|
ESOPH IMPED FUNCTION TEST 9103726
|
Professional
|
Both
|
$549.00
|
|
|
Service Code
|
CPT 91037 26
|
| Hospital Charge Code |
5472737
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.69 |
| Max. Negotiated Rate |
$542.41 |
| Rate for Payer: Aetna Commercial |
$542.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$491.03
|
| Rate for Payer: Aetna Managed Medicare |
$51.50
|
| Rate for Payer: Anthem Medicare Advantage |
$51.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$51.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$51.50
|
| Rate for Payer: Cash Price |
$164.70
|
| Rate for Payer: Cash Price |
$164.70
|
| Rate for Payer: Cigna Commercial |
$542.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.50
|
| Rate for Payer: Health EOS Commercial |
$519.57
|
| Rate for Payer: HFN Commercial |
$542.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$176.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$176.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$51.50
|
| Rate for Payer: Multiplan Commercial |
$456.77
|
| Rate for Payer: NAPHCARE Commercial |
$77.25
|
| Rate for Payer: Preferred Network Access Commercial |
$542.41
|
| Rate for Payer: Quartz Beloit One Network |
$251.22
|
| Rate for Payer: Quartz Commercial |
$325.45
|
| Rate for Payer: Quartz Medicare Advantage |
$51.50
|
| Rate for Payer: The Alliance Commercial |
$128.75
|
| Rate for Payer: United Healthcare Medicaid |
$47.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51.50
|
| Rate for Payer: WEA Trust Commercial |
$314.03
|
| Rate for Payer: WPS Commercial |
$206.00
|
|
|
ESRD CASE MANAGEMENT
|
Facility
|
OP
|
$14.41
|
|
|
Service Code
|
EAPG 00261
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Anthem Medicaid |
$13.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$13.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.86
|
| Rate for Payer: Dean Health Medicaid |
$13.86
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13.86
|
| Rate for Payer: Managed Health Services Medicaid |
$14.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.86
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13.86
|
| Rate for Payer: United Healthcare Medicaid |
$13.86
|
|
|
ESTABLISH ACCESS TO ARTERY 36140
|
Professional
|
Both
|
$2,444.00
|
|
|
Service Code
|
CPT 36140
|
| Hospital Charge Code |
3014509
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.70 |
| Max. Negotiated Rate |
$2,414.67 |
| Rate for Payer: Aetna Commercial |
$2,414.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,185.91
|
| Rate for Payer: Aetna Managed Medicare |
$72.70
|
| Rate for Payer: Anthem Medicare Advantage |
$72.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$72.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$72.70
|
| Rate for Payer: Cash Price |
$733.20
|
| Rate for Payer: Cash Price |
$733.20
|
| Rate for Payer: Cash Price |
$733.20
|
| Rate for Payer: Cigna Commercial |
$2,414.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.70
|
| Rate for Payer: Health EOS Commercial |
$2,313.00
|
| Rate for Payer: HFN Commercial |
$2,414.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$298.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$298.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$72.70
|
| Rate for Payer: Multiplan Commercial |
$2,033.41
|
| Rate for Payer: NAPHCARE Commercial |
$109.04
|
| Rate for Payer: Preferred Network Access Commercial |
$2,414.67
|
| Rate for Payer: Quartz Beloit One Network |
$1,118.37
|
| Rate for Payer: Quartz Commercial |
$1,448.80
|
| Rate for Payer: Quartz Medicare Advantage |
$72.70
|
| Rate for Payer: The Alliance Commercial |
$308.96
|
| Rate for Payer: United Healthcare Medicaid |
$73.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$72.70
|
| Rate for Payer: WEA Trust Commercial |
$1,397.97
|
| Rate for Payer: WPS Commercial |
$327.13
|
|
|
Establish Access To Artery 3614022
|
Professional
|
Both
|
$2,932.00
|
|
|
Service Code
|
CPT 36140 22
|
| Hospital Charge Code |
5492669
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.83 |
| Max. Negotiated Rate |
$2,896.82 |
| Rate for Payer: Aetna Commercial |
$2,896.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,622.38
|
| Rate for Payer: Cash Price |
$879.60
|
| Rate for Payer: Cash Price |
$879.60
|
| Rate for Payer: Cash Price |
$879.60
|
| Rate for Payer: Cigna Commercial |
$2,896.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,829.57
|
| Rate for Payer: Health EOS Commercial |
$2,774.84
|
| Rate for Payer: HFN Commercial |
$2,896.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$298.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$298.25
|
| Rate for Payer: Multiplan Commercial |
$2,439.42
|
| Rate for Payer: Preferred Network Access Commercial |
$2,896.82
|
| Rate for Payer: Quartz Beloit One Network |
$1,341.68
|
| Rate for Payer: Quartz Commercial |
$1,738.09
|
| Rate for Payer: The Alliance Commercial |
$1,524.64
|
| Rate for Payer: United Healthcare Medicaid |
$73.83
|
| Rate for Payer: WEA Trust Commercial |
$1,677.10
|
| Rate for Payer: WPS Commercial |
$2,258.52
|
|
|
