|
Yes - Mechanical Traction Charge
|
Facility
IP
|
$232.00
|
|
|
Service Code
|
CPT 97012 GP
|
| Hospital Charge Code |
2989810
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$113.68 |
| Max. Negotiated Rate |
$213.44 |
| Rate for Payer: Aetna Commercial |
$208.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.96
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$213.44
|
| Rate for Payer: Health EOS Commercial |
$206.48
|
| Rate for Payer: HFN Commercial |
$213.44
|
| Rate for Payer: Multiplan Commercial |
$185.60
|
| Rate for Payer: NAPHCARE Commercial |
$139.20
|
| Rate for Payer: Preferred Network Access Commercial |
$213.44
|
| Rate for Payer: Quartz Beloit One Network |
$113.68
|
| Rate for Payer: Quartz Commercial |
$139.20
|
| Rate for Payer: WEA Trust Commercial |
$127.60
|
| Rate for Payer: WPS Commercial |
$171.84
|
|
|
Yes - Medication Unit Dose Charge
|
Facility
OP
|
$21.00
|
|
| Hospital Charge Code |
3006960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.06
|
| Rate for Payer: Aetna Managed Medicare |
$5.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.13
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$19.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.75
|
| Rate for Payer: Health EOS Commercial |
$18.69
|
| Rate for Payer: HFN Commercial |
$19.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.75
|
| Rate for Payer: Multiplan Commercial |
$16.80
|
| Rate for Payer: NAPHCARE Commercial |
$12.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19.32
|
| Rate for Payer: Quartz Beloit One Network |
$10.29
|
| Rate for Payer: Quartz Commercial |
$13.65
|
| Rate for Payer: Quartz Medicare Advantage |
$12.60
|
| Rate for Payer: The Alliance Commercial |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$11.55
|
| Rate for Payer: WPS Commercial |
$15.55
|
|
|
Yes - Medication Unit Dose Charge
|
Facility
IP
|
$21.00
|
|
| Hospital Charge Code |
3006960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$19.32 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.13
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$19.32
|
| Rate for Payer: Health EOS Commercial |
$18.69
|
| Rate for Payer: HFN Commercial |
$19.32
|
| Rate for Payer: Multiplan Commercial |
$16.80
|
| Rate for Payer: NAPHCARE Commercial |
$12.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19.32
|
| Rate for Payer: Quartz Beloit One Network |
$10.29
|
| Rate for Payer: Quartz Commercial |
$12.60
|
| Rate for Payer: WEA Trust Commercial |
$11.55
|
| Rate for Payer: WPS Commercial |
$15.55
|
|
|
Yes - Metered Dose Inhaler- Instruct Charge
|
Facility
OP
|
$200.00
|
|
|
Service Code
|
CPT 94664
|
| Hospital Charge Code |
3006937
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$96.00 |
| Max. Negotiated Rate |
$784.25 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.00
|
| Rate for Payer: Aetna Managed Medicare |
$210.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$130.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.00
|
| Rate for Payer: Anthem Medicare Advantage |
$210.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.00
|
| 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 |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$210.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$210.82
|
| Rate for Payer: Health EOS Commercial |
$178.00
|
| Rate for Payer: HFN Commercial |
$184.00
|
| 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 |
$160.00
|
| Rate for Payer: NAPHCARE Commercial |
$316.23
|
| Rate for Payer: Preferred Network Access Commercial |
$184.00
|
| Rate for Payer: Quartz Beloit One Network |
$98.00
|
| Rate for Payer: Quartz Commercial |
$130.00
|
| Rate for Payer: Quartz Medicare Advantage |
$210.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.82
|
| Rate for Payer: United Healthcare PPO |
$150.00
|
| Rate for Payer: WEA Trust Commercial |
$110.00
|
| Rate for Payer: Wellcare Medicare |
$210.82
|
| Rate for Payer: WPS Commercial |
$148.14
|
|
|
Yes - Metered Dose Inhaler- Instruct Charge
|
Facility
IP
|
$200.00
|
|
|
Service Code
|
CPT 94664
|
| Hospital Charge Code |
3006937
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Health EOS Commercial |
$178.00
|
| Rate for Payer: HFN Commercial |
$184.00
|
