|
Yes - CPT Palm Percussor Charge
|
Facility
|
OP
|
$28.00
|
|
| Hospital Charge Code |
2990206
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Aetna Managed Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.44
|
| 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: Dean Health DHI/DHP/ASO |
$15.67
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.00
|
| 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 |
$18.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.80
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
Yes - CPT Vest Charge
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
CPT 94669
|
| Hospital Charge Code |
3006947
|
|
Hospital Revenue Code
|
419
|
| Min. Negotiated Rate |
$74.88 |
| Max. Negotiated Rate |
$843.28 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Aetna Managed Medicare |
$210.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$101.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$74.88
|
| Rate for Payer: Anthem Medicare Advantage |
$210.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| 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 |
$46.80
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$210.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$210.82
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| 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 |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$316.23
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$101.40
|
| Rate for Payer: Quartz Medicare Advantage |
$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 |
$117.00
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: Wellcare Medicare |
$210.82
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
Yes - CPT Vest Charge
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
CPT 94669
|
| Hospital Charge Code |
3006947
|
|
Hospital Revenue Code
|
419
|
| Min. Negotiated Rate |
$76.44 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.60
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
Yes - Disposable BFlex Bronchoscope
|
Facility
|
IP
|
$3,389.00
|
|
| Hospital Charge Code |
5478913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,660.61 |
| Max. Negotiated Rate |
$3,117.88 |
| Rate for Payer: Aetna Commercial |
$3,050.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,914.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,796.17
|
| Rate for Payer: Cash Price |
$1,016.70
|
| Rate for Payer: Cigna Commercial |
$3,117.88
|
| Rate for Payer: Health EOS Commercial |
$3,016.21
|
| Rate for Payer: HFN Commercial |
$3,117.88
|
| Rate for Payer: Multiplan Commercial |
$2,711.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,033.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,117.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,660.61
|
| Rate for Payer: Quartz Commercial |
$2,033.40
|
| Rate for Payer: WEA Trust Commercial |
$1,863.95
|
| Rate for Payer: WPS Commercial |
$2,510.23
|
|
|
Yes - Disposable BFlex Bronchoscope
|
Facility
|
OP
|
$3,389.00
|
|
| Hospital Charge Code |
5478913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$948.92 |
| Max. Negotiated Rate |
$13,556.00 |
| Rate for Payer: Aetna Commercial |
$3,050.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,914.54
|
| Rate for Payer: Aetna Managed Medicare |
$948.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,202.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,694.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,626.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,796.17
|
| Rate for Payer: Cash Price |
$1,016.70
|
| Rate for Payer: Cigna Commercial |
$3,117.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,896.48
|
| Rate for Payer: Health EOS Commercial |
$3,016.21
|
| Rate for Payer: HFN Commercial |
$3,117.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,541.75
|
| Rate for Payer: Multiplan Commercial |
$2,711.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,033.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,117.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,660.61
|
| Rate for Payer: Quartz Commercial |
$2,202.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,033.40
|
| Rate for Payer: The Alliance Commercial |
$13,556.00
|
| Rate for Payer: WEA Trust Commercial |
$1,863.95
|
| Rate for Payer: WPS Commercial |
$2,510.23
|
|
|
Yes - Disposable Brochoscopy Cytology Charge
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2990202
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$67.62 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$82.80
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Yes - Disposable Brochoscopy Cytology Charge
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2990202
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$38.64 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Aetna Managed Medicare |
$38.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$89.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.22
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$103.50
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$89.70
|
| Rate for Payer: Quartz Medicare Advantage |
$82.80
|
| Rate for Payer: The Alliance Commercial |
$552.00
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Yes - Disposable Brochoscopy Forceps Charge
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2990203
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$67.62 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$82.80
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Yes - Disposable Brochoscopy Forceps Charge
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2990203
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$38.64 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Aetna Managed Medicare |
$38.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$89.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.22
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$103.50
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$89.70
|
