|
Inhibin A
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
CPT 86336
|
| Hospital Charge Code |
2942985
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$172.75 |
| Max. Negotiated Rate |
$324.36 |
| Rate for Payer: Aetna Commercial |
$317.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$303.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$186.86
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cigna Commercial |
$324.36
|
| Rate for Payer: Health EOS Commercial |
$313.78
|
| Rate for Payer: HFN Commercial |
$324.36
|
| Rate for Payer: Multiplan Commercial |
$282.05
|
| Rate for Payer: Preferred Network Access Commercial |
$324.36
|
| Rate for Payer: Quartz Beloit One Network |
$172.75
|
| Rate for Payer: Quartz Commercial |
$211.54
|
| Rate for Payer: WEA Trust Commercial |
$193.91
|
| Rate for Payer: WPS Commercial |
$261.13
|
|
|
Inhibin A
|
Professional
|
Both
|
$339.00
|
|
|
Service Code
|
CPT 86336
|
| Hospital Charge Code |
2942985
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.21 |
| Max. Negotiated Rate |
$334.93 |
| Rate for Payer: Aetna Commercial |
$334.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$303.20
|
| Rate for Payer: Aetna Managed Medicare |
$16.21
|
| Rate for Payer: Anthem Medicare Advantage |
$16.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.21
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cigna Commercial |
$334.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$176.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.21
|
| Rate for Payer: Health EOS Commercial |
$320.83
|
| Rate for Payer: HFN Commercial |
$334.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.21
|
| Rate for Payer: Multiplan Commercial |
$282.05
|
| Rate for Payer: NAPHCARE Commercial |
$24.32
|
| Rate for Payer: Preferred Network Access Commercial |
$334.93
|
| Rate for Payer: Quartz Beloit One Network |
$155.13
|
| Rate for Payer: Quartz Commercial |
$200.96
|
| Rate for Payer: Quartz Medicare Advantage |
$16.21
|
| Rate for Payer: The Alliance Commercial |
$64.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.21
|
| Rate for Payer: WEA Trust Commercial |
$193.91
|
| Rate for Payer: WPS Commercial |
$71.34
|
|
|
Inhibin A
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
CPT 86336
|
| Hospital Charge Code |
2942985
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.21 |
| Max. Negotiated Rate |
$324.36 |
| Rate for Payer: Aetna Commercial |
$317.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$303.20
|
| Rate for Payer: Aetna Managed Medicare |
$16.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.91
|
| Rate for Payer: Anthem Medicare Advantage |
$16.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$186.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.21
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cigna Commercial |
$324.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.21
|
| Rate for Payer: Health EOS Commercial |
$313.78
|
| Rate for Payer: HFN Commercial |
$324.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.21
|
| Rate for Payer: Multiplan Commercial |
$282.05
|
| Rate for Payer: NAPHCARE Commercial |
$24.32
|
| Rate for Payer: Preferred Network Access Commercial |
$324.36
|
| Rate for Payer: Quartz Beloit One Network |
$172.75
|
| Rate for Payer: Quartz Commercial |
$229.16
|
| Rate for Payer: Quartz Medicare Advantage |
$16.21
|
| Rate for Payer: The Alliance Commercial |
$64.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.21
|
| Rate for Payer: United Healthcare PPO |
$264.42
|
| Rate for Payer: WEA Trust Commercial |
$193.91
|
| Rate for Payer: Wellcare Medicare |
$16.21
|
| Rate for Payer: WPS Commercial |
$261.13
|
|
|
Inhibin A Level
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
CPT 86336
|
| Hospital Charge Code |
5542684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.21 |
| Max. Negotiated Rate |
$127.25 |
| Rate for Payer: Aetna Commercial |
$124.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.96
|
| Rate for Payer: Aetna Managed Medicare |
$16.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.91
|
| Rate for Payer: Anthem Medicare Advantage |
$16.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.21
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cigna Commercial |
$127.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.21
|
| Rate for Payer: Health EOS Commercial |
$123.10
|
| Rate for Payer: HFN Commercial |
$127.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.21
|
| Rate for Payer: Multiplan Commercial |
$110.66
|
| Rate for Payer: NAPHCARE Commercial |
$24.32
|
| Rate for Payer: Preferred Network Access Commercial |
$127.25
|
| Rate for Payer: Quartz Beloit One Network |
$67.78
|
| Rate for Payer: Quartz Commercial |
$89.91
|
| Rate for Payer: Quartz Medicare Advantage |
$16.21
|
| Rate for Payer: The Alliance Commercial |
$64.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.21
|
