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LA RABIDA CHILDREN'S HOSPITAL
SHOPPPABLE SERVICES
Rev. 12/2020 REIMBURSEMENT
IL Medicaid United
Service CPT CMS- Charge Managed BCBS Health Cash
Location Service Type Description Code Req Amount QTY IL Medicaid Care BCBS PPO HMO Cigna Aetna Care Price
INPATIENT MEDICAL ROOM AND BOARD ROOM AND BOARD 120 $2,627.00 PER DAY $2,315.16 $2,315.16 $2,348.96 $1,019.00 $2,125.00 $1,700.00 $2,102.00 -
INPATIENT REHAB ROOM AND BOARD ROOM AND BOARD 120 $2,627.00 PER DAY $2,315.16 $2,315.16 $2,348.96 $1,019.00 $2,125.00 $1,700.00 $2,102.00 -
INPATIENT TRACH ROOM AND BOARD ROOM AND BOARD 120 $2,889.00 PER DAY $2,315.16 $2,315.16 $2,348.96 $3,800.00 $2,125.00 $1,700.00 $2,102.00 -
INPATIENT VENT ROOM AND BOARD ROOM AND BOARD 120 $3,021.00 PER DAY $2,315.16 $2,315.16 $2,348.96 $3,800.00 $2,125.00 $1,700.00 $2,102.00 -
INITIAL INPATIENT HISTORY & PROFESSIONAL
INPATIENT EXAM (LOW) SERVICES 99221 $204.00 PER UNIT $33.90 $33.90 $42.66 $42.66 $38.28 $98.39 $38.28 -
INITIAL INPATIENT HISTORY & PROFESSIONAL
INPATIENT EXAM (MOD) SERVICES 99222 $319.00 PER UNIT $51.40 $51.40 $56.47 $56.47 $53.94 $132.68 $53.94 -
INITIAL INPATIENT HISTORY & PROFESSIONAL
INPATIENT EXAM (HIGH) SERVICES 99223 $446.00 PER UNIT $69.00 $69.00 $112.93 $112.93 $90.97 $193.93 $115.97 -
SUBSEQUENT INPATIENT VISIT PROFESSIONAL
INPATIENT (LOW) SERVICES 99231 $117.00 PER UNIT $16.40 $16.40 $45.39 $45.69 $30.89 $37.13 $30.89 -
SUBSEQUENT INPATIENT VISIT PROFESSIONAL
INPATIENT (MOD) SERVICES 99232 $170.00 PER UNIT $24.90 $24.90 $78.59 $78.59 $67.92 $67.92 $78.59 -
SUBSEQUENT INPATIENT VISIT PROFESSIONAL
INPATIENT (HIGH) SERVICES 99233 $238.00 PER UNIT $35.05 $35.05 $56.65 $56.65 $78.45 $98.07 $78.45 -
INPATIENT CONSULT PROBLEM PROFESSIONAL
INPATIENT FOCUSED SERVICES 99251 $170.00 PER UNIT $32.15 $32.15 $51.44 $51.44 $43.72 $43.72 $59.58 -
INPATIENT CONSULT EXP PROFESSIONAL
INPATIENT PROBLEM FOCUSED SERVICES 99252 $239.00 PER UNIT $33.95 $33.95 $54.32 $54.32 $61.05 $67.69 $61.05 -
PROFESSIONAL
INPATIENT INPATIENT CONSULT - DETAILED SERVICES 99253 $285.00 PER UNIT $46.45 $46.45 $140.61 $140.61 $96.41 $102.16 $96.41 -
INPATIENT CONSULT - PROFESSIONAL
INPATIENT MODERATE SERVICES 99254 $404.00 PER UNIT $66.40 $66.40 $153.60 $153.60 $106.30 $146.20 $146.20 -
PROFESSIONAL
INPATIENT INPATIENT CONSULT - HIGH SERVICES 99255 $553.00 PER UNIT $87.10 $87.10 $139.36 $139.36 $111.48 $182.80 $111.48 -
$36.71- $36.71- $53.00- $62.30-