| Rate for Payer: Quartz Medicare Advantage |
$82.80
|
| Rate for Payer: The Alliance Commercial |
$552.00
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Yes - Disposable EBUS Needle 22g
|
Facility
|
IP
|
$2,436.00
|
|
| Hospital Charge Code |
5476743
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,193.64 |
| Max. Negotiated Rate |
$2,241.12 |
| Rate for Payer: Aetna Commercial |
$2,192.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,094.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,291.08
|
| Rate for Payer: Cash Price |
$730.80
|
| Rate for Payer: Cigna Commercial |
$2,241.12
|
| Rate for Payer: Health EOS Commercial |
$2,168.04
|
| Rate for Payer: HFN Commercial |
$2,241.12
|
| Rate for Payer: Multiplan Commercial |
$1,948.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,461.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,241.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,193.64
|
| Rate for Payer: Quartz Commercial |
$1,461.60
|
| Rate for Payer: WEA Trust Commercial |
$1,339.80
|
| Rate for Payer: WPS Commercial |
$1,804.35
|
|
|
Yes - Disposable EBUS Needle 22g
|
Facility
|
OP
|
$2,436.00
|
|
| Hospital Charge Code |
5476743
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$682.08 |
| Max. Negotiated Rate |
$9,744.00 |
| Rate for Payer: Aetna Commercial |
$2,192.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,094.96
|
| Rate for Payer: Aetna Managed Medicare |
$682.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,583.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,218.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,169.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,291.08
|
| Rate for Payer: Cash Price |
$730.80
|
| Rate for Payer: Cigna Commercial |
$2,241.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,363.19
|
| Rate for Payer: Health EOS Commercial |
$2,168.04
|
| Rate for Payer: HFN Commercial |
$2,241.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,827.00
|
| Rate for Payer: Multiplan Commercial |
$1,948.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,461.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,241.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,193.64
|
| Rate for Payer: Quartz Commercial |
$1,583.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,461.60
|
| Rate for Payer: The Alliance Commercial |
$9,744.00
|
| Rate for Payer: WEA Trust Commercial |
$1,339.80
|
| Rate for Payer: WPS Commercial |
$1,804.35
|
|
|
Yes - Disposable EBUS Needle 22g - Procore
|
Facility
|
OP
|
$2,953.00
|
|
| Hospital Charge Code |
5476744
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$826.84 |
| Max. Negotiated Rate |
$11,812.00 |
| Rate for Payer: Aetna Commercial |
$2,657.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,539.58
|
| Rate for Payer: Aetna Managed Medicare |
$826.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,919.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,476.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,417.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,565.09
|
| Rate for Payer: Cash Price |
$885.90
|
| Rate for Payer: Cigna Commercial |
$2,716.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,652.50
|
| Rate for Payer: Health EOS Commercial |
$2,628.17
|
| Rate for Payer: HFN Commercial |
$2,716.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,214.75
|
| Rate for Payer: Multiplan Commercial |
$2,362.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,771.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,716.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,446.97
|
| Rate for Payer: Quartz Commercial |
$1,919.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,771.80
|
| Rate for Payer: The Alliance Commercial |
$11,812.00
|
| Rate for Payer: WEA Trust Commercial |
$1,624.15
|
| Rate for Payer: WPS Commercial |
$2,187.29
|
|
|
Yes - Disposable EBUS Needle 22g - Procore
|
Facility
|
IP
|
$2,953.00
|
|
| Hospital Charge Code |
5476744
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,446.97 |
| Max. Negotiated Rate |
$2,716.76 |
| Rate for Payer: Aetna Commercial |
$2,657.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,539.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,565.09
|
| Rate for Payer: Cash Price |
$885.90
|
| Rate for Payer: Cigna Commercial |
$2,716.76
|
| Rate for Payer: Health EOS Commercial |
$2,628.17
|
| Rate for Payer: HFN Commercial |
$2,716.76
|
| Rate for Payer: Multiplan Commercial |
$2,362.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,771.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,716.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,446.97
|
| Rate for Payer: Quartz Commercial |
$1,771.80
|
| Rate for Payer: WEA Trust Commercial |
$1,624.15
|
| Rate for Payer: WPS Commercial |
$2,187.29
|
|
|
Yes - EMS Arrival with Notification Level 1*
|
Facility
|
OP
|
$3,987.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
4962606
|
|
Hospital Revenue Code
|
683
|
| Min. Negotiated Rate |
$1,353.23 |
| Max. Negotiated Rate |
$5,412.92 |
| Rate for Payer: Aetna Commercial |
$3,588.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,428.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,353.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,591.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,993.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,913.76
|
| Rate for Payer: Anthem Medicare Advantage |
$1,353.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,113.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,353.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,353.23
|
| Rate for Payer: Cash Price |
$1,196.10
|
| Rate for Payer: Cash Price |
$1,196.10
|
| Rate for Payer: Cigna Commercial |
$3,668.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,353.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,231.13
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,353.23
|
| Rate for Payer: Health EOS Commercial |
$3,548.43
|
| Rate for Payer: HFN Commercial |
