|
Yes (CBI bag changed)* - CBI Bag Changed
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
4075877
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
Yes - Continuous Nebulizer, subsequent Charge
|
Facility
|
IP
|
$2,210.00
|
|
|
Service Code
|
CPT 94645
|
| Hospital Charge Code |
3006934
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$1,126.22 |
| Max. Negotiated Rate |
$2,114.53 |
| Rate for Payer: Aetna Commercial |
$2,068.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,976.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,218.15
|
| Rate for Payer: Cash Price |
$663.00
|
| Rate for Payer: Cigna Commercial |
$2,114.53
|
| Rate for Payer: Health EOS Commercial |
$2,045.58
|
| Rate for Payer: HFN Commercial |
$2,114.53
|
| Rate for Payer: Multiplan Commercial |
$1,838.72
|
| Rate for Payer: Preferred Network Access Commercial |
$2,114.53
|
| Rate for Payer: Quartz Beloit One Network |
$1,126.22
|
| Rate for Payer: Quartz Commercial |
$1,379.04
|
| Rate for Payer: WEA Trust Commercial |
$1,264.12
|
| Rate for Payer: WPS Commercial |
$1,702.36
|
|
|
Yes - Continuous Nebulizer, subsequent Charge
|
Facility
|
OP
|
$2,210.00
|
|
|
Service Code
|
CPT 94645
|
| Hospital Charge Code |
3006934
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$65.64 |
| Max. Negotiated Rate |
$2,114.53 |
| Rate for Payer: Aetna Commercial |
$2,068.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,976.62
|
| Rate for Payer: Aetna Managed Medicare |
$643.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,493.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,149.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,103.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,218.15
|
| Rate for Payer: Cash Price |
$663.00
|
| Rate for Payer: Cash Price |
$663.00
|
| Rate for Payer: Cigna Commercial |
$2,114.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,286.22
|
| Rate for Payer: Health EOS Commercial |
$2,045.58
|
| Rate for Payer: HFN Commercial |
$2,114.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,723.80
|
| Rate for Payer: Multiplan Commercial |
$1,838.72
|
| Rate for Payer: NAPHCARE Commercial |
$1,379.04
|
| Rate for Payer: Preferred Network Access Commercial |
$2,114.53
|
| Rate for Payer: Quartz Beloit One Network |
$1,126.22
|
| Rate for Payer: Quartz Commercial |
$1,493.96
|
| Rate for Payer: Quartz Medicare Advantage |
$1,379.04
|
| Rate for Payer: The Alliance Commercial |
$65.64
|
| Rate for Payer: United Healthcare PPO |
$1,723.80
|
| Rate for Payer: WEA Trust Commercial |
$1,264.12
|
| Rate for Payer: WPS Commercial |
$1,702.36
|
|
|
Yes - Continuous Oximeter Monitor Charge
|
Facility
|
OP
|
$1,115.00
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
3023868
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$16.39 |
| Max. Negotiated Rate |
$1,066.83 |
| Rate for Payer: Aetna Commercial |
$1,043.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.26
|
| Rate for Payer: Aetna Managed Medicare |
$324.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$753.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$579.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$556.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.59
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,066.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$648.93
|
| Rate for Payer: Health EOS Commercial |
$1,032.04
|
| Rate for Payer: HFN Commercial |
$1,066.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$869.70
|
| Rate for Payer: Multiplan Commercial |
$927.68
|
| Rate for Payer: NAPHCARE Commercial |
$695.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,066.83
|
| Rate for Payer: Quartz Beloit One Network |
$568.20
|
| Rate for Payer: Quartz Commercial |
$753.74
|
| Rate for Payer: Quartz Medicare Advantage |
$695.76
|
| Rate for Payer: The Alliance Commercial |
$16.39
|
| Rate for Payer: United Healthcare PPO |
$869.70
|
| Rate for Payer: WEA Trust Commercial |
$637.78
|
| Rate for Payer: WPS Commercial |
$858.88
|
|
|
Yes - Continuous Oximeter Monitor Charge
|
Facility
|
IP
|
$1,115.00
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
3023868
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$568.20 |
| Max. Negotiated Rate |
$1,066.83 |
| Rate for Payer: Aetna Commercial |
$1,043.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.59
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,066.83
|
| Rate for Payer: Health EOS Commercial |
$1,032.04
|
| Rate for Payer: HFN Commercial |
$1,066.83
|
| Rate for Payer: Multiplan Commercial |
$927.68
|
| Rate for Payer: Preferred Network Access Commercial |
$1,066.83
|
| Rate for Payer: Quartz Beloit One Network |
$568.20
|
| Rate for Payer: Quartz Commercial |
$695.76
|
| Rate for Payer: WEA Trust Commercial |
$637.78
|
| Rate for Payer: WPS Commercial |
$858.88
|
|
|
Yes - Corrugated Tubing Charge
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
3006949
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.55
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.60
|