OBSERVATION OBSERVATION CHARGE OBSERVATION CARE 762 $89.00 PER HOUR $2989.43 $2989.43 $53.00-$1219 $1219 $1432.90 $35-$805 $35-$805 -
ACUTE CARE $94.94- $94.94- $103.11- $103.11-
CLINIC ER LEVEL 1 PROBLEM FOCUSED ACUTE CARE CLINIC 99281 $346.00 PER DAY $227.87 $227.87 $477.83 $477.83 $160.00 $248.53 $497.00 -
LA RABIDA CHILDREN'S HOSPITAL
SHOPPPABLE SERVICES
Rev. 12/2020 REIMBURSEMENT
IL Medicaid United
Service CPT CMS- Charge Managed BCBS Health Cash
Location Service Type Description Code Req Amount QTY IL Medicaid Care BCBS PPO HMO Cigna Aetna Care Price
ACUTE CARE $94.94- $94.94- $103.11- $103.11-
CLINIC ER LEVEL 2 PRBLM FOCUSED LOW ACUTE CARE CLINIC 99282 $461.00 PER DAY $227.87 $227.87 $477.83 $477.83 $160.00 $336.40 $497.00 -
ACUTE CARE ER LEVEL 3 EXPANDED PRBLM $121.28- $121.28- $103.11-
CLINIC MOD ACUTE CARE CLINIC 99283 $576.00 PER DAY $152.54 $152.54 $477.83 $489.60 $160.00 $374.40 $497.00 -
ACUTE CARE ER LEVEL 4 DETD MOD $121.28- $121.28- $103.11- $103.11-
CLINIC COMPLEXITY ACUTE CARE CLINIC 99284 $865.00 PER DAY $152.54 $152.54 $477.83 $477.83 $160.00 $435.00 $497.00 -
ACUTE CARE ER LEVEL COMPRHNSVE HIGH $121.28- $121.28- $103.11- $103.11-
CLINIC COMP ACUTE CARE CLINIC 99285 $865.00 PER DAY $152.54 $152.54 $477.83 $477.83 $160.00 $435.00 $497.00 -
ACUTE CARE
CLINIC DCFS EXAM ACUTE CARE CLINIC 99281 $461.00 PER UNIT $126.56 $126.56 n/a n/a n/a n/a n/a -
ACUTE CARE G TUBE CHANGE &
CLINIC REPLACEMENT ACUTE CARE CLINIC 43760 $146.88 PER UNIT $35.65 $35.65 $66.58 $66.08 $70.14 $48.36 $70.14 -
CLINIC OFFICE OUTPT NEW 20 MINUTES OUTPATIENT CLINIC 99202 $201.07 PER UNIT $33.60 $33.60 $56.63 $21.31 $64.81 $54.32 $54.32 -
CLINIC OFFICE OUTPT NEW 30 MINUTES OUTPATIENT CLINIC 99203 * $201.07 PER UNIT $43.55 $43.55 $65.26 $44.94 $72.62 $74.61 $62.60 -
CLINIC OFFICE OUTPT NEW 45 MIN OUTPATIENT CLINIC 99204 * $418.51 PER UNIT $69.65 $69.65 $143.11 $97.88 $84.50 $126.99 $130.51 -
CLINIC OFFICE OUTPT NEW 60 MIN OUTPATIENT CLINIC 99205 * $444.74 PER UNIT $74.10 $74.10 $186.71 $186.71 $178.54 $162.21 $178.54 -
CLINIC OFFICE O/P EST 5 MIN OUTPATIENT CLINIC 99211 $90.04 PER UNIT $12.88 $12.88 $29.41 $26.23 $21.46 $39.22 $39.22 -
CLINIC OFFICE OUTPT EST 10 MIN OUTPATIENT CLINIC 99212 $168.94 PER UNIT $25.65 $25.65 $45.27 $38.26 $23.78 $24.12 $27.97 -
CLINIC OFFICE OUTPT EST15 MIN OUTPATIENT CLINIC 99213 $256.69 PER UNIT $46.56 $46.56 $84.21 $75.79 $47.56 $48.56 $53.10 -
CLINIC OFFICE OUTPT EST 25 MIN OUTPATIENT CLINIC 99214 $361.60 PER UNIT $72.97 $72.97 $123.12 $98.12 $85.37 $74.59 $110.26 -