$3,668.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,034.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,353.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,353.23
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,353.23
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,353.23
|
| Rate for Payer: Multiplan Commercial |
$3,189.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,029.84
|
| Rate for Payer: Preferred Network Access Commercial |
$3,668.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,953.63
|
| Rate for Payer: Quartz Commercial |
$2,591.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,353.23
|
| Rate for Payer: The Alliance Commercial |
$5,412.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,353.23
|
| Rate for Payer: WEA Trust Commercial |
$2,192.85
|
| Rate for Payer: Wellcare Medicare |
$1,353.23
|
| Rate for Payer: WPS Commercial |
$2,953.17
|
|
|
Yes - EMS Arrival with Notification Level 1*
|
Facility
|
IP
|
$3,987.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
4962606
|
|
Hospital Revenue Code
|
683
|
| Min. Negotiated Rate |
$1,953.63 |
| Max. Negotiated Rate |
$3,668.04 |
| Rate for Payer: Aetna Commercial |
$3,588.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,428.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,113.11
|
| Rate for Payer: Cash Price |
$1,196.10
|
| Rate for Payer: Cigna Commercial |
$3,668.04
|
| Rate for Payer: Health EOS Commercial |
$3,548.43
|
| Rate for Payer: HFN Commercial |
$3,668.04
|
| Rate for Payer: Multiplan Commercial |
$3,189.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,392.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,668.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,953.63
|
| Rate for Payer: Quartz Commercial |
$2,392.20
|
| Rate for Payer: WEA Trust Commercial |
$2,192.85
|
| Rate for Payer: WPS Commercial |
$2,953.17
|
|
|
Yes - EMS Arrival with Notification Level 2*
|
Facility
|
IP
|
$2,991.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
4962607
|
|
Hospital Revenue Code
|
683
|
| Min. Negotiated Rate |
$1,465.59 |
| Max. Negotiated Rate |
$2,751.72 |
| Rate for Payer: Aetna Commercial |
$2,691.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,572.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,585.23
|
| Rate for Payer: Cash Price |
$897.30
|
| Rate for Payer: Cigna Commercial |
$2,751.72
|
| Rate for Payer: Health EOS Commercial |
$2,661.99
|
| Rate for Payer: HFN Commercial |
$2,751.72
|
| Rate for Payer: Multiplan Commercial |
$2,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,794.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,751.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,465.59
|
| Rate for Payer: Quartz Commercial |
$1,794.60
|
| Rate for Payer: WEA Trust Commercial |
$1,645.05
|
| Rate for Payer: WPS Commercial |
$2,215.43
|
|
|
Yes - EMS Arrival with Notification Level 2*
|
Facility
|
OP
|
$2,991.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
4962607
|
|
Hospital Revenue Code
|
683
|
| Min. Negotiated Rate |
$1,353.23 |
| Max. Negotiated Rate |
$5,412.92 |
| Rate for Payer: Aetna Commercial |
$2,691.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,572.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,353.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,944.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,495.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,435.68
|
| Rate for Payer: Anthem Medicare Advantage |
$1,353.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,585.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,353.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,353.23
|
| Rate for Payer: Cash Price |
$897.30
|
| Rate for Payer: Cash Price |
$897.30
|
| Rate for Payer: Cigna Commercial |
$2,751.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,353.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,673.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,353.23
|
| Rate for Payer: Health EOS Commercial |
$2,661.99
|
| Rate for Payer: HFN Commercial |
$2,751.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,034.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,353.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,353.23
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,353.23
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,353.23
|
| Rate for Payer: Multiplan Commercial |
$2,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,029.84
|
| Rate for Payer: Preferred Network Access Commercial |
$2,751.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,465.59
|
| Rate for Payer: Quartz Commercial |
$1,944.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,353.23
|
| Rate for Payer: The Alliance Commercial |
$5,412.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,353.23
|
| Rate for Payer: WEA Trust Commercial |
$1,645.05
|
| Rate for Payer: Wellcare Medicare |
$1,353.23
|
| Rate for Payer: WPS Commercial |
$2,215.43
|
|
|
Yes - EMS Arrival with Notification Level 3*
|
Facility
|
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
4962608
|
|
Hospital Revenue Code
|
683
|
| Min. Negotiated Rate |
$962.40 |
| Max. Negotiated Rate |
$5,412.92 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,353.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Anthem Medicare Advantage |
$1,353.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,353.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,353.23
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,353.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,353.23
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,034.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,353.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,353.23
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,353.23
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,353.23
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,029.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,353.23
|
| Rate for Payer: The Alliance Commercial |
$5,412.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,353.23