| Rate for Payer: Multiplan Commercial |
$160.00
|
| Rate for Payer: NAPHCARE Commercial |
$120.00
|
| Rate for Payer: Preferred Network Access Commercial |
$184.00
|
| Rate for Payer: Quartz Beloit One Network |
$98.00
|
| Rate for Payer: Quartz Commercial |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$110.00
|
| Rate for Payer: WPS Commercial |
$148.14
|
|
|
Yes - Multiple Sleep Latency Test Charge
|
Facility
OP
|
$4,159.00
|
|
|
Service Code
|
CPT 95805
|
| Hospital Charge Code |
2990214
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$529.77 |
| Max. Negotiated Rate |
$3,826.28 |
| Rate for Payer: Aetna Commercial |
$3,743.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,576.74
|
| Rate for Payer: Aetna Managed Medicare |
$529.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$529.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,204.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$529.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$529.77
|
| Rate for Payer: Cash Price |
$1,247.70
|
| Rate for Payer: Cash Price |
$1,247.70
|
| Rate for Payer: Cash Price |
$1,247.70
|
| Rate for Payer: Cigna Commercial |
$3,826.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$529.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,327.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$529.77
|
| Rate for Payer: Health EOS Commercial |
$3,701.51
|
| Rate for Payer: HFN Commercial |
$3,826.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,970.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$529.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$529.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$529.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$529.77
|
| Rate for Payer: Multiplan Commercial |
$3,327.20
|
| Rate for Payer: NAPHCARE Commercial |
$794.66
|
| Rate for Payer: Preferred Network Access Commercial |
$3,826.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,037.91
|
| Rate for Payer: Quartz Commercial |
$2,703.35
|
| Rate for Payer: Quartz Medicare Advantage |
$529.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$529.77
|
| Rate for Payer: United Healthcare PPO |
$3,119.25
|
| Rate for Payer: WEA Trust Commercial |
$2,287.45
|
| Rate for Payer: Wellcare Medicare |
$529.77
|
| Rate for Payer: WPS Commercial |
$3,080.57
|
|
|
Yes - Multiple Sleep Latency Test Charge
|
Facility
IP
|
$4,159.00
|
|
|
Service Code
|
CPT 95805
|
| Hospital Charge Code |
2990214
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$2,037.91 |
| Max. Negotiated Rate |
$3,826.28 |
| Rate for Payer: Aetna Commercial |
$3,743.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,204.27
|
| Rate for Payer: Cash Price |
$1,247.70
|
| Rate for Payer: Cigna Commercial |
$3,826.28
|
| Rate for Payer: Health EOS Commercial |
$3,701.51
|
| Rate for Payer: HFN Commercial |
$3,826.28
|
| Rate for Payer: Multiplan Commercial |
$3,327.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,495.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,826.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,037.91
|
| Rate for Payer: Quartz Commercial |
$2,495.40
|
| Rate for Payer: WEA Trust Commercial |
$2,287.45
|
| Rate for Payer: WPS Commercial |
$3,080.57
|
|
|
Yes - Nasal Cannula(25ft) Charge
|
Facility
IP
|
$240.00
|
|
| Hospital Charge Code |
3006965
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$117.60 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$216.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.20
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$220.80
|
| Rate for Payer: Health EOS Commercial |
$213.60
|
| Rate for Payer: HFN Commercial |
$220.80
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: NAPHCARE Commercial |
$144.00
|
| Rate for Payer: Preferred Network Access Commercial |
$220.80
|
| Rate for Payer: Quartz Beloit One Network |
$117.60
|
| Rate for Payer: Quartz Commercial |
$144.00
|
| Rate for Payer: WEA Trust Commercial |
$132.00
|
| Rate for Payer: WPS Commercial |
$177.77
|
|
|
Yes - Nasal Cannula(25ft) Charge
|
Facility
OP
|
$240.00
|
|
| Hospital Charge Code |
3006965
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$216.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.40
|
| Rate for Payer: Aetna Managed Medicare |