Established major dressing charge
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3165538
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Aetna Managed Medicare |
$43.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$101.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$74.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.30
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.00
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.60
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$101.40
|
| Rate for Payer: Quartz Medicare Advantage |
$93.60
|
| Rate for Payer: The Alliance Commercial |
$122.47
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
Established major dressing charge
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3165538
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$76.44 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
Established minor dressing charge
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3165537
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$27.37 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Aetna Managed Medicare |
$27.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.71
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.32
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: NAPHCARE Commercial |
$58.66
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$63.54
|
| Rate for Payer: Quartz Medicare Advantage |
$58.66
|
| Rate for Payer: The Alliance Commercial |
$30.74
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
Established minor dressing charge
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3165537
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.90 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$58.66
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
Established Patient Home Visit 40 Minutes
|
Professional
|
Both
|
$467.00
|
|
|
Service Code
|
CPT 99349
|
| Hospital Charge Code |
1122862
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$102.39 |
| Max. Negotiated Rate |
$461.40 |
| Rate for Payer: Aetna Commercial |
$461.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$417.68
|
| Rate for Payer: Aetna Managed Medicare |
$131.73
|
| Rate for Payer: Anthem Medicare Advantage |
$131.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$131.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$131.73
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cigna Commercial |
$461.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$102.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$131.73
|
| Rate for Payer: Health EOS Commercial |
$441.97
|
| Rate for Payer: HFN Commercial |
$461.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$451.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$451.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$131.73
|
| Rate for Payer: Multiplan Commercial |
$388.54
|
| Rate for Payer: NAPHCARE Commercial |
$197.59
|
| Rate for Payer: Preferred Network Access Commercial |
$461.40
|
| Rate for Payer: Quartz Beloit One Network |
$213.70
|
| Rate for Payer: Quartz Commercial |
$276.84
|
| Rate for Payer: Quartz Medicare Advantage |
$131.73
|
| Rate for Payer: The Alliance Commercial |
$316.14
|
| Rate for Payer: United Healthcare Medicaid |
$102.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$131.73
|
| Rate for Payer: WEA Trust Commercial |
$267.12
|
| Rate for Payer: WPS Commercial |
$362.25
|
|
|
Established Pt Consult Level 2
|
Facility
|
OP
|
$274.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
3040420
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$79.79 |
| Max. Negotiated Rate |
$262.16 |
| Rate for Payer: Aetna Commercial |
$256.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.07
|
| Rate for Payer: Aetna Managed Medicare |
$79.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$142.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$136.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.03
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$262.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.47
|
| Rate for Payer: Health EOS Commercial |
$253.61
|
| Rate for Payer: HFN Commercial |
$262.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.72
|
| Rate for Payer: Multiplan Commercial |
$227.97
|
| Rate for Payer: NAPHCARE Commercial |
$170.98
|
| Rate for Payer: Preferred Network Access Commercial |
$262.16
|
| Rate for Payer: Quartz Beloit One Network |
$139.63
|
| Rate for Payer: Quartz Commercial |
$185.22
|
| Rate for Payer: Quartz Medicare Advantage |
$170.98
|
| Rate for Payer: The Alliance Commercial |
$142.48
|
| Rate for Payer: WEA Trust Commercial |
$156.73
|
| Rate for Payer: WPS Commercial |
$211.06
|
|
|
Established Pt Consult Level 2
|
Facility
|
IP
|
$274.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
3040420
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$139.63 |
| Max. Negotiated Rate |
$262.16 |
| Rate for Payer: Aetna Commercial |
$256.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.03
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$262.16
|
| Rate for Payer: Health EOS Commercial |
