|
Yes - OT TH Evaluation Moderate Complexity Chg
|
Facility
OP
|
$667.00
|
|
|
Service Code
|
CPT 97166 95,GO
|
| Hospital Charge Code |
5585290
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$186.76 |
| Max. Negotiated Rate |
$2,668.00 |
| Rate for Payer: Aetna Commercial |
$600.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$573.62
|
| Rate for Payer: Aetna Managed Medicare |
$186.76
|
| 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 |
$353.51
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cigna Commercial |
$613.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$373.25
|
| Rate for Payer: Health EOS Commercial |
$593.63
|
| Rate for Payer: HFN Commercial |
$613.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$533.60
|
| Rate for Payer: NAPHCARE Commercial |
$400.20
|
| Rate for Payer: Preferred Network Access Commercial |
$613.64
|
| Rate for Payer: Quartz Beloit One Network |
$326.83
|
| Rate for Payer: Quartz Commercial |
$433.55
|
| Rate for Payer: Quartz Medicare Advantage |
$400.20
|
| Rate for Payer: The Alliance Commercial |
$2,668.00
|
| Rate for Payer: United Healthcare PPO |
$500.25
|
| Rate for Payer: WEA Trust Commercial |
$366.85
|
| Rate for Payer: WPS Commercial |
$494.05
|
|
|
Yes - OT TH Evaluation Moderate Complexity Chg
|
Facility
IP
|
$667.00
|
|
|
Service Code
|
CPT 97166 95,GO
|
| Hospital Charge Code |
5585290
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$326.83 |
| Max. Negotiated Rate |
$613.64 |
| Rate for Payer: Aetna Commercial |
$600.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$353.51
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cigna Commercial |
$613.64
|
| Rate for Payer: Health EOS Commercial |
$593.63
|
| Rate for Payer: HFN Commercial |
$613.64
|
| Rate for Payer: Multiplan Commercial |
$533.60
|
| Rate for Payer: NAPHCARE Commercial |
$400.20
|
| Rate for Payer: Preferred Network Access Commercial |
$613.64
|
| Rate for Payer: Quartz Beloit One Network |
$326.83
|
| Rate for Payer: Quartz Commercial |
$400.20
|
| Rate for Payer: WEA Trust Commercial |
$366.85
|
| Rate for Payer: WPS Commercial |
$494.05
|
|
|
Yes - OT TH Reevaluation Chg
|
Facility
IP
|
$693.00
|
|
|
Service Code
|
CPT 97168 GO,95
|
| Hospital Charge Code |
5585302
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$339.57 |
| Max. Negotiated Rate |
$637.56 |
| Rate for Payer: Aetna Commercial |
$623.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.29
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$637.56
|
| Rate for Payer: Health EOS Commercial |
$616.77
|
| Rate for Payer: HFN Commercial |
$637.56
|
| Rate for Payer: Multiplan Commercial |
$554.40
|
| Rate for Payer: NAPHCARE Commercial |
$415.80
|
| Rate for Payer: Preferred Network Access Commercial |
$637.56
|
| Rate for Payer: Quartz Beloit One Network |
$339.57
|
| Rate for Payer: Quartz Commercial |
$415.80
|
| Rate for Payer: WEA Trust Commercial |
$381.15
|
| Rate for Payer: WPS Commercial |
$513.31
|
|
|
Yes - OT TH Reevaluation Chg
|
Facility
OP
|
$693.00
|
|
|
Service Code
|
CPT 97168 GO,95
|
| Hospital Charge Code |
5585302
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$194.04 |
| Max. Negotiated Rate |
$2,772.00 |
| Rate for Payer: Aetna Commercial |
$623.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$595.98
|
| Rate for Payer: Aetna Managed Medicare |
$194.04
|
| 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 |
$367.29
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$637.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$387.80
|
| Rate for Payer: Health EOS Commercial |
$616.77
|
| Rate for Payer: HFN Commercial |
$637.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$554.40
|
| Rate for Payer: NAPHCARE Commercial |
$415.80
|
| Rate for Payer: Preferred Network Access Commercial |
$637.56
|
| Rate for Payer: Quartz Beloit One Network |
$339.57
|
| Rate for Payer: Quartz Commercial |
$450.45
|
| Rate for Payer: Quartz Medicare Advantage |
$415.80
|
| Rate for Payer: The Alliance Commercial |
$2,772.00
|
| Rate for Payer: United Healthcare PPO |
$519.75
|
| Rate for Payer: WEA Trust Commercial |
$381.15
|
| Rate for Payer: WPS Commercial |
$513.31
|
|
|
Yes - OT Unattended Electrical Therapy Charge
|
Facility
OP
|
$158.00
|
|
|
Service Code
|
CPT 97014 GO
|
| Hospital Charge Code |
2989792
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$44.24 |
| Max. Negotiated Rate |
$632.00 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Aetna Managed Medicare |
$44.24
|
| 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 |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.42
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$102.70
|
| Rate for Payer: Quartz Medicare Advantage |