$67.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$156.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$120.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$115.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.20
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$220.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.30
|
| Rate for Payer: Health EOS Commercial |
$213.60
|
| Rate for Payer: HFN Commercial |
$220.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: NAPHCARE Commercial |
$144.00
|
| Rate for Payer: Preferred Network Access Commercial |
$220.80
|
| Rate for Payer: Quartz Beloit One Network |
$117.60
|
| Rate for Payer: Quartz Commercial |
$156.00
|
| Rate for Payer: Quartz Medicare Advantage |
$144.00
|
| Rate for Payer: The Alliance Commercial |
$960.00
|
| Rate for Payer: WEA Trust Commercial |
$132.00
|
| Rate for Payer: WPS Commercial |
$177.77
|
|
|
Yes - Nasal Cannula Holder Charge
|
Facility
OP
|
$29.00
|
|
| Hospital Charge Code |
2990208
|
|
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 - Nasal Cannula Holder Charge
|
Facility
IP
|
$29.00
|
|
| Hospital Charge Code |
2990208
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.21 |
| Max. Negotiated Rate |
$26.68 |
| Rate for Payer: Aetna Commercial |
$26.10
|
| 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 - Nasal Cannula(std) Charge
|
Facility
OP
|
$49.00
|
|
| Hospital Charge Code |
3006964
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Aetna Managed Medicare |
$13.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.42
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.75
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$31.85
|
| Rate for Payer: Quartz Medicare Advantage |
$29.40
|
| Rate for Payer: The Alliance Commercial |
$196.00
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Yes - Nasal Cannula(std) Charge
|
Facility
IP
|
$49.00
|
|
| Hospital Charge Code |
3006964
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.01 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$29.40
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Yes - Nebulizer Setup Charge
|
Facility
OP
|
$453.00
|
|
| Hospital Charge Code |
3006961
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$126.84 |
| Max. Negotiated Rate |
$1,812.00 |
| Rate for Payer: Aetna Commercial |
$407.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$389.58
|
| Rate for Payer: Aetna Managed Medicare |
$126.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$294.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$226.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$217.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$240.09
|
| Rate for Payer: Cash Price |
$135.90
|
| Rate for Payer: Cigna Commercial |
$416.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$253.50
|
| Rate for Payer: Health EOS Commercial |
$403.17
|
| Rate for Payer: HFN Commercial |
$416.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$339.75
|
| Rate for Payer: Multiplan Commercial |
$362.40
|
| Rate for Payer: NAPHCARE Commercial |
$271.80
|
| Rate for Payer: Preferred Network Access Commercial |
$416.76
|
| Rate for Payer: Quartz Beloit One Network |
$221.97
|
| Rate for Payer: Quartz Commercial |
$294.45
|
| Rate for Payer: Quartz Medicare Advantage |
$271.80
|
| Rate for Payer: The Alliance Commercial |
$1,812.00
|
| Rate for Payer: WEA Trust Commercial |
$249.15
|
| Rate for Payer: WPS Commercial |
$335.54
|
|
|
Yes - Nebulizer Setup Charge
|
Facility
IP
|
$453.00
|
|
| Hospital Charge Code |
3006961
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$221.97 |
| Max. Negotiated Rate |
$416.76 |
| Rate for Payer: Aetna Commercial |
$407.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$240.09
|
| Rate for Payer: Cash Price |
$135.90
|
| Rate for Payer: Cigna Commercial |
$416.76
|
| Rate for Payer: Health EOS Commercial |
$403.17
|
| Rate for Payer: HFN Commercial |
$416.76
|
| Rate for Payer: Multiplan Commercial |
$362.40
|
| Rate for Payer: NAPHCARE Commercial |
$271.80
|
| Rate for Payer: Preferred Network Access Commercial |
$416.76
|
| Rate for Payer: Quartz Beloit One Network |
$221.97
|
| Rate for Payer: Quartz Commercial |
$271.80
|
| Rate for Payer: WEA Trust Commercial |
$249.15
