|
Yes - Applied Peds UA collection bag
|
Facility
|
OP
|
$55.00
|
|
| Hospital Charge Code |
3249481
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$220.00 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.78
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.25
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$35.75
|
| Rate for Payer: Quartz Medicare Advantage |
$33.00
|
| Rate for Payer: The Alliance Commercial |
$220.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
Yes - Applied Peds UA collection bag
|
Facility
|
IP
|
$55.00
|
|
| Hospital Charge Code |
3249481
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$50.60 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
Yes - Balloon Tamponade Catheter Charge
|
Facility
|
OP
|
$490.00
|
|
| Hospital Charge Code |
2990204
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$1,960.00 |
| Rate for Payer: Aetna Commercial |
$441.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$421.40
|
| Rate for Payer: Aetna Managed Medicare |
$137.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$318.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$245.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$235.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$259.70
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$450.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$274.20
|
| Rate for Payer: Health EOS Commercial |
$436.10
|
| Rate for Payer: HFN Commercial |
$450.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$367.50
|
| Rate for Payer: Multiplan Commercial |
$392.00
|
| Rate for Payer: NAPHCARE Commercial |
$294.00
|
| Rate for Payer: Preferred Network Access Commercial |
$450.80
|
| Rate for Payer: Quartz Beloit One Network |
$240.10
|
| Rate for Payer: Quartz Commercial |
$318.50
|
| Rate for Payer: Quartz Medicare Advantage |
$294.00
|
| Rate for Payer: The Alliance Commercial |
$1,960.00
|
| Rate for Payer: WEA Trust Commercial |
$269.50
|
| Rate for Payer: WPS Commercial |
$362.94
|
|
|
Yes - Balloon Tamponade Catheter Charge
|
Facility
|
IP
|
$490.00
|
|
| Hospital Charge Code |
2990204
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$240.10 |
| Max. Negotiated Rate |
$450.80 |
| Rate for Payer: Aetna Commercial |
$441.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$421.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$259.70
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$450.80
|
| Rate for Payer: Health EOS Commercial |
$436.10
|
| Rate for Payer: HFN Commercial |
$450.80
|
| Rate for Payer: Multiplan Commercial |
$392.00
|
| Rate for Payer: NAPHCARE Commercial |
$294.00
|
| Rate for Payer: Preferred Network Access Commercial |
$450.80
|
| Rate for Payer: Quartz Beloit One Network |
$240.10
|
| Rate for Payer: Quartz Commercial |
$294.00
|
| Rate for Payer: WEA Trust Commercial |
$269.50
|
| Rate for Payer: WPS Commercial |
$362.94
|
|
|
Yes - Bipap/CPAP Circuit Charge
|
Facility
|
OP
|
$128.00
|
|
| Hospital Charge Code |
3006942
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$35.84 |
| Max. Negotiated Rate |
$512.00 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Aetna Managed Medicare |
$35.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.63
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.00
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$76.80
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$83.20
|
| Rate for Payer: Quartz Medicare Advantage |
$76.80
|
| Rate for Payer: The Alliance Commercial |
$512.00
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Yes - Bipap/CPAP Circuit Charge
|
Facility
|
IP
|
$128.00
|
|
| Hospital Charge Code |
3006942
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$62.72 |
| Max. Negotiated Rate |
$117.76 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$76.80
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$76.80
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Yes - BiPAP/CPAP Full Face Mask Charge
|
Facility
|
IP
|
$277.00
|
|
| Hospital Charge Code |
3006944
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$135.73 |
| Max. Negotiated Rate |
$254.84 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$166.20
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
Yes - BiPAP/CPAP Full Face Mask Charge
|
Facility
|
OP
|
$277.00
|
|
| Hospital Charge Code |
3006944
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.56 |
| Max. Negotiated Rate |
$1,108.00 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Aetna Managed Medicare |
$77.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$180.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$138.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.01
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$207.75
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$180.05
|
| Rate for Payer: Quartz Medicare Advantage |
$166.20
|
| Rate for Payer: The Alliance Commercial |
$1,108.00
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
Yes - Bipap/CPAP Nasal Mask Charge
|
Facility
|
OP
|
$277.00
|
|
| Hospital Charge Code |
3006943
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.56 |
| Max. Negotiated Rate |
$1,108.00 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Aetna Managed Medicare |
$77.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$180.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$138.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.01
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$207.75
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$180.05
|
| Rate for Payer: Quartz Medicare Advantage |
$166.20
|
| Rate for Payer: The Alliance Commercial |
$1,108.00