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: Wellcare Medicare |
$1,353.23
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
Yes - EMS Arrival with Notification Level 3*
|
Facility
|
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
4962608
|
|
Hospital Revenue Code
|
683
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
Yes - Endotracheal Tube Holder Charge
|
Facility
|
OP
|
$29.00
|
|
| Hospital Charge Code |
2990201
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$8.12 |
| Max. Negotiated Rate |
$116.00 |
| Rate for Payer: Aetna Commercial |
$26.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| Rate for Payer: Aetna Managed Medicare |
$8.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.37
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$26.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.23
|
| Rate for Payer: Health EOS Commercial |
$25.81
|
| Rate for Payer: HFN Commercial |
$26.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.75
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: NAPHCARE Commercial |
$17.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.68
|
| Rate for Payer: Quartz Beloit One Network |
$14.21
|
| Rate for Payer: Quartz Commercial |
$18.85
|
| Rate for Payer: Quartz Medicare Advantage |
$17.40
|
| Rate for Payer: The Alliance Commercial |
$116.00
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
Yes - Endotracheal Tube Holder Charge
|
Facility
|
IP
|
$29.00
|
|
| Hospital Charge Code |
2990201
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.21 |
| Max. Negotiated Rate |
$26.68 |
| Rate for Payer: Aetna Commercial |
$26.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.37
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$26.68
|
| Rate for Payer: Health EOS Commercial |
$25.81
|
| Rate for Payer: HFN Commercial |
$26.68
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: NAPHCARE Commercial |
$17.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.68
|
| Rate for Payer: Quartz Beloit One Network |
$14.21
|
| Rate for Payer: Quartz Commercial |
$17.40
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
Yes - ETCO2 Adapter Charge
|
Facility
|
OP
|
$101.00
|
|
| Hospital Charge Code |
3006950
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.28 |
| Max. Negotiated Rate |
$404.00 |
| Rate for Payer: Aetna Commercial |
$90.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.86
|
| Rate for Payer: Aetna Managed Medicare |
$28.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.53
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$92.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.52
|
| Rate for Payer: Health EOS Commercial |
$89.89
|
| Rate for Payer: HFN Commercial |
$92.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.75
|
| Rate for Payer: Multiplan Commercial |
$80.80
|
| Rate for Payer: NAPHCARE Commercial |
$60.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.92
|
| Rate for Payer: Quartz Beloit One Network |
$49.49
|
| Rate for Payer: Quartz Commercial |
$65.65
|
| Rate for Payer: Quartz Medicare Advantage |
$60.60
|
| Rate for Payer: The Alliance Commercial |
$404.00
|
| Rate for Payer: WEA Trust Commercial |
$55.55
|
| Rate for Payer: WPS Commercial |
$74.81
|
|
|
Yes - ETCO2 Adapter Charge
|
Facility
|
IP
|
$101.00
|
|
| Hospital Charge Code |
3006950
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$49.49 |
| Max. Negotiated Rate |
$92.92 |
| Rate for Payer: Aetna Commercial |
$90.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.53
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$92.92
|
| Rate for Payer: Health EOS Commercial |
$89.89
|
| Rate for Payer: HFN Commercial |
$92.92
|
| Rate for Payer: Multiplan Commercial |
$80.80
|
| Rate for Payer: NAPHCARE Commercial |
$60.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.92
|
| Rate for Payer: Quartz Beloit One Network |
$49.49
|
| Rate for Payer: Quartz Commercial |
$60.60
|
| Rate for Payer: WEA Trust Commercial |
$55.55
|
| Rate for Payer: WPS Commercial |
$74.81
|
|
|
Yes - ETCO2 Adult Oxymask Charge
|
Facility
|
OP
|
$153.00
|
|
|
Service Code
|
HCPCS A4620
|
| Hospital Charge Code |
5543166
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.84 |
| Max. Negotiated Rate |
$612.00 |
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.58
|
| Rate for Payer: Aetna Managed Medicare |
$42.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$99.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.09
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$140.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.62
|
| Rate for Payer: Health EOS Commercial |
$136.17
|
| Rate for Payer: HFN Commercial |
$140.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.75
|
| Rate for Payer: Multiplan Commercial |
$122.40
|
| Rate for Payer: NAPHCARE Commercial |
$91.80
|
| Rate for Payer: Preferred Network Access Commercial |
$140.76
|
| Rate for Payer: Quartz Beloit One Network |
$74.97
|
| Rate for Payer: Quartz Commercial |
$99.45
|
| Rate for Payer: Quartz Medicare Advantage |
$91.80
|
| Rate for Payer: The Alliance Commercial |
$612.00
|
| Rate for Payer: WEA Trust Commercial |
$84.15
|
| Rate for Payer: WPS Commercial |
$113.33
|
|
|
Yes - ETCO2 Adult Oxymask Charge
|
Facility
|
IP
|
$153.00
|
|
|
Service Code
|
HCPCS A4620
|
| Hospital Charge Code |
5543166
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$74.97 |
| Max. Negotiated Rate |
$140.76 |
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.09
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$140.76
|
| Rate for Payer: Health EOS Commercial |
$136.17
|
| Rate for Payer: HFN Commercial |
$140.76
|
| Rate for Payer: Multiplan Commercial |
$122.40
|
| Rate for Payer: NAPHCARE Commercial |
$91.80
|
| Rate for Payer: Preferred Network Access Commercial |
$140.76
|
| Rate for Payer: Quartz Beloit One Network |
$74.97
|
| Rate for Payer: Quartz Commercial |
$91.80
|
| Rate for Payer: WEA Trust Commercial |
$84.15
|
| Rate for Payer: WPS Commercial |
$113.33
|
|