$253.61
|
| Rate for Payer: HFN Commercial |
$262.16
|
| Rate for Payer: Multiplan Commercial |
$227.97
|
| Rate for Payer: Preferred Network Access Commercial |
$262.16
|
| Rate for Payer: Quartz Beloit One Network |
$139.63
|
| Rate for Payer: Quartz Commercial |
$170.98
|
| Rate for Payer: WEA Trust Commercial |
$156.73
|
| Rate for Payer: WPS Commercial |
$211.06
|
|
|
Established Pt Consult Level 3
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
3040421
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$459.39 |
| Rate for Payer: Aetna Commercial |
$327.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Aetna Managed Medicare |
$101.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$236.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$182.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$174.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.92
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$334.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.70
|
| Rate for Payer: Health EOS Commercial |
$323.96
|
| Rate for Payer: HFN Commercial |
$334.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$273.00
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: NAPHCARE Commercial |
$218.40
|
| Rate for Payer: Preferred Network Access Commercial |
$334.88
|
| Rate for Payer: Quartz Beloit One Network |
$178.36
|
| Rate for Payer: Quartz Commercial |
$236.60
|
| Rate for Payer: Quartz Medicare Advantage |
$218.40
|
| Rate for Payer: The Alliance Commercial |
$459.39
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
Established Pt Consult Level 3
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
3040421
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$178.36 |
| Max. Negotiated Rate |
$334.88 |
| Rate for Payer: Aetna Commercial |
$327.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.92
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$334.88
|
| Rate for Payer: Health EOS Commercial |
$323.96
|
| Rate for Payer: HFN Commercial |
$334.88
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: Preferred Network Access Commercial |
$334.88
|
| Rate for Payer: Quartz Beloit One Network |
$178.36
|
| Rate for Payer: Quartz Commercial |
$218.40
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
Established Pt Consult Level 4
|
Facility
|
IP
|
$406.00
|
|
|
Service Code
|
CPT 99244
|
| Hospital Charge Code |
3040422
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$206.90 |
| Max. Negotiated Rate |
$388.46 |
| Rate for Payer: Aetna Commercial |
$380.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.79
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$388.46
|
| Rate for Payer: Health EOS Commercial |
$375.79
|
| Rate for Payer: HFN Commercial |
$388.46
|
| Rate for Payer: Multiplan Commercial |
$337.79
|
| Rate for Payer: Preferred Network Access Commercial |
$388.46
|
| Rate for Payer: Quartz Beloit One Network |
$206.90
|
| Rate for Payer: Quartz Commercial |
$253.34
|
| Rate for Payer: WEA Trust Commercial |
$232.23
|
| Rate for Payer: WPS Commercial |
$312.74
|
|
|
Established Pt Consult Level 4
|
Facility
|
OP
|
$406.00
|
|
|
Service Code
|
CPT 99244
|
| Hospital Charge Code |
3040422
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$118.23 |
| Max. Negotiated Rate |
$388.46 |
| Rate for Payer: Aetna Commercial |
$380.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.13
|
| Rate for Payer: Aetna Managed Medicare |
$118.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$274.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$211.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$202.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.79
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$388.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.29
|
| Rate for Payer: Health EOS Commercial |
$375.79
|
| Rate for Payer: HFN Commercial |
$388.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$316.68
|
| Rate for Payer: Multiplan Commercial |
$337.79
|
| Rate for Payer: NAPHCARE Commercial |
$253.34
|
| Rate for Payer: Preferred Network Access Commercial |
$388.46
|
| Rate for Payer: Quartz Beloit One Network |
$206.90
|
| Rate for Payer: Quartz Commercial |
$274.46
|
| Rate for Payer: Quartz Medicare Advantage |
$253.34
|
| Rate for Payer: The Alliance Commercial |
$211.12
|
| Rate for Payer: WEA Trust Commercial |
$232.23
|
| Rate for Payer: WPS Commercial |
$312.74
|
|
|
Est Office Visit Routine
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040417
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$76.00 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Aetna Managed Medicare |
$76.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.90
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$203.58
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: NAPHCARE Commercial |
$162.86
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$176.44
|
| Rate for Payer: Quartz Medicare Advantage |
$162.86
|
| Rate for Payer: The Alliance Commercial |
$228.43
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
Est Office Visit Routine