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
Yes - Bipap/CPAP Nasal Mask Charge
|
Facility
|
IP
|
$277.00
|
|
| Hospital Charge Code |
3006943
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$135.73 |
| Max. Negotiated Rate |
$254.84 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$166.20
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
Yes - Box of Saline Vials Charge
|
Facility
|
OP
|
$59.00
|
|
| Hospital Charge Code |
3006946
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.52 |
| Max. Negotiated Rate |
$236.00 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Aetna Managed Medicare |
$16.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.02
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.25
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$38.35
|
| Rate for Payer: Quartz Medicare Advantage |
$35.40
|
| Rate for Payer: The Alliance Commercial |
$236.00
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
Yes - Box of Saline Vials Charge
|
Facility
|
IP
|
$59.00
|
|
| Hospital Charge Code |
3006946
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.91 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$35.40
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
Yes - Bronchoscopy Ventilator Adapter Charge
|
Facility
|
OP
|
$50.00
|
|
| Hospital Charge Code |
3006945
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.00
|
| Rate for Payer: Aetna Managed Medicare |
$14.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.50
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$46.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.98
|
| Rate for Payer: Health EOS Commercial |
$44.50
|
| Rate for Payer: HFN Commercial |
$46.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.50
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: NAPHCARE Commercial |
$30.00
|
| Rate for Payer: Preferred Network Access Commercial |
$46.00
|
| Rate for Payer: Quartz Beloit One Network |
$24.50
|
| Rate for Payer: Quartz Commercial |
$32.50
|
| Rate for Payer: Quartz Medicare Advantage |
$30.00
|
| Rate for Payer: The Alliance Commercial |
$200.00
|
| Rate for Payer: WEA Trust Commercial |
$27.50
|
| Rate for Payer: WPS Commercial |
$37.04
|
|
|
Yes - Bronchoscopy Ventilator Adapter Charge
|
Facility
|
IP
|
$50.00
|
|
| Hospital Charge Code |
3006945
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$46.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.50
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$46.00
|
| Rate for Payer: Health EOS Commercial |
$44.50
|
| Rate for Payer: HFN Commercial |
$46.00
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: NAPHCARE Commercial |
$30.00
|
| Rate for Payer: Preferred Network Access Commercial |
$46.00
|
| Rate for Payer: Quartz Beloit One Network |
$24.50
|
| Rate for Payer: Quartz Commercial |
$30.00
|
| Rate for Payer: WEA Trust Commercial |
$27.50
|
| Rate for Payer: WPS Commercial |
$37.04
|
|
|
Yes (CBI bag changed)* - CBI Bag Changed
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
4075877
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
Yes (CBI bag changed)* - CBI Bag Changed
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
4075877
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$516.00 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$36.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.75
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$77.40
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
Yes - Continuous Nebulizer, subsequent Charge
|
Facility
|
OP
|
$2,210.00
|
|
|
Service Code
|
CPT 94645
|
| Hospital Charge Code |
3006934
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$618.80 |
| Max. Negotiated Rate |
$8,840.00 |
| Rate for Payer: Aetna Commercial |
$1,989.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,900.60
|
| Rate for Payer: Aetna Managed Medicare |
$618.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,436.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,105.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,060.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,171.30
|
| Rate for Payer: Cash Price |
$663.00
|
| Rate for Payer: Cigna Commercial |
$2,033.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,236.72
|
| Rate for Payer: Health EOS Commercial |
$1,966.90
|
| Rate for Payer: HFN Commercial |
$2,033.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,657.50
|
| Rate for Payer: Multiplan Commercial |
$1,768.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,326.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,033.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,082.90
|
| Rate for Payer: Quartz Commercial |
$1,436.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,326.00
|
| Rate for Payer: The Alliance Commercial |
$8,840.00
|
| Rate for Payer: United Healthcare PPO |
$1,657.50
|
| Rate for Payer: WEA Trust Commercial |
$1,215.50
|
| Rate for Payer: WPS Commercial |
$1,636.95
|
|
|
Yes - Continuous Nebulizer, subsequent Charge
|
Facility
|
IP
|
$2,210.00
|
|
|
Service Code
|
CPT 94645
|
| Hospital Charge Code |
3006934
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$1,082.90 |
| Max. Negotiated Rate |
$2,033.20 |
| Rate for Payer: Aetna Commercial |
$1,989.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,900.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,171.30
|
| Rate for Payer: Cash Price |
$663.00
|
| Rate for Payer: Cigna Commercial |
$2,033.20
|
| Rate for Payer: Health EOS Commercial |
$1,966.90
|
| Rate for Payer: HFN Commercial |
$2,033.20
|
| Rate for Payer: Multiplan Commercial |
