|
Inhibin A Level
|
Professional
|
Both
|
$133.00
|
|
|
Service Code
|
CPT 86336
|
| Hospital Charge Code |
5542684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$55.03 |
| Max. Negotiated Rate |
$126.35 |
| Rate for Payer: Aetna Commercial |
$126.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.38
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cigna Commercial |
$126.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$66.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79.80
|
| Rate for Payer: Health EOS Commercial |
$121.03
|
| Rate for Payer: HFN Commercial |
$126.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$55.03
|
| Rate for Payer: Multiplan Commercial |
$106.40
|
| Rate for Payer: Preferred Network Access Commercial |
$126.35
|
| Rate for Payer: Quartz Beloit One Network |
$58.52
|
| Rate for Payer: Quartz Commercial |
$75.81
|
| Rate for Payer: The Alliance Commercial |
$66.50
|
| Rate for Payer: WEA Trust Commercial |
$73.15
|
| Rate for Payer: WPS Commercial |
$98.51
|
|
|
Inhibin B Level
|
Professional
|
Both
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
1040828
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.96 |
| Max. Negotiated Rate |
$338.20 |
| Rate for Payer: Aetna Commercial |
$338.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$338.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$178.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$213.60
|
| Rate for Payer: Health EOS Commercial |
$323.96
|
| Rate for Payer: HFN Commercial |
$338.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.96
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: Preferred Network Access Commercial |
$338.20
|
| Rate for Payer: Quartz Beloit One Network |
$156.64
|
| Rate for Payer: Quartz Commercial |
$202.92
|
| Rate for Payer: The Alliance Commercial |
$178.00
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
Inhibin B Level
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
1040828
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$174.44 |
| Max. Negotiated Rate |
$327.52 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$213.60
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$213.60
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
Inhibin B Level
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
1040828
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$327.52 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Aetna Managed Medicare |
$17.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.67
|
| Rate for Payer: Anthem Medicaid |
$17.85
|
| Rate for Payer: Anthem Medicare Advantage |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.27
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.22
|
| Rate for Payer: Dean Health Medicaid |
$17.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.27
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.27
|
| Rate for Payer: Managed Health Services Medicaid |
$18.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.27
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$25.90
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.85
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$231.40
|
| Rate for Payer: Quartz Medicare Advantage |
$17.27
|
| Rate for Payer: The Alliance Commercial |
$69.08
|
| Rate for Payer: United Healthcare Medicaid |
$17.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.27
|
| Rate for Payer: United Healthcare PPO |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: Wellcare Medicare |
$17.27
|
| Rate for Payer: WMAP Medicaid |
$17.85
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
Initial application of EPCs for this admission* - Antiembolism Device
|
Facility
|
IP
|
$2,034.00
|
|
| Hospital Charge Code |
4075889
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$996.66 |
| Max. Negotiated Rate |
$1,871.28 |
| Rate for Payer: Aetna Commercial |
$1,830.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,749.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,078.02
|
| Rate for Payer: Cash Price |
$610.20
|
| Rate for Payer: Cigna Commercial |
$1,871.28
|
| Rate for Payer: Health EOS Commercial |
$1,810.26
|
| Rate for Payer: HFN Commercial |
$1,871.28
|
| Rate for Payer: Multiplan Commercial |
$1,627.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,220.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,871.28
|
| Rate for Payer: Quartz Beloit One Network |
$996.66
|
| Rate for Payer: Quartz Commercial |
$1,220.40
|
| Rate for Payer: WEA Trust Commercial |
$1,118.70
|
| Rate for Payer: WPS Commercial |
$1,506.58
|
|
|
Initial application of EPCs for this admission* - Antiembolism Device
|
Facility
|
OP
|
$2,034.00
|
|
| Hospital Charge Code |
4075889
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$569.52 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$1,830.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,749.24
|
| Rate for Payer: Aetna Managed Medicare |
$569.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,322.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,017.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$976.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,078.02