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040417
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$133.01 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$162.86
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
Est Patient Office Visit Brief
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3040416
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$117.72 |
| Max. Negotiated Rate |
$221.02 |
| Rate for Payer: Aetna Commercial |
$216.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.33
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna Commercial |
$221.02
|
| Rate for Payer: Health EOS Commercial |
$213.81
|
| Rate for Payer: HFN Commercial |
$221.02
|
| Rate for Payer: Multiplan Commercial |
$192.19
|
| Rate for Payer: Preferred Network Access Commercial |
$221.02
|
| Rate for Payer: Quartz Beloit One Network |
$117.72
|
| Rate for Payer: Quartz Commercial |
$144.14
|
| Rate for Payer: WEA Trust Commercial |
$132.13
|
| Rate for Payer: WPS Commercial |
$177.94
|
|
|
Est Patient Office Visit Brief
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3040416
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.27 |
| Max. Negotiated Rate |
$221.02 |
| Rate for Payer: Aetna Commercial |
$216.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.61
|
| Rate for Payer: Aetna Managed Medicare |
$67.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$156.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$120.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$115.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.33
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna Commercial |
$221.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.44
|
| Rate for Payer: Health EOS Commercial |
$213.81
|
| Rate for Payer: HFN Commercial |
$221.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.18
|
| Rate for Payer: Multiplan Commercial |
$192.19
|
| Rate for Payer: NAPHCARE Commercial |
$144.14
|
| Rate for Payer: Preferred Network Access Commercial |
$221.02
|
| Rate for Payer: Quartz Beloit One Network |
$117.72
|
| Rate for Payer: Quartz Commercial |
$156.16
|
| Rate for Payer: Quartz Medicare Advantage |
$144.14
|
| Rate for Payer: The Alliance Commercial |
$122.47
|
| Rate for Payer: WEA Trust Commercial |
$132.13
|
| Rate for Payer: WPS Commercial |
$177.94
|
|
|
Est Patient Office Visit Ext
|
Facility
|
OP
|
$448.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
3040418
|
|
Hospital Revenue Code
|
510
|
| 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: 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 |
$335.34
|
| Rate for Payer: WEA Trust Commercial |
$256.26
|
| Rate for Payer: WPS Commercial |
$345.09
|
|
|
Est Patient Office Visit Ext
|
Facility
|
IP
|
$448.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
3040418
|
|
Hospital Revenue Code
|
510
|
| 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
|
|
|
Est/P Exam Min 99211PP
|
Professional
|
Both
|
$147.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3133510
|
|
Hospital Revenue Code
|
500
|
| Min. Negotiated Rate |
$7.69 |
| Max. Negotiated Rate |
$145.24 |
| Rate for Payer: Aetna Commercial |
$145.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| 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 |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$145.24
|
| 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 |
$139.12
|
| Rate for Payer: HFN Commercial |
$145.24
|
| 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 |
$122.30
|
| Rate for Payer: NAPHCARE Commercial |
$11.53
|
| Rate for Payer: Preferred Network Access Commercial |
$145.24
|
| Rate for Payer: Quartz Beloit One Network |
$67.27
|
| Rate for Payer: Quartz Commercial |
$87.14
|
| 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 |
$84.08
|
| Rate for Payer: WPS Commercial |
$16.14
|
|
|
estradiol 10 mg Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
2958929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$30.99 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.91
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$30.99
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$22.51
|
|
|
estradiol 10 mg Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
2958929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
estradiol 10 mg Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
2958929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$22.51 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$7.75
|
| Rate for Payer: Anthem Medicare Advantage |
$7.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.75
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.00
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.75
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$11.62
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: Quartz Medicare Advantage |
$7.75
|
| Rate for Payer: The Alliance Commercial |
$21.31
|
| Rate for Payer: United Healthcare Medicaid |
$7.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.75
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$22.51
|
|