CLINIC OFFICE OUTPT EST 40 MIN OUTPATIENT CLINIC 99215 $453.81 PER UNIT $49.95 $49.95 $165.50 $140.67 $120.37 $193.95 $196.07 -
CLINIC OFFICE CONSLT 15 MIN OUTPATIENT CLINIC 99241 $256.69 PER UNIT $39.19 $39.19 $42.40 $42.40 $30.56 $30.56 $30.56 -
CLINIC OFFICE CONSLT 30 MIN OUTPATIENT CLINIC 99242 $346.40 PER UNIT $72.91 $72.91 $86.96 $56.63 $56.63 $63.83 $63.83 -
LA RABIDA CHILDREN'S HOSPITAL
SHOPPPABLE SERVICES
Rev. 12/2020 REIMBURSEMENT
IL Medicaid United
Service CPT CMS- Charge Managed BCBS Health Cash
Location Service Type Description Code Req Amount QTY IL Medicaid Care BCBS PPO HMO Cigna Aetna Care Price
CLINIC OFFICE CONSLT 40 MIN OUTPATIENT CLINIC 99243 * $493.37 PER UNIT $99.86 $99.86 $121.83 $121.83 $88.39 $88.39 $88.39 -
CLINIC OFFICE CONSLT 60 MIN OUTPATIENT CLINIC 99244 * $651.16 PER UNIT $147.24 $147.24 $166.75 $153.40 $153.40 $186.54 $168.89 -
CLINIC OFFICE CONSLT 80 MIN OUTPATIENT CLINIC 99245 $749.50 PER UNIT $182.82 $182.82 $198.48 $198.48 $171.66 $185.07 $171.66 -
1ST PREVENTIVE MEDICINE NEW
CLINIC PATIENT < 1YR OUTPATIENT CLINIC 99381 $326.35 PER UNIT $91.90 $91.90 $102.68 $102.68 $67.60 $67.60 $79.29 -
1ST PREVENTIVE MEDICINE NEW
CLINIC PATIENT AGE 1-4 YRS OUTPATIENT CLINIC 99382 $369.69 PER UNIT $98.65 $98.65 $126.71 $109.57 $71.11 $71.11 $92.42 -
1ST PREVENTIVE MEDICINE NEW
CLINIC PATIENT AGE 5-11 YRS OUTPATIENT CLINIC 99383 $369.69 PER UNIT $96.60 $96.60 $115.90 $115.90 $108.75 $136.95 $108.75 -
1ST PREVENTIVE MEDICINE NEW
CLINIC PATIENT AGE 12-17 YR OUTPATIENT CLINIC 99384 $416.77 PER UNIT $104.96 $104.96 $137.53 $137.53 $89.84 $89.84 $89.84 -
1ST PREVENTIVE MEDICINE NEW
CLINIC PATIENT AGE 18-39YRS OUTPATIENT CLINIC 99385 * $416.77 PER UNIT $104.96 $104.96 $137.53 $137.53 $86.62 $86.62 $86.62 -
1ST PREVENTIVE MEDICINE NEW
CLINIC PATIENT AGE 40-64YRS OUTPATIENT CLINIC 99386 * $416.77 PER UNIT $66.40 $66.40 $92.22 $92.22 $98.36 $104.47 $98.36 -
PERIODIC PREVENTIVE MED
CLINIC ESTABLISHED PATIENT <1YR OUTPATIENT CLINIC 99391 $281.13 PER UNIT $69.52 $69.52 $109.54 $109.54 $78.65 $61.45 $90.31 -
PERIODIC PREVENTIVE MED EST
CLINIC PATIENT AGE 1-4YRS OUTPATIENT CLINIC 99392 $326.35 PER UNIT $77.87 $77.87 $139.21 $118.33 $88.16 $125.86 $100.74 -
PERIODIC PREVENTIVE MED EST
CLINIC PATIENT AGE 5-11YRS OUTPATIENT CLINIC 99393 $326.35 PER UNIT $76.84 $76.84 $138.76 $101.32 $87.00 $67.60 $100.31 -
PERIODIC PREVENTIVE MED EST
CLINIC PATIENT AGE 12-17YRS OUTPATIENT CLINIC 99394 $369.69 PER UNIT $84.62 $84.62 $152.90 $129.97 $96.26 $188.14 $120.72 -
CLINIC TELEHEALTH EST. PT 5-10 MIN OUTPATIENT CLINIC 99421 $40.76 PER UNIT $13.19 $13.19 $39.57 $35.61 $18.89 $31.36 $18.89 -
CLINIC TELEHEALTH EST PT 11-20 MIN OUTPATIENT CLINIC 99422 $83.86 PER UNIT $27.14 $27.14 $44.00 $44.00 $43.89 $53.89 $33.78 -
CLINIC TELEHEALTH EST PT 21+ MIN OUTPATIENT CLINIC 99423 $133.58 PER UNIT $43.23 $43.23 $29.00 $29.00 $29.00 $87.07 $53.10 -
MED NUTR THER RE-
CLINIC ASSMT&IVNTJ INDIV EA 15 MIN NUTRITION 97803 $30.92 PER UNIT $0.00 $0.00 $32.81 $32.81 $18.76 $63.70 $24.63 -
LA RABIDA CHILDREN'S HOSPITAL
SHOPPPABLE SERVICES
Rev. 12/2020 REIMBURSEMENT
IL Medicaid United
Service CPT CMS- Charge Managed BCBS Health Cash
Location Service Type Description Code Req Amount QTY IL Medicaid Care BCBS PPO HMO Cigna Aetna Care Price
RADIOLOGY RADEX SKL < 4 VIEWS RADIOLOGY 70250 $483.76 PER UNIT $21.50 $21.50 $50.48 $50.48 $35.99 $26.14 $35.99 -
RADIOLOGY RADEX NCK SOFT TISS RADIOLOGY 70360 $216.03 PER UNIT $14.35 $14.35 $39.60 $39.60 $26.97 $19.62 $26.97 -
We do not
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offer this
RADIOLOGY CT HEAD/BRAIN W/O DYE RADIOLOGY 70450 * service
We do not
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offer this
RADIOLOGY MRI BRAIN STEM W/O & W/DYE RADIOLOGY 70553 * service
RADIOLOGIC EXAMINATION,
RADIOLOGY CHEST; SINGLE VIEW RADIOLOGY 71045 $188.82 PER UNIT $68.88 $68.88 $58.14 $46.83 $68.10 $68.10 $68.10 -
RADIOLOGY RADEX RIBS BI 3 VIEWS RADIOLOGY 71110 $251.68 PER UNIT $26.15 $26.15 $52.44 $52.44 $39.84 $27.35 $39.84 -
RADIOLOGY RADEX SPI CRV 2/3 VIEWS RADIOLOGY 72040 $314.38 PER UNIT $24.15 $24.15 $43.52 $43.52 $35.87 $35.87 $35.87 -
RADIOLOGY RADEX SPI THRC 2 VIEWS RADIOLOGY 72070 $377.09 PER UNIT $19.60 $19.60 $31.36 $31.36 $22.84 $22.84 $31.36 -
RADIOLOGIC EXAMINATION,
SPINE, ENTIRE THORACIC AND
LUMBAR, INCLUDING SKULL,
CERVICAL AND SACRAL SPINE IF
PERFORMED (EG, SCOLIOSIS
RADIOLOGY EVALUATION); ONE VIEW RADIOLOGY 72081 $303.67 PER UNIT $22.01 $22.01 $58.15 $58.15 $35.21 $58.15 $35.21 -
RADIOLOGIC EXAMINATION,
SPINE, ENTIRE THORACIC AND
LUMBAR, INCLUDING SKULL,
CERVICAL AND SACRAL SPINE IF
PERFORMED (EG, SCOLIOSIS
RADIOLOGY EVALUATION); 2 OR 3 VIEWS RADIOLOGY 72082 $341.49 PER UNIT $35.00 $35.00 $96.46 $96.46 $86.82 $86.82 $86.62 -
RADIOLOGY RADEX SPI LUMBOSAC 2/3 VIEWS RADIOLOGY 72100 $408.24 PER UNIT $28.70 $28.70 $49.97 $49.97 $33.14 $33.14 $89.31 -
RADIOLOGY X-RAY EXAM L-2 SPINE 4/>VWS RADIOLOGY 72110 * $213.85 PER UNIT $37.90 $37.90 $89.02 $89.02 $48.68 $48.68 $48.68 -
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