|
| Rate for Payer: Cash Price |
$610.20
|
| Rate for Payer: Cigna Commercial |
$1,871.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,138.23
|
| Rate for Payer: Health EOS Commercial |
$1,810.26
|
| Rate for Payer: HFN Commercial |
$1,871.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,525.50
|
| Rate for Payer: Multiplan Commercial |
$1,627.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,220.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,871.28
|
| Rate for Payer: Quartz Beloit One Network |
$996.66
|
| Rate for Payer: Quartz Commercial |
$1,322.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,220.40
|
| Rate for Payer: The Alliance Commercial |
$8,136.00
|
| Rate for Payer: WEA Trust Commercial |
$1,118.70
|
| Rate for Payer: WPS Commercial |
$1,506.58
|
|
|
Initial - Chest Physiotherapy Charge
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2990159
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$88.32 |
| Max. Negotiated Rate |
$505.04 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$119.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.32
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$119.60
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$138.00
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
Initial - Chest Physiotherapy Charge
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2990159
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
Initial Comp Preventive Medicine 5-11 Yrs New - 99383
|
Professional
|
Both
|
$331.00
|
|
|
Service Code
|
CPT 99383
|
| Hospital Charge Code |
2982408
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$79.38 |
| Max. Negotiated Rate |
$314.45 |
| Rate for Payer: Aetna Commercial |
$314.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$284.66
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$314.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$79.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$198.60
|
| Rate for Payer: Health EOS Commercial |
$301.21
|
| Rate for Payer: HFN Commercial |
$314.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$291.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$291.08
|
| Rate for Payer: Multiplan Commercial |
$264.80
|
| Rate for Payer: Preferred Network Access Commercial |
$314.45
|
| Rate for Payer: Quartz Beloit One Network |
$145.64
|
| Rate for Payer: Quartz Commercial |
$188.67
|
| Rate for Payer: The Alliance Commercial |
$165.50
|
| Rate for Payer: United Healthcare Medicaid |
$79.38
|
| Rate for Payer: WEA Trust Commercial |
$182.05
|
| Rate for Payer: WPS Commercial |
$245.17
|
|
|
Initial Comprehensive Preventive Medicine 12-17 Years New
|
Professional
|
Both
|
$361.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
1122823
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$89.35 |
| Max. Negotiated Rate |
$342.95 |
| Rate for Payer: Aetna Commercial |
$342.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$310.46
|
| Rate for Payer: Cash Price |
$108.30
|
| Rate for Payer: Cash Price |
$108.30
|
| Rate for Payer: Cash Price |
$108.30
|
| Rate for Payer: Cigna Commercial |
$342.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$216.60
|
| Rate for Payer: Health EOS Commercial |
$328.51
|
| Rate for Payer: HFN Commercial |
$342.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$341.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$341.53
|
| Rate for Payer: Multiplan Commercial |
$288.80
|
| Rate for Payer: Preferred Network Access Commercial |
$342.95
|
| Rate for Payer: Quartz Beloit One Network |
$158.84
|
| Rate for Payer: Quartz Commercial |
$205.77
|
| Rate for Payer: The Alliance Commercial |
$180.50
|
| Rate for Payer: United Healthcare Medicaid |
$89.35
|
| Rate for Payer: WEA Trust Commercial |
$198.55
|
| Rate for Payer: WPS Commercial |
$267.39
|
|
|
Initial Comprehensive Preventive Medicine 1-4 Years New
|
Professional
|
Both
|
$298.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
1122821
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$76.34 |
| Max. Negotiated Rate |
$283.10 |
| Rate for Payer: Aetna Commercial |
$283.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$256.28
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cigna Commercial |
$283.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$178.80
|
| Rate for Payer: Health EOS Commercial |
$271.18
|
| Rate for Payer: HFN Commercial |
$283.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$273.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$273.75
|
| Rate for Payer: Multiplan Commercial |
$238.40
|
| Rate for Payer: Preferred Network Access Commercial |
$283.10
|
| Rate for Payer: Quartz Beloit One Network |
$131.12
|
| Rate for Payer: Quartz Commercial |
$169.86
|
| Rate for Payer: The Alliance Commercial |
$149.00
|
| Rate for Payer: United Healthcare Medicaid |
$76.34
|
| Rate for Payer: WEA Trust Commercial |
$163.90
|
| Rate for Payer: WPS Commercial |
$220.73
|
|
|
Initial Comprehensive Preventive Medicine 18-39 Years New
|
Professional
|
Both
|