|
| Rate for Payer: WPS Commercial |
$335.54
|
|
|
Yes - Nebulizer T-Adapter Charge
|
Facility
IP
|
$11.00
|
|
| Hospital Charge Code |
3006962
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$6.60
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$8.15
|
|
|
Yes - Nebulizer T-Adapter Charge
|
Facility
OP
|
$11.00
|
|
| Hospital Charge Code |
3006962
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Aetna Managed Medicare |
$3.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.16
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.25
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$7.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6.60
|
| Rate for Payer: The Alliance Commercial |
$44.00
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$8.15
|
|
|
Yes - Nocturnal Oximetry Study Charge
|
Facility
OP
|
$444.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
3026389
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$41.75 |
| Max. Negotiated Rate |
$574.33 |
| Rate for Payer: Aetna Commercial |
$399.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$381.84
|
| Rate for Payer: Aetna Managed Medicare |
$154.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.75
|
| Rate for Payer: Anthem Medicare Advantage |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$154.39
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cigna Commercial |
$408.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$154.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$248.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$154.39
|
| Rate for Payer: Health EOS Commercial |
$395.16
|
| Rate for Payer: HFN Commercial |
$408.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$154.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$154.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$154.39
|
| Rate for Payer: Multiplan Commercial |
$355.20
|
| Rate for Payer: NAPHCARE Commercial |
$231.58
|
| Rate for Payer: Preferred Network Access Commercial |
$408.48
|
| Rate for Payer: Quartz Beloit One Network |
$217.56
|
| Rate for Payer: Quartz Commercial |
$288.60
|
| Rate for Payer: Quartz Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare PPO |
$333.00
|
| Rate for Payer: WEA Trust Commercial |
$244.20
|
| Rate for Payer: Wellcare Medicare |
$154.39
|
| Rate for Payer: WPS Commercial |
$328.87
|
|
|
Yes - Nocturnal Oximetry Study Charge
|
Facility
IP
|
$444.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
3026389
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$217.56 |
| Max. Negotiated Rate |
$408.48 |
| Rate for Payer: Aetna Commercial |
$399.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.32
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cigna Commercial |
$408.48
|
| Rate for Payer: Health EOS Commercial |
$395.16
|
| Rate for Payer: HFN Commercial |
$408.48
|
| Rate for Payer: Multiplan Commercial |
$355.20
|
| Rate for Payer: NAPHCARE Commercial |
$266.40
|
| Rate for Payer: Preferred Network Access Commercial |
$408.48
|
| Rate for Payer: Quartz Beloit One Network |
$217.56
|
| Rate for Payer: Quartz Commercial |
$266.40
|
| Rate for Payer: WEA Trust Commercial |
$244.20
|
| Rate for Payer: WPS Commercial |
$328.87
|
|
|
Yes - Non-Rebeather Mask Charge
|
Facility
OP
|
$77.00
|
|
| Hospital Charge Code |
3006963
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$308.00 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.22
|
| Rate for Payer: Aetna Managed Medicare |
$21.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.81
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$70.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.09
|
| Rate for Payer: Health EOS Commercial |
$68.53
|
| Rate for Payer: HFN Commercial |
$70.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.75
|
| Rate for Payer: Multiplan Commercial |
$61.60
|
| Rate for Payer: NAPHCARE Commercial |
$46.20
|
| Rate for Payer: Preferred Network Access Commercial |
$70.84
|
| Rate for Payer: Quartz Beloit One Network |
$37.73
|
| Rate for Payer: Quartz Commercial |
$50.05
|
| Rate for Payer: Quartz Medicare Advantage |
$46.20
|
| Rate for Payer: The Alliance Commercial |
$308.00
|
| Rate for Payer: WEA Trust Commercial |
$42.35
|
| Rate for Payer: WPS Commercial |