$94.80
|
| Rate for Payer: The Alliance Commercial |
$632.00
|
| Rate for Payer: United Healthcare PPO |
$118.50
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Yes - OT Unattended Electrical Therapy Charge
|
Facility
IP
|
$158.00
|
|
|
Service Code
|
CPT 97014 GO
|
| Hospital Charge Code |
2989792
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$77.42 |
| Max. Negotiated Rate |
$145.36 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$94.80
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Yes - OT Vasopneumatic Charge
|
Facility
OP
|
$193.00
|
|
|
Service Code
|
CPT 97016 GO
|
| Hospital Charge Code |
2989879
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$54.04 |
| Max. Negotiated Rate |
$772.00 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Aetna Managed Medicare |
$54.04
|
| 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 |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.00
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$125.45
|
| Rate for Payer: Quartz Medicare Advantage |
$115.80
|
| Rate for Payer: The Alliance Commercial |
$772.00
|
| Rate for Payer: United Healthcare PPO |
$144.75
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
Yes - OT Vasopneumatic Charge
|
Facility
IP
|
$193.00
|
|
|
Service Code
|
CPT 97016 GO
|
| Hospital Charge Code |
2989879
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$94.57 |
| Max. Negotiated Rate |
$177.56 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$115.80
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
Yes - OT Whirlpool Charge
|
Facility
IP
|
$296.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2987961
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$145.04 |
| Max. Negotiated Rate |
$272.32 |
| Rate for Payer: Aetna Commercial |
$266.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$156.88
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$272.32
|
| Rate for Payer: Health EOS Commercial |
$263.44
|
| Rate for Payer: HFN Commercial |
$272.32
|
| Rate for Payer: Multiplan Commercial |
$236.80
|
| Rate for Payer: NAPHCARE Commercial |
$177.60
|
| Rate for Payer: Preferred Network Access Commercial |
$272.32
|
| Rate for Payer: Quartz Beloit One Network |
$145.04
|
| Rate for Payer: Quartz Commercial |
$177.60
|
| Rate for Payer: WEA Trust Commercial |
$162.80
|
| Rate for Payer: WPS Commercial |
$219.25
|
|
|
Yes - OT Whirlpool Charge
|
Facility
OP
|
$296.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2987961
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$82.88 |
| Max. Negotiated Rate |
$1,184.00 |
| Rate for Payer: Aetna Commercial |
$266.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.56
|
| Rate for Payer: Aetna Managed Medicare |
$82.88
|
| 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 |
$156.88
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$272.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.64
|
| Rate for Payer: Health EOS Commercial |
$263.44
|
| Rate for Payer: HFN Commercial |
$272.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$236.80
|
| Rate for Payer: NAPHCARE Commercial |
$177.60
|
| Rate for Payer: Preferred Network Access Commercial |
$272.32
|
| Rate for Payer: Quartz Beloit One Network |
$145.04
|
| Rate for Payer: Quartz Commercial |
$192.40
|
| Rate for Payer: Quartz Medicare Advantage |
$177.60
|
| Rate for Payer: The Alliance Commercial |
$1,184.00
|
| Rate for Payer: United Healthcare PPO |
$222.00
|
| Rate for Payer: WEA Trust Commercial |
$162.80
|
| Rate for Payer: WPS Commercial |
$219.25
|
|
|
Yes - Oximeter Probe Charge
|
Facility
IP
|
$287.00
|
|
| Hospital Charge Code |
3006967
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$140.63 |
| Max. Negotiated Rate |
$264.04 |
| Rate for Payer: Aetna Commercial |
$258.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.11
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$264.04
|
| Rate for Payer: Health EOS Commercial |
$255.43
|
| Rate for Payer: HFN Commercial |
$264.04
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: NAPHCARE Commercial |
$172.20
|
| Rate for Payer: Preferred Network Access Commercial |
$264.04
|
| Rate for Payer: Quartz Beloit One Network |
$140.63
|
| Rate for Payer: Quartz Commercial |
$172.20
|
| Rate for Payer: WEA Trust Commercial |
$157.85
|
| Rate for Payer: WPS Commercial |
$212.58
|
|
|
Yes - Oximeter Probe Charge
|
Facility
OP
|
$287.00
|
|
| Hospital Charge Code |
3006967
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$80.36 |
| Max. Negotiated Rate |
$1,148.00 |
| Rate for Payer: Aetna Commercial |
$258.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.82
|
| Rate for Payer: Aetna Managed Medicare |