$539.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
1122824
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$86.78 |
| Max. Negotiated Rate |
$512.05 |
| Rate for Payer: Aetna Commercial |
$512.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$463.54
|
| Rate for Payer: Cash Price |
$161.70
|
| Rate for Payer: Cash Price |
$161.70
|
| Rate for Payer: Cash Price |
$161.70
|
| Rate for Payer: Cigna Commercial |
$512.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$86.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$323.40
|
| Rate for Payer: Health EOS Commercial |
$490.49
|
| Rate for Payer: HFN Commercial |
$512.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$327.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$327.83
|
| Rate for Payer: Multiplan Commercial |
$431.20
|
| Rate for Payer: Preferred Network Access Commercial |
$512.05
|
| Rate for Payer: Quartz Beloit One Network |
$237.16
|
| Rate for Payer: Quartz Commercial |
$307.23
|
| Rate for Payer: The Alliance Commercial |
$269.50
|
| Rate for Payer: United Healthcare Medicaid |
$86.78
|
| Rate for Payer: WEA Trust Commercial |
$296.45
|
| Rate for Payer: WPS Commercial |
$399.24
|
|
|
Initial Comprehensive Preventive Medicine < 1 Year New
|
Professional
|
Both
|
$267.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
1122820
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.06 |
| Max. Negotiated Rate |
$256.81 |
| Rate for Payer: Aetna Commercial |
$253.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$229.62
|
| Rate for Payer: Cash Price |
$80.10
|
| Rate for Payer: Cash Price |
$80.10
|
| Rate for Payer: Cash Price |
$80.10
|
| Rate for Payer: Cigna Commercial |
$253.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.20
|
| Rate for Payer: Health EOS Commercial |
$242.97
|
| Rate for Payer: HFN Commercial |
$253.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$256.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$256.81
|
| Rate for Payer: Multiplan Commercial |
$213.60
|
| Rate for Payer: Preferred Network Access Commercial |
$253.65
|
| Rate for Payer: Quartz Beloit One Network |
$117.48
|
| Rate for Payer: Quartz Commercial |
$152.19
|
| Rate for Payer: The Alliance Commercial |
$133.50
|
| Rate for Payer: United Healthcare Medicaid |
$73.06
|
| Rate for Payer: WEA Trust Commercial |
$146.85
|
| Rate for Payer: WPS Commercial |
$197.77
|
|
|
Initial Comprehensive Preventive Medicine 40-64 Years New
|
Professional
|
Both
|
$397.00
|
|
|
Service Code
|
CPT 99386
|
| Hospital Charge Code |
1122825
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$100.03 |
| Max. Negotiated Rate |
$398.36 |
| Rate for Payer: Aetna Commercial |
$377.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$377.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$100.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$238.20
|
| Rate for Payer: Health EOS Commercial |
$361.27
|
| Rate for Payer: HFN Commercial |
$377.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$398.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$398.36
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: Preferred Network Access Commercial |
$377.15
|
| Rate for Payer: Quartz Beloit One Network |
$174.68
|
| Rate for Payer: Quartz Commercial |
$226.29
|
| Rate for Payer: The Alliance Commercial |
$198.50
|
| Rate for Payer: United Healthcare Medicaid |
$100.03
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
Initial Comprehensive Preventive Medicine 65 Years and Older New
|
Professional
|
Both
|
$459.00
|
|
|
Service Code
|
CPT 99387
|
| Hospital Charge Code |
1122826
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$108.57 |
| Max. Negotiated Rate |
$436.05 |
| Rate for Payer: Aetna Commercial |
$436.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$394.74
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$436.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$108.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$275.40
|
| Rate for Payer: Health EOS Commercial |
$417.69
|
| Rate for Payer: HFN Commercial |
$436.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$428.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$428.12
|
| Rate for Payer: Multiplan Commercial |
$367.20
|
| Rate for Payer: Preferred Network Access Commercial |
$436.05
|
| Rate for Payer: Quartz Beloit One Network |
$201.96
|
| Rate for Payer: Quartz Commercial |
$261.63
|
| Rate for Payer: The Alliance Commercial |
$229.50
|
| Rate for Payer: United Healthcare Medicaid |
$108.57
|
| Rate for Payer: WEA Trust Commercial |
$252.45
|
| Rate for Payer: WPS Commercial |
$339.98
|
|
|
Initial emergency room strip posted* - ED Initial Rhythm Strip Posted
|
Facility
|
OP
|
$64.00
|
|
| Hospital Charge Code |
4075881
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.92 |
| Max. Negotiated Rate |
$256.00 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Aetna Managed Medicare |
$17.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.81
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$41.60
|
| Rate for Payer: Quartz Medicare Advantage |
$38.40
|
| Rate for Payer: The Alliance Commercial |