$57.03
|
|
|
Yes - Non-Rebeather Mask Charge
|
Facility
IP
|
$77.00
|
|
| Hospital Charge Code |
3006963
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.73 |
| Max. Negotiated Rate |
$70.84 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.81
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$70.84
|
| Rate for Payer: Health EOS Commercial |
$68.53
|
| Rate for Payer: HFN Commercial |
$70.84
|
| Rate for Payer: Multiplan Commercial |
$61.60
|
| Rate for Payer: NAPHCARE Commercial |
$46.20
|
| Rate for Payer: Preferred Network Access Commercial |
$70.84
|
| Rate for Payer: Quartz Beloit One Network |
$37.73
|
| Rate for Payer: Quartz Commercial |
$46.20
|
| Rate for Payer: WEA Trust Commercial |
$42.35
|
| Rate for Payer: WPS Commercial |
$57.03
|
|
|
Yes - Noturnal Oximetry Charge
|
Facility
OP
|
$356.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
2990180
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$41.75 |
| Max. Negotiated Rate |
$574.33 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Aetna Managed Medicare |
$154.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.75
|
| Rate for Payer: Anthem Medicare Advantage |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$154.39
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$154.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$154.39
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$154.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$154.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$154.39
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$231.58
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$231.40
|
| Rate for Payer: Quartz Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare PPO |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: Wellcare Medicare |
$154.39
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
Yes - Noturnal Oximetry Charge
|
Facility
IP
|
$356.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
2990180
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$174.44 |
| Max. Negotiated Rate |
$327.52 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$213.60
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$213.60
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
Yes - OTA Aquatic Therapy Charge
|
Facility
OP
|
$246.00
|
|
|
Service Code
|
CPT 97113 GO,CO
|
| Hospital Charge Code |
5571954
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$68.88 |
| Max. Negotiated Rate |
$984.00 |
| Rate for Payer: Aetna Commercial |
$221.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.56
|
| Rate for Payer: Aetna Managed Medicare |
$68.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.38
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$226.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.66
|
| Rate for Payer: Health EOS Commercial |
$218.94
|
| Rate for Payer: HFN Commercial |
$226.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$196.80
|
| Rate for Payer: NAPHCARE Commercial |
$147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$226.32
|
| Rate for Payer: Quartz Beloit One Network |
$120.54
|
| Rate for Payer: Quartz Commercial |
$159.90
|
| Rate for Payer: Quartz Medicare Advantage |
$147.60
|
| Rate for Payer: The Alliance Commercial |
$984.00
|
| Rate for Payer: United Healthcare PPO |
$184.50
|
| Rate for Payer: WEA Trust Commercial |
$135.30
|
| Rate for Payer: WPS Commercial |
$182.21
|
|
|
Yes - OTA Aquatic Therapy Charge
|
Facility
IP
|
$246.00
|
|
|
Service Code
|
CPT 97113 GO,CO
|
| Hospital Charge Code |
5571954
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$120.54 |
| Max. Negotiated Rate |
$226.32 |
| Rate for Payer: Aetna Commercial |
$221.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.38
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$226.32
|
| Rate for Payer: Health EOS Commercial |
$218.94
|
| Rate for Payer: HFN Commercial |
$226.32
|
| Rate for Payer: Multiplan Commercial |
$196.80
|
| Rate for Payer: NAPHCARE Commercial |
$147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$226.32
|
| Rate for Payer: Quartz Beloit One Network |
$120.54
|
| Rate for Payer: Quartz Commercial |
$147.60
|
| Rate for Payer: WEA Trust Commercial |
$135.30
|
| Rate for Payer: WPS Commercial |
$182.21
|
|