| Rate for Payer: United Healthcare PPO |
$103.74
|
| Rate for Payer: WEA Trust Commercial |
$76.08
|
| Rate for Payer: Wellcare Medicare |
$16.21
|
| Rate for Payer: WPS Commercial |
$102.45
|
|
|
Inhibin A Level
|
Professional
|
Both
|
$133.00
|
|
|
Service Code
|
CPT 86336
|
| Hospital Charge Code |
5542684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.21 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.96
|
| Rate for Payer: Aetna Managed Medicare |
$16.21
|
| Rate for Payer: Anthem Medicare Advantage |
$16.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.21
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cigna Commercial |
$131.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.21
|
| Rate for Payer: Health EOS Commercial |
$125.87
|
| Rate for Payer: HFN Commercial |
$131.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.21
|
| Rate for Payer: Multiplan Commercial |
$110.66
|
| Rate for Payer: NAPHCARE Commercial |
$24.32
|
| Rate for Payer: Preferred Network Access Commercial |
$131.40
|
| Rate for Payer: Quartz Beloit One Network |
$60.86
|
| Rate for Payer: Quartz Commercial |
$78.84
|
| Rate for Payer: Quartz Medicare Advantage |
$16.21
|
| Rate for Payer: The Alliance Commercial |
$64.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.21
|
| Rate for Payer: WEA Trust Commercial |
$76.08
|
| Rate for Payer: WPS Commercial |
$71.34
|
|
|
Inhibin A Level
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
CPT 86336
|
| Hospital Charge Code |
5542684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.78 |
| Max. Negotiated Rate |
$127.25 |
| Rate for Payer: Aetna Commercial |
$124.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.31
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cigna Commercial |
$127.25
|
| Rate for Payer: Health EOS Commercial |
$123.10
|
| Rate for Payer: HFN Commercial |
$127.25
|
| Rate for Payer: Multiplan Commercial |
$110.66
|
| Rate for Payer: Preferred Network Access Commercial |
$127.25
|
| Rate for Payer: Quartz Beloit One Network |
$67.78
|
| Rate for Payer: Quartz Commercial |
$82.99
|
| Rate for Payer: WEA Trust Commercial |
$76.08
|
| Rate for Payer: WPS Commercial |
$102.45
|
|
|
Inhibin B Level
|
Professional
|
Both
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
1040828
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$351.73 |
| Rate for Payer: Aetna Commercial |
$351.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$351.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$185.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$336.92
|
| Rate for Payer: HFN Commercial |
$351.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$351.73
|
| Rate for Payer: Quartz Beloit One Network |
$162.91
|
| Rate for Payer: Quartz Commercial |
$211.04
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
Inhibin B Level
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
1040828
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| 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 |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| 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 |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
Inhibin B Level
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
1040828
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
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 |
$1,036.53 |
| Max. Negotiated Rate |
$1,946.13 |
| Rate for Payer: Aetna Commercial |
$1,903.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,819.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,121.14
|
| Rate for Payer: Cash Price |
$610.20
|
| Rate for Payer: Cigna Commercial |
$1,946.13
|
| Rate for Payer: Health EOS Commercial |
$1,882.67
|
| Rate for Payer: HFN Commercial |
$1,946.13
|
| Rate for Payer: Multiplan Commercial |
$1,692.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,946.13
|
| Rate for Payer: Quartz Beloit One Network |
$1,036.53
|
| Rate for Payer: Quartz Commercial |
$1,269.22
|
| Rate for Payer: WEA Trust Commercial |
$1,163.45
|
| Rate for Payer: WPS Commercial |
$1,566.79
|
|
|
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 |
$592.30 |
| Max. Negotiated Rate |
$1,946.13 |
| Rate for Payer: Aetna Commercial |
$1,903.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,819.21
|
| Rate for Payer: Aetna Managed Medicare |
$592.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,374.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,057.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,015.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,121.14
|
| Rate for Payer: Cash Price |
$610.20
|
| Rate for Payer: Cigna Commercial |
$1,946.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,183.79
|
| Rate for Payer: Health EOS Commercial |
$1,882.67
|
| Rate for Payer: HFN Commercial |
$1,946.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,586.52
|
| Rate for Payer: Multiplan Commercial |
$1,692.29
|