$256.00
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
Initial emergency room strip posted* - ED Initial Rhythm Strip Posted
|
Facility
|
IP
|
$64.00
|
|
| Hospital Charge Code |
4075881
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$31.36 |
| Max. Negotiated Rate |
$58.88 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$38.40
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
Initial - Handheld Nebulizer Charge
|
Facility
|
OP
|
$337.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
2990157
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$161.76 |
| Max. Negotiated Rate |
$843.28 |
| Rate for Payer: Aetna Commercial |
$303.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$289.82
|
| Rate for Payer: Aetna Managed Medicare |
$210.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$219.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$168.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$161.76
|
| Rate for Payer: Anthem Medicare Advantage |
$210.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$178.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$210.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$210.82
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$310.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$210.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$188.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$210.82
|
| Rate for Payer: Health EOS Commercial |
$299.93
|
| Rate for Payer: HFN Commercial |
$310.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$210.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$210.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$210.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$210.82
|
| Rate for Payer: Multiplan Commercial |
$269.60
|
| Rate for Payer: NAPHCARE Commercial |
$316.23
|
| Rate for Payer: Preferred Network Access Commercial |
$310.04
|
| Rate for Payer: Quartz Beloit One Network |
$165.13
|
| Rate for Payer: Quartz Commercial |
$219.05
|
| Rate for Payer: Quartz Medicare Advantage |
$210.82
|
| Rate for Payer: The Alliance Commercial |
$843.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.82
|
| Rate for Payer: United Healthcare PPO |
$252.75
|
| Rate for Payer: WEA Trust Commercial |
$185.35
|
| Rate for Payer: Wellcare Medicare |
$210.82
|
| Rate for Payer: WPS Commercial |
$249.62
|
|
|
Initial - Handheld Nebulizer Charge
|
Facility
|
IP
|
$337.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
2990157
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$165.13 |
| Max. Negotiated Rate |
$310.04 |
| Rate for Payer: Aetna Commercial |
$303.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$289.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$178.61
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$310.04
|
| Rate for Payer: Health EOS Commercial |
$299.93
|
| Rate for Payer: HFN Commercial |
$310.04
|
| Rate for Payer: Multiplan Commercial |
$269.60
|
| Rate for Payer: NAPHCARE Commercial |
$202.20
|
| Rate for Payer: Preferred Network Access Commercial |
$310.04
|
| Rate for Payer: Quartz Beloit One Network |
$165.13
|
| Rate for Payer: Quartz Commercial |
$202.20
|
| Rate for Payer: WEA Trust Commercial |
$185.35
|
| Rate for Payer: WPS Commercial |
$249.62
|
|
|
Initial Hospital Care 99221
|
Facility
|
OP
|
$691.00
|
|
|
Service Code
|
CPT 99221
|
| Hospital Charge Code |
4001093
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$193.48 |
| Max. Negotiated Rate |
$2,764.00 |
| Rate for Payer: Aetna Commercial |
$621.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$594.26
|
| Rate for Payer: Aetna Managed Medicare |
$193.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$449.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$345.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$331.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$366.23
|
| Rate for Payer: Cash Price |
$207.30
|
| Rate for Payer: Cigna Commercial |
$635.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$386.68
|
| Rate for Payer: Health EOS Commercial |
$614.99
|
| Rate for Payer: HFN Commercial |
$635.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$518.25
|
| Rate for Payer: Multiplan Commercial |
$552.80
|
| Rate for Payer: NAPHCARE Commercial |
$414.60
|
| Rate for Payer: Preferred Network Access Commercial |
$635.72
|
| Rate for Payer: Quartz Beloit One Network |
$338.59
|
| Rate for Payer: Quartz Commercial |
$449.15
|
| Rate for Payer: Quartz Medicare Advantage |
$414.60
|
| Rate for Payer: The Alliance Commercial |
$2,764.00
|
| Rate for Payer: WEA Trust Commercial |
$380.05
|
| Rate for Payer: WPS Commercial |
$511.82
|
|
|
Initial Hospital Care 99221
|
Facility
|
IP
|
$691.00
|
|
|
Service Code
|
CPT 99221
|
| Hospital Charge Code |
4001093
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$338.59 |
| Max. Negotiated Rate |
$635.72 |
| Rate for Payer: Aetna Commercial |
$621.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$594.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$366.23
|
| Rate for Payer: Cash Price |
$207.30
|