$80.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$186.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$143.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$137.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.11
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$264.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.61
|
| Rate for Payer: Health EOS Commercial |
$255.43
|
| Rate for Payer: HFN Commercial |
$264.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$215.25
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: NAPHCARE Commercial |
$172.20
|
| Rate for Payer: Preferred Network Access Commercial |
$264.04
|
| Rate for Payer: Quartz Beloit One Network |
$140.63
|
| Rate for Payer: Quartz Commercial |
$186.55
|
| Rate for Payer: Quartz Medicare Advantage |
$172.20
|
| Rate for Payer: The Alliance Commercial |
$1,148.00
|
| Rate for Payer: WEA Trust Commercial |
$157.85
|
| Rate for Payer: WPS Commercial |
$212.58
|
|
|
Yes - Oxygen Extension Tubing(7ft) Charge
|
Facility
IP
|
$11.00
|
|
| Hospital Charge Code |
3006952
|
|
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 - Oxygen Extension Tubing(7ft) Charge
|
Facility
OP
|
$11.00
|
|
| Hospital Charge Code |
3006952
|
|
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 - Oxymask
|
Facility
OP
|
$126.00
|
|
| Hospital Charge Code |
5543173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.28 |
| Max. Negotiated Rate |
$504.00 |
| Rate for Payer: Aetna Commercial |
$113.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.36
|
| Rate for Payer: Aetna Managed Medicare |
$35.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.78
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$115.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.51
|
| Rate for Payer: Health EOS Commercial |
$112.14
|
| Rate for Payer: HFN Commercial |
$115.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.50
|
| Rate for Payer: Multiplan Commercial |
$100.80
|
| Rate for Payer: NAPHCARE Commercial |
$75.60
|
| Rate for Payer: Preferred Network Access Commercial |
$115.92
|
| Rate for Payer: Quartz Beloit One Network |
$61.74
|
| Rate for Payer: Quartz Commercial |
$81.90
|
| Rate for Payer: Quartz Medicare Advantage |
$75.60
|
| Rate for Payer: The Alliance Commercial |
$504.00
|
| Rate for Payer: WEA Trust Commercial |
$69.30
|
| Rate for Payer: WPS Commercial |
$93.33
|
|
|
Yes - Oxymask
|
Facility
IP
|
$126.00
|
|
| Hospital Charge Code |
5543173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$61.74 |
| Max. Negotiated Rate |
$115.92 |
| Rate for Payer: Aetna Commercial |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.78
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$115.92
|
| Rate for Payer: Health EOS Commercial |
$112.14
|
| Rate for Payer: HFN Commercial |
$115.92
|
| Rate for Payer: Multiplan Commercial |
$100.80
|
| Rate for Payer: NAPHCARE Commercial |
$75.60
|
| Rate for Payer: Preferred Network Access Commercial |
$115.92
|
| Rate for Payer: Quartz Beloit One Network |
$61.74
|
| Rate for Payer: Quartz Commercial |
$75.60
|
| Rate for Payer: WEA Trust Commercial |
$69.30
|
| Rate for Payer: WPS Commercial |
$93.33
|
|
|
Yes - Peak Flow Measurement Charge
|
Facility
IP
|
$158.00
|
|
|
Service Code
|
CPT 94150
|
| Hospital Charge Code |
2990197
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$77.42 |
| Max. Negotiated Rate |
$145.36 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$94.80
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Yes - Peak Flow Measurement Charge
|
Facility
OP
|
$158.00
|
|
|
Service Code
|
CPT 94150
|
| Hospital Charge Code |
2990197
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$75.84 |
| Max. Negotiated Rate |
$574.33 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Aetna Managed Medicare |
$154.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.84
|
| Rate for Payer: Anthem Medicare Advantage |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| 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 |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$154.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$154.39
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| 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 |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$231.58
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$102.70
|
| Rate for Payer: Quartz Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare PPO |
$118.50
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: Wellcare Medicare |
$154.39
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Yes - Peak Flow Meter Charge
|
Facility
OP
|
$243.00
|
|
| Hospital Charge Code |
3006968
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$68.04 |