| Rate for Payer: NAPHCARE Commercial |
$1,269.22
|
| Rate for Payer: Preferred Network Access Commercial |
$1,946.13
|
| Rate for Payer: Quartz Beloit One Network |
$1,036.53
|
| Rate for Payer: Quartz Commercial |
$1,374.98
|
| Rate for Payer: Quartz Medicare Advantage |
$1,269.22
|
| Rate for Payer: The Alliance Commercial |
$1,057.68
|
| Rate for Payer: WEA Trust Commercial |
$1,163.45
|
| Rate for Payer: WPS Commercial |
$1,566.79
|
|
|
Initial - Chest Physiotherapy Charge
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2990159
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$93.77 |
| Max. Negotiated Rate |
$176.05 |
| Rate for Payer: Aetna Commercial |
$172.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.42
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$176.05
|
| Rate for Payer: Health EOS Commercial |
$170.31
|
| Rate for Payer: HFN Commercial |
$176.05
|
| Rate for Payer: Multiplan Commercial |
$153.09
|
| Rate for Payer: Preferred Network Access Commercial |
$176.05
|
| Rate for Payer: Quartz Beloit One Network |
$93.77
|
| Rate for Payer: Quartz Commercial |
$114.82
|
| Rate for Payer: WEA Trust Commercial |
$105.25
|
| Rate for Payer: WPS Commercial |
$141.74
|
|
|
Initial - Chest Physiotherapy Charge
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2990159
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$91.85 |
| Max. Negotiated Rate |
$560.06 |
| Rate for Payer: Aetna Commercial |
$172.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.57
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$124.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$95.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$91.85
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.42
|
| 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 |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$176.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$170.31
|
| Rate for Payer: HFN Commercial |
$176.05
|
| 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 |
$153.09
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$176.05
|
| Rate for Payer: Quartz Beloit One Network |
$93.77
|
| Rate for Payer: Quartz Commercial |
$124.38
|
| 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 |
$143.52
|
| Rate for Payer: WEA Trust Commercial |
$105.25
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$141.74
|
|
|
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 |
$82.56 |
| Max. Negotiated Rate |
$327.03 |
| Rate for Payer: Aetna Commercial |
$327.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.05
|
| 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 |
$327.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$82.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.54
|
| Rate for Payer: Health EOS Commercial |
$313.26
|
| Rate for Payer: HFN Commercial |
$327.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$302.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$302.72
|
| Rate for Payer: Multiplan Commercial |
$275.39
|
| Rate for Payer: Preferred Network Access Commercial |
$327.03
|
| Rate for Payer: Quartz Beloit One Network |
$151.47
|
| Rate for Payer: Quartz Commercial |
$196.22
|
| Rate for Payer: The Alliance Commercial |
$172.12
|
| Rate for Payer: United Healthcare Medicaid |
$82.56
|
| Rate for Payer: WEA Trust Commercial |
$189.33
|
| Rate for Payer: WPS Commercial |
$254.97
|
|
|
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 |
$92.92 |
| Max. Negotiated Rate |
$356.67 |
| Rate for Payer: Aetna Commercial |
$356.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$322.88
|
| 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 |
$356.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$92.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$225.26
|
| Rate for Payer: Health EOS Commercial |
$341.65
|
| Rate for Payer: HFN Commercial |
$356.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$355.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$355.19
|
| Rate for Payer: Multiplan Commercial |
$300.35
|
| Rate for Payer: Preferred Network Access Commercial |
$356.67
|
| Rate for Payer: Quartz Beloit One Network |
$165.19
|
| Rate for Payer: Quartz Commercial |
$214.00
|
| Rate for Payer: The Alliance Commercial |
$187.72
|
| Rate for Payer: United Healthcare Medicaid |
$92.92
|
| Rate for Payer: WEA Trust Commercial |
$206.49
|
| Rate for Payer: WPS Commercial |
$278.08
|
|
|
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 |
$79.39 |
| Max. Negotiated Rate |
$294.42 |
| Rate for Payer: Aetna Commercial |
$294.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$266.53
|
| 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 |
$294.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$79.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$185.95
|
| Rate for Payer: Health EOS Commercial |
$282.03
|
| Rate for Payer: HFN Commercial |
$294.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$284.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$284.70
|
| Rate for Payer: Multiplan Commercial |
$247.94
|
| Rate for Payer: Preferred Network Access Commercial |
$294.42
|
| Rate for Payer: Quartz Beloit One Network |
$136.36
|
| Rate for Payer: Quartz Commercial |
$176.65
|
| Rate for Payer: The Alliance Commercial |
$154.96
|
| Rate for Payer: United Healthcare Medicaid |
$79.39
|
| Rate for Payer: WEA Trust Commercial |
$170.46
|
| Rate for Payer: WPS Commercial |
$229.55
|
|
|
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 |
$90.25 |
| Max. Negotiated Rate |
$532.53 |
| Rate for Payer: Aetna Commercial |
$532.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$482.08
|
| 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 |
$532.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$90.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$336.34
|
| Rate for Payer: Health EOS Commercial |
$510.11
|
| Rate for Payer: HFN Commercial |
$532.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$340.94
|
| Rate for Payer: Multiplan Commercial |
$448.45
|
| Rate for Payer: Preferred Network Access Commercial |
$532.53
|
| Rate for Payer: Quartz Beloit One Network |
$246.65
|
| Rate for Payer: Quartz Commercial |
$319.52
|
| Rate for Payer: The Alliance Commercial |
$280.28
|
| Rate for Payer: United Healthcare Medicaid |
$90.25
|
| Rate for Payer: WEA Trust Commercial |
$308.31
|
| Rate for Payer: WPS Commercial |
$415.19
|
|
|
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 |
$75.98 |
| Max. Negotiated Rate |
$267.08 |
| Rate for Payer: Aetna Commercial |
$263.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.80
|
| 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 |
$263.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$166.61
|
| Rate for Payer: Health EOS Commercial |
$252.69
|
| Rate for Payer: HFN Commercial |
$263.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$267.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$267.08
|
| Rate for Payer: Multiplan Commercial |
$222.14
|
| Rate for Payer: Preferred Network Access Commercial |
$263.80
|
| Rate for Payer: Quartz Beloit One Network |
$122.18
|
| Rate for Payer: Quartz Commercial |
$158.28
|
| Rate for Payer: The Alliance Commercial |
$138.84
|
| Rate for Payer: United Healthcare Medicaid |
$75.98
|
| Rate for Payer: WEA Trust Commercial |
$152.72
|
| Rate for Payer: WPS Commercial |
$205.67
|
|
|
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 |
$104.03 |
| Max. Negotiated Rate |
$414.29 |
| Rate for Payer: Aetna Commercial |
$392.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.08
|
| 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 |
$392.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$247.73
|
| Rate for Payer: Health EOS Commercial |
$375.72
|
| Rate for Payer: HFN Commercial |
$392.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$414.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$414.29
|
| Rate for Payer: Multiplan Commercial |
$330.30
|
| Rate for Payer: Preferred Network Access Commercial |
$392.24
|
| Rate for Payer: Quartz Beloit One Network |
$181.67
|
| Rate for Payer: Quartz Commercial |
$235.34
|
| Rate for Payer: The Alliance Commercial |
$206.44
|
| Rate for Payer: United Healthcare Medicaid |
$104.03
|
| Rate for Payer: WEA Trust Commercial |
$227.08
|
| Rate for Payer: WPS Commercial |
$305.81
|
|
|
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 |
$112.91 |
| Max. Negotiated Rate |
$453.49 |
| Rate for Payer: Aetna Commercial |
$453.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$410.53
|
| 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 |
$453.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$112.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$286.42
|
| Rate for Payer: Health EOS Commercial |
$434.40
|
| Rate for Payer: HFN Commercial |
$453.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$445.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$445.24
|
| Rate for Payer: Multiplan Commercial |
$381.89
|
| Rate for Payer: Preferred Network Access Commercial |
$453.49
|
| Rate for Payer: Quartz Beloit One Network |
$210.04
|
| Rate for Payer: Quartz Commercial |
$272.10
|
| Rate for Payer: The Alliance Commercial |
$238.68
|
| Rate for Payer: United Healthcare Medicaid |
$112.91
|
| Rate for Payer: WEA Trust Commercial |
$262.55
|
| Rate for Payer: WPS Commercial |
$353.57
|
|
|
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 |
$18.64 |
| Max. Negotiated Rate |
$61.24 |
| Rate for Payer: Aetna Commercial |
$59.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.24
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.28
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$61.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.25
|
| Rate for Payer: Health EOS Commercial |
$59.24
|
| Rate for Payer: HFN Commercial |
$61.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.92