| Rate for Payer: The Alliance Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
Yes - Corrugated Tubing Charge
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
3006949
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
Yes - CPAP Nasal Mask Charge
|
Facility
|
OP
|
$266.00
|
|
| Hospital Charge Code |
3004216
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$77.46 |
| Max. Negotiated Rate |
$254.51 |
| Rate for Payer: Aetna Commercial |
$248.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.91
|
| Rate for Payer: Aetna Managed Medicare |
$77.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$179.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$138.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.62
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$254.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$154.81
|
| Rate for Payer: Health EOS Commercial |
$246.21
|
| Rate for Payer: HFN Commercial |
$254.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$207.48
|
| Rate for Payer: Multiplan Commercial |
$221.31
|
| Rate for Payer: NAPHCARE Commercial |
$165.98
|
| Rate for Payer: Preferred Network Access Commercial |
$254.51
|
| Rate for Payer: Quartz Beloit One Network |
$135.55
|
| Rate for Payer: Quartz Commercial |
$179.82
|
| Rate for Payer: Quartz Medicare Advantage |
$165.98
|
| Rate for Payer: The Alliance Commercial |
$138.32
|
| Rate for Payer: United Healthcare PPO |
$207.48
|
| Rate for Payer: WEA Trust Commercial |
$152.15
|
| Rate for Payer: WPS Commercial |
$204.90
|
|
|
Yes - CPAP Nasal Mask Charge
|
Facility
|
IP
|
$266.00
|
|
| Hospital Charge Code |
3004216
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$135.55 |
| Max. Negotiated Rate |
$254.51 |
| Rate for Payer: Aetna Commercial |
$248.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.62
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$254.51
|
| Rate for Payer: Health EOS Commercial |
$246.21
|
| Rate for Payer: HFN Commercial |
$254.51
|
| Rate for Payer: Multiplan Commercial |
$221.31
|
| Rate for Payer: Preferred Network Access Commercial |
$254.51
|
| Rate for Payer: Quartz Beloit One Network |
$135.55
|
| Rate for Payer: Quartz Commercial |
$165.98
|
| Rate for Payer: WEA Trust Commercial |
$152.15
|
| Rate for Payer: WPS Commercial |
$204.90
|
|
|
Yes - CPT Palm Percussor Charge
|
Facility
|
IP
|
$28.00
|
|
| Hospital Charge Code |
2990206
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$26.79 |
| Rate for Payer: Aetna Commercial |
$26.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.43
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.79
|
| Rate for Payer: Health EOS Commercial |
$25.92
|
| Rate for Payer: HFN Commercial |
$26.79
|
| Rate for Payer: Multiplan Commercial |
$23.30
|
| Rate for Payer: Preferred Network Access Commercial |
$26.79
|
| Rate for Payer: Quartz Beloit One Network |
$14.27
|
| Rate for Payer: Quartz Commercial |
$17.47
|
| Rate for Payer: WEA Trust Commercial |
$16.02
|
| Rate for Payer: WPS Commercial |
$21.57
|
|
|
Yes - CPT Palm Percussor Charge
|
Facility
|
OP
|
$28.00
|
|
| Hospital Charge Code |
2990206
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$8.15 |
| Max. Negotiated Rate |
$26.79 |
| Rate for Payer: Aetna Commercial |
$26.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.04
|
| Rate for Payer: Aetna Managed Medicare |
$8.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.43
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.30
|
| Rate for Payer: Health EOS Commercial |
$25.92
|
| Rate for Payer: HFN Commercial |
$26.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.84
|
| Rate for Payer: Multiplan Commercial |
$23.30
|
| Rate for Payer: NAPHCARE Commercial |
$17.47
|
| Rate for Payer: Preferred Network Access Commercial |
$26.79
|
| Rate for Payer: Quartz Beloit One Network |
$14.27
|
| Rate for Payer: Quartz Commercial |
$18.93
|
| Rate for Payer: Quartz Medicare Advantage |
$17.47
|
| Rate for Payer: The Alliance Commercial |
$14.56
|
| Rate for Payer: WEA Trust Commercial |
$16.02
|
| Rate for Payer: WPS Commercial |
$21.57
|
|
|
Yes - CPT Vest Charge
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
CPT 94669
|
| Hospital Charge Code |
3006947
|
|
Hospital Revenue Code
|
419
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$149.26 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$97.34
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
Yes - CPT Vest Charge
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
CPT 94669
|
| Hospital Charge Code |
3006947
|
|
Hospital Revenue Code
|
419
|
| Min. Negotiated Rate |
$77.88 |
| Max. Negotiated Rate |
$921.81 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Aetna Managed Medicare |
$230.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$105.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.88
|
| Rate for Payer: Anthem Medicare Advantage |
$230.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$230.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$230.45
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$230.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$230.45
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$857.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$230.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$230.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$230.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$230.45
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: NAPHCARE Commercial |
$345.68
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$105.46
|
| Rate for Payer: Quartz Medicare Advantage |
$230.45
|
| Rate for Payer: The Alliance Commercial |
$921.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$230.45
|
| Rate for Payer: United Healthcare PPO |
$121.68
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: Wellcare Medicare |
$230.45
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
Yes - Disposable BFlex Bronchoscope
|
Facility
|
IP
|
$3,389.00
|
|
| Hospital Charge Code |
5478913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,727.03 |
| Max. Negotiated Rate |
$3,242.60 |
| Rate for Payer: Aetna Commercial |
$3,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,031.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,868.02
|
| Rate for Payer: Cash Price |
$1,016.70
|
| Rate for Payer: Cigna Commercial |
$3,242.60
|
| Rate for Payer: Health EOS Commercial |
$3,136.86
|
| Rate for Payer: HFN Commercial |
$3,242.60
|
| Rate for Payer: Multiplan Commercial |
$2,819.65
|
| Rate for Payer: Preferred Network Access Commercial |
$3,242.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,727.03
|
| Rate for Payer: Quartz Commercial |
$2,114.74
|
| Rate for Payer: WEA Trust Commercial |
$1,938.51
|
| Rate for Payer: WPS Commercial |
$2,610.55
|
|
|
Yes - Disposable BFlex Bronchoscope
|
Facility
|
OP
|
$3,389.00
|
|
| Hospital Charge Code |
5478913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$986.88 |
| Max. Negotiated Rate |
$3,242.60 |
| Rate for Payer: Aetna Commercial |
$3,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,031.12
|
| Rate for Payer: Aetna Managed Medicare |
$986.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,290.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,762.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,691.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,868.02
|
| Rate for Payer: Cash Price |
$1,016.70
|
| Rate for Payer: Cigna Commercial |
$3,242.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,972.40
|
| Rate for Payer: Health EOS Commercial |
$3,136.86
|
| Rate for Payer: HFN Commercial |
$3,242.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,643.42
|
| Rate for Payer: Multiplan Commercial |
$2,819.65
|
| Rate for Payer: NAPHCARE Commercial |
$2,114.74
|
| Rate for Payer: Preferred Network Access Commercial |
$3,242.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,727.03
|
| Rate for Payer: Quartz Commercial |
$2,290.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,114.74
|
| Rate for Payer: The Alliance Commercial |
$1,762.28
|
| Rate for Payer: WEA Trust Commercial |
$1,938.51
|
| Rate for Payer: WPS Commercial |
$2,610.55
|
|
|
Yes - Disposable Brochoscopy Cytology Charge
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2990202
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.32 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$86.11
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
Yes - Disposable Brochoscopy Cytology Charge
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2990202
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.19 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$40.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.32
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.64
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$86.11
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$93.29
|
| Rate for Payer: Quartz Medicare Advantage |
$86.11
|
| Rate for Payer: The Alliance Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
Yes - Disposable Brochoscopy Forceps Charge
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2990203
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.19 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Quartz Commercial |
$93.29
|
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$40.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.32
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.64
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$86.11
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Medicare Advantage |
$86.11
|
| Rate for Payer: The Alliance Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
Yes - Disposable Brochoscopy Forceps Charge
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2990203
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.32 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$86.11
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
Yes - Disposable EBUS Needle 22g
|
Facility
|
IP
|
$2,436.00
|
|
| Hospital Charge Code |
5476743
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,241.39 |
| Max. Negotiated Rate |
$2,330.76 |
| Rate for Payer: Aