate for Payer: HFN Commercial |
$633.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$222.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32.00
|
| Rate for Payer: Multiplan Commercial |
$533.31
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$633.31
|
| Rate for Payer: Quartz Beloit One Network |
$293.32
|
| Rate for Payer: Quartz Commercial |
$379.98
|
| Rate for Payer: Quartz Medicare Advantage |
$32.00
|
| Rate for Payer: The Alliance Commercial |
$80.00
|
| Rate for Payer: United Healthcare Medicaid |
$74.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.00
|
| Rate for Payer: WEA Trust Commercial |
$366.65
|
| Rate for Payer: WPS Commercial |
$128.00
|
|
|
Continuous Positive Airway Pressure Initiation and Management 9466026
|
Professional
|
Both
|
$641.00
|
|
|
Service Code
|
CPT 94660 26
|
| Hospital Charge Code |
5230606
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$74.83 |
| Max. Negotiated Rate |
$633.31 |
| Rate for Payer: Aetna Commercial |
$633.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$573.31
|
| Rate for Payer: Cash Price |
$192.30
|
| Rate for Payer: Cash Price |
$192.30
|
| Rate for Payer: Cigna Commercial |
$633.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$399.98
|
| Rate for Payer: Health EOS Commercial |
$606.64
|
| Rate for Payer: HFN Commercial |
$633.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$222.33
|
| Rate for Payer: Multiplan Commercial |
$533.31
|
| Rate for Payer: Preferred Network Access Commercial |
$633.31
|
| Rate for Payer: Quartz Beloit One Network |
$293.32
|
| Rate for Payer: Quartz Commercial |
$379.98
|
| Rate for Payer: The Alliance Commercial |
$333.32
|
| Rate for Payer: United Healthcare Medicaid |
$74.83
|
| Rate for Payer: WEA Trust Commercial |
$366.65
|
| Rate for Payer: WPS Commercial |
$493.76
|
|