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
| Rate for Payer: NAPHCARE Commercial |
$39.94
|
| Rate for Payer: Preferred Network Access Commercial |
$61.24
|
| Rate for Payer: Quartz Beloit One Network |
$32.61
|
| Rate for Payer: Quartz Commercial |
$43.26
|
| Rate for Payer: Quartz Medicare Advantage |
$39.94
|
| Rate for Payer: The Alliance Commercial |
$33.28
|
| Rate for Payer: WEA Trust Commercial |
$36.61
|
| Rate for Payer: WPS Commercial |
$49.30
|
|
|
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 |
$32.61 |
| Max. Negotiated Rate |
$61.24 |
| Rate for Payer: Aetna Commercial |
$59.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.28
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$61.24
|
| Rate for Payer: Health EOS Commercial |
$59.24
|
| Rate for Payer: HFN Commercial |
$61.24
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
| Rate for Payer: Preferred Network Access Commercial |
$61.24
|
| Rate for Payer: Quartz Beloit One Network |
$32.61
|
| Rate for Payer: Quartz Commercial |
$39.94
|
| Rate for Payer: WEA Trust Commercial |
$36.61
|
| Rate for Payer: WPS Commercial |
$49.30
|
|
|
Initial - Handheld Nebulizer Charge
|
Facility
|
OP
|
$337.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
2990157
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$168.23 |
| Max. Negotiated Rate |
$921.81 |
| Rate for Payer: Aetna Commercial |
$315.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$301.41
|
| Rate for Payer: Aetna Managed Medicare |
$230.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$227.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$175.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$168.23
|
| Rate for Payer: Anthem Medicare Advantage |
$230.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$185.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$230.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$230.45
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$322.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$230.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$196.13
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$230.45
|
| Rate for Payer: Health EOS Commercial |
$311.93
|
| Rate for Payer: HFN Commercial |
$322.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$857.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$230.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$230.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$230.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$230.45
|
| Rate for Payer: Multiplan Commercial |
$280.38
|
| Rate for Payer: NAPHCARE Commercial |
$345.68
|
| Rate for Payer: Preferred Network Access Commercial |
$322.44
|
| Rate for Payer: Quartz Beloit One Network |
$171.74
|
| Rate for Payer: Quartz Commercial |
$227.81
|
| Rate for Payer: Quartz Medicare Advantage |
$230.45
|
| Rate for Payer: The Alliance Commercial |
$921.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$230.45
|
| Rate for Payer: United Healthcare PPO |
$262.86
|
| Rate for Payer: WEA Trust Commercial |
$192.76
|
| Rate for Payer: Wellcare Medicare |
$230.45
|
| Rate for Payer: WPS Commercial |
$259.59
|
|
|
Initial - Handheld Nebulizer Charge
|
Facility
|
IP
|
$337.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
2990157
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$171.74 |
| Max. Negotiated Rate |
$322.44 |
| Rate for Payer: Aetna Commercial |
$315.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$301.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$185.75
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$322.44
|
| Rate for Payer: Health EOS Commercial |
$311.93
|
| Rate for Payer: HFN Commercial |
$322.44
|
| Rate for Payer: Multiplan Commercial |
$280.38
|
| Rate for Payer: Preferred Network Access Commercial |
$322.44
|
| Rate for Payer: Quartz Beloit One Network |
$171.74
|
| Rate for Payer: Quartz Commercial |
$210.29
|
| Rate for Payer: WEA Trust Commercial |
$192.76
|
| Rate for Payer: WPS Commercial |
$259.59
|
|
|
Initial Hospital Care 99221
|
Facility
|
IP
|
$691.00
|
|
|
Service Code
|
CPT 99221
|
| Hospital Charge Code |
4001093
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$352.13 |
| Max. Negotiated Rate |
$661.15 |
| Rate for Payer: Aetna Commercial |
$646.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$618.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$380.88
|
| Rate for Payer: Cash Price |
$207.30
|
| Rate for Payer: Cigna Commercial |
$661.15
|
| Rate for Payer: Health EOS Commercial |
$639.59
|
| Rate for Payer: HFN Commercial |
$661.15
|
| Rate for Payer: Multiplan Commercial |
$574.91
|
| Rate for Payer: Preferred Network Access Commercial |
$661.15
|
| Rate for Payer: Quartz Beloit One Network |
$352.13
|
| Rate for Payer: Quartz Commercial |
$431.18
|
| Rate for Payer: WEA Trust Commercial |
$395.25
|
| Rate for Payer: WPS Commercial |
$532.28
|
|