| Max. Negotiated Rate |
$972.00 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Aetna Managed Medicare |
$68.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$157.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$121.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$116.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.98
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.25
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$157.95
|
| Rate for Payer: Quartz Medicare Advantage |
$145.80
|
| Rate for Payer: The Alliance Commercial |
$972.00
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
Yes - Peak Flow Meter Charge
|
Facility
IP
|
$243.00
|
|
| Hospital Charge Code |
3006968
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$223.56 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$145.80
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
Yes - PEEP Valve Adjustable Charge
|
Facility
IP
|
$50.00
|
|
| Hospital Charge Code |
2990205
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$46.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| 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 - PEEP Valve Adjustable Charge
|
Facility
OP
|
$50.00
|
|
| Hospital Charge Code |
2990205
|
|
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 - Pentamidine Treatment Charge
|
Facility
OP
|
$249.00
|
|
|
Service Code
|
CPT 94642
|
| Hospital Charge Code |
3006936
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$119.52 |
| Max. Negotiated Rate |
$784.25 |
| Rate for Payer: Aetna Commercial |
$224.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$214.14
|
| Rate for Payer: Aetna Managed Medicare |
$210.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$161.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$124.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$119.52
|
| Rate for Payer: Anthem Medicare Advantage |
$210.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.97
|
| 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 |
$74.70
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna Commercial |
$229.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$210.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$139.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$210.82
|
| Rate for Payer: Health EOS Commercial |
$221.61
|
| Rate for Payer: HFN Commercial |
$229.08
|
| 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 |
$199.20
|
| Rate for Payer: NAPHCARE Commercial |
$316.23
|
| Rate for Payer: Preferred Network Access Commercial |
$229.08
|
| Rate for Payer: Quartz Beloit One Network |
$122.01
|
| Rate for Payer: Quartz Commercial |
$161.85
|
| Rate for Payer: Quartz Medicare Advantage |
$210.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.82
|
| Rate for Payer: United Healthcare PPO |
$186.75
|
| Rate for Payer: WEA Trust Commercial |
$136.95
|
| Rate for Payer: Wellcare Medicare |
$210.82
|
| Rate for Payer: WPS Commercial |
$184.43
|
|
|
Yes - Pentamidine Treatment Charge
|
Facility
IP
|
$249.00
|
|
|
Service Code
|
CPT 94642
|
| Hospital Charge Code |
3006936
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$122.01 |
| Max. Negotiated Rate |
$229.08 |
| Rate for Payer: Aetna Commercial |
$224.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.97
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna Commercial |
$229.08
|
| Rate for Payer: Health EOS Commercial |
$221.61
|
| Rate for Payer: HFN Commercial |
$229.08
|
| Rate for Payer: Multiplan Commercial |
$199.20
|
| Rate for Payer: NAPHCARE Commercial |
$149.40
|
| Rate for Payer: Preferred Network Access Commercial |
$229.08
|
| Rate for Payer: Quartz Beloit One Network |
$122.01
|
| Rate for Payer: Quartz Commercial |
$149.40
|
| Rate for Payer: WEA Trust Commercial |
$136.95
|
| Rate for Payer: WPS Commercial |
$184.43
|
|
|
Yes - Polysomnogram Charge
|
Facility
IP
|
$6,863.00
|
|
|
Service Code
|
CPT 94811
|
| Hospital Charge Code |
2990211
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$3,362.87 |
| Max. Negotiated Rate |
$6,313.96 |
| Rate for Payer: Aetna Commercial |
$6,176.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,637.39
|
| Rate for Payer: Cash Price |
$2,058.90
|
| Rate for Payer: Cigna Commercial |
$6,313.96
|
| Rate for Payer: Health EOS Commercial |
$6,108.07
|
| Rate for Payer: HFN Commercial |
$6,313.96
|
| Rate for Payer: Multiplan Commercial |
$5,490.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,117.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,313.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,362.87
|
| Rate for Payer: Quartz Commercial |
$4,117.80
|
| Rate for Payer: WEA Trust Commercial |
$3,774.65
|
| Rate for Payer: WPS Commercial |
$5,083.42
|
|