| Rate for Payer: Cigna Commercial |
$635.72
|
| Rate for Payer: Health EOS Commercial |
$614.99
|
| Rate for Payer: HFN Commercial |
$635.72
|
| Rate for Payer: Multiplan Commercial |
$552.80
|
| Rate for Payer: NAPHCARE Commercial |
$414.60
|
| Rate for Payer: Preferred Network Access Commercial |
$635.72
|
| Rate for Payer: Quartz Beloit One Network |
$338.59
|
| Rate for Payer: Quartz Commercial |
$414.60
|
| Rate for Payer: WEA Trust Commercial |
$380.05
|
| Rate for Payer: WPS Commercial |
$511.82
|
|
|
Initial Hospital Care 99222
|
Facility
|
IP
|
$891.00
|
|
|
Service Code
|
CPT 99222
|
| Hospital Charge Code |
4001094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$436.59 |
| Max. Negotiated Rate |
$819.72 |
| Rate for Payer: Aetna Commercial |
$801.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$766.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$472.23
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna Commercial |
$819.72
|
| Rate for Payer: Health EOS Commercial |
$792.99
|
| Rate for Payer: HFN Commercial |
$819.72
|
| Rate for Payer: Multiplan Commercial |
$712.80
|
| Rate for Payer: NAPHCARE Commercial |
$534.60
|
| Rate for Payer: Preferred Network Access Commercial |
$819.72
|
| Rate for Payer: Quartz Beloit One Network |
$436.59
|
| Rate for Payer: Quartz Commercial |
$534.60
|
| Rate for Payer: WEA Trust Commercial |
$490.05
|
| Rate for Payer: WPS Commercial |
$659.96
|
|
|
Initial Hospital Care 99222
|
Facility
|
OP
|
$891.00
|
|
|
Service Code
|
CPT 99222
|
| Hospital Charge Code |
4001094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$249.48 |
| Max. Negotiated Rate |
$3,564.00 |
| Rate for Payer: Aetna Commercial |
$801.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$766.26
|
| Rate for Payer: Aetna Managed Medicare |
$249.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$579.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$445.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$427.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$472.23
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna Commercial |
$819.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$498.60
|
| Rate for Payer: Health EOS Commercial |
$792.99
|
| Rate for Payer: HFN Commercial |
$819.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$668.25
|
| Rate for Payer: Multiplan Commercial |
$712.80
|
| Rate for Payer: NAPHCARE Commercial |
$534.60
|
| Rate for Payer: Preferred Network Access Commercial |
$819.72
|
| Rate for Payer: Quartz Beloit One Network |
$436.59
|
| Rate for Payer: Quartz Commercial |
$579.15
|
| Rate for Payer: Quartz Medicare Advantage |
$534.60
|
| Rate for Payer: The Alliance Commercial |
$3,564.00
|
| Rate for Payer: WEA Trust Commercial |
$490.05
|
| Rate for Payer: WPS Commercial |
$659.96
|
|
|
Initial Hospital Care 99223
|
Facility
|
OP
|
$1,093.00
|
|
|
Service Code
|
CPT 99223
|
| Hospital Charge Code |
4001095
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$306.04 |
| Max. Negotiated Rate |
$4,372.00 |
| Rate for Payer: Aetna Commercial |
$983.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$939.98
|
| Rate for Payer: Aetna Managed Medicare |
$306.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$710.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$546.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$524.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$579.29
|
| Rate for Payer: Cash Price |
$327.90
|
| Rate for Payer: Cigna Commercial |
$1,005.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$611.64
|
| Rate for Payer: Health EOS Commercial |
$972.77
|
| Rate for Payer: HFN Commercial |
$1,005.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$819.75
|
| Rate for Payer: Multiplan Commercial |
$874.40
|
| Rate for Payer: NAPHCARE Commercial |
$655.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,005.56
|
| Rate for Payer: Quartz Beloit One Network |
$535.57
|
| Rate for Payer: Quartz Commercial |
$710.45
|
| Rate for Payer: Quartz Medicare Advantage |
$655.80
|
| Rate for Payer: The Alliance Commercial |
$4,372.00
|
| Rate for Payer: WEA Trust Commercial |
$601.15
|
| Rate for Payer: WPS Commercial |
$809.59
|
|
|
Initial Hospital Care 99223
|
Facility
|
IP
|
$1,093.00
|
|
|
Service Code
|
CPT 99223
|
| Hospital Charge Code |
4001095
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$535.57 |
| Max. Negotiated Rate |
$1,005.56 |
| Rate for Payer: Aetna Commercial |
$983.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$939.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$579.29
|
| Rate for Payer: Cash Price |
$327.90
|
| Rate for Payer: Cigna Commercial |
$1,005.56
|
| Rate for Payer: Health EOS Commercial |
$972.77
|
| Rate for Payer: HFN Commercial |
$1,005.56
|
| Rate for Payer: Multiplan Commercial |
$874.40
|
| Rate for Payer: NAPHCARE Commercial |
$655.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,005.56
|
| Rate for Payer: Quartz Beloit One Network |
$535.57
|
| Rate for Payer: Quartz Commercial |
$655.80
|
| Rate for Payer: WEA Trust Commercial |
$601.15
|
| Rate for Payer: WPS Commercial |
$809.59
|
|