$1,768.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,326.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,033.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,082.90
|
| Rate for Payer: Quartz Commercial |
$1,326.00
|
| Rate for Payer: WEA Trust Commercial |
$1,215.50
|
| Rate for Payer: WPS Commercial |
$1,636.95
|
|
|
Yes - Continuous Oximeter Monitor Charge
|
Facility
|
OP
|
$1,115.00
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
3023868
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$312.20 |
| Max. Negotiated Rate |
$4,460.00 |
| Rate for Payer: Aetna Commercial |
$1,003.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$958.90
|
| Rate for Payer: Aetna Managed Medicare |
$312.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$724.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$557.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$535.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$590.95
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,025.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$623.95
|
| Rate for Payer: Health EOS Commercial |
$992.35
|
| Rate for Payer: HFN Commercial |
$1,025.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$836.25
|
| Rate for Payer: Multiplan Commercial |
$892.00
|
| Rate for Payer: NAPHCARE Commercial |
$669.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,025.80
|
| Rate for Payer: Quartz Beloit One Network |
$546.35
|
| Rate for Payer: Quartz Commercial |
$724.75
|
| Rate for Payer: Quartz Medicare Advantage |
$669.00
|
| Rate for Payer: The Alliance Commercial |
$4,460.00
|
| Rate for Payer: United Healthcare PPO |
$836.25
|
| Rate for Payer: WEA Trust Commercial |
$613.25
|
| Rate for Payer: WPS Commercial |
$825.88
|
|
|
Yes - Continuous Oximeter Monitor Charge
|
Facility
|
IP
|
$1,115.00
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
3023868
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$546.35 |
| Max. Negotiated Rate |
$1,025.80 |
| Rate for Payer: Aetna Commercial |
$1,003.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$958.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$590.95
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,025.80
|
| Rate for Payer: Health EOS Commercial |
$992.35
|
| Rate for Payer: HFN Commercial |
$1,025.80
|
| Rate for Payer: Multiplan Commercial |
$892.00
|
| Rate for Payer: NAPHCARE Commercial |
$669.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,025.80
|
| Rate for Payer: Quartz Beloit One Network |
$546.35
|
| Rate for Payer: Quartz Commercial |
$669.00
|
| Rate for Payer: WEA Trust Commercial |
$613.25
|
| Rate for Payer: WPS Commercial |
$825.88
|
|
|
Yes - Corrugated Tubing Charge
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
3006949
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$15.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$18.52
|
|
|
Yes - Corrugated Tubing Charge
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
3006949
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Aetna Managed Medicare |
$7.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.99
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.75
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$15.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$16.25
|
| Rate for Payer: Quartz Medicare Advantage |
$15.00
|
| Rate for Payer: The Alliance Commercial |
$100.00
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$18.52
|
|
|
Yes - CPAP Nasal Mask Charge
|
Facility
|
OP
|
$266.00
|
|
| Hospital Charge Code |
3004216
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$74.48 |
| Max. Negotiated Rate |
$1,064.00 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.76
|
| Rate for Payer: Aetna Managed Medicare |
$74.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$172.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$133.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$127.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.98
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$244.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.85
|
| Rate for Payer: Health EOS Commercial |
$236.74
|
| Rate for Payer: HFN Commercial |
$244.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.50
|
| Rate for Payer: Multiplan Commercial |
$212.80
|
| Rate for Payer: NAPHCARE Commercial |
$159.60
|
| Rate for Payer: Preferred Network Access Commercial |
$244.72
|
| Rate for Payer: Quartz Beloit One Network |
$130.34
|
| Rate for Payer: Quartz Commercial |
$172.90
|
| Rate for Payer: Quartz Medicare Advantage |
$159.60
|
| Rate for Payer: The Alliance Commercial |
$1,064.00
|
| Rate for Payer: United Healthcare PPO |
$199.50
|
| Rate for Payer: WEA Trust Commercial |
$146.30
|
| Rate for Payer: WPS Commercial |
$197.03
|
|
|
Yes - CPAP Nasal Mask Charge
|
Facility
|
IP
|
$266.00
|
|
| Hospital Charge Code |
3004216
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$130.34 |
| Max. Negotiated Rate |
$244.72 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.98
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$244.72
|
| Rate for Payer: Health EOS Commercial |
$236.74
|
| Rate for Payer: HFN Commercial |
$244.72
|
| Rate for Payer: Multiplan Commercial |
$212.80
|
| Rate for Payer: NAPHCARE Commercial |
$159.60
|
| Rate for Payer: Preferred Network Access Commercial |
$244.72
|
| Rate for Payer: Quartz Beloit One Network |
$130.34
|
| Rate for Payer: Quartz Commercial |
$159.60
|
| Rate for Payer: WEA Trust Commercial |
$146.30
|
| Rate for Payer: WPS Commercial |
$197.03
|
|
|
Yes - CPT Palm Percussor Charge
|
Facility
|
IP
|
$28.00
|
|
| Hospital Charge Code |
2990206
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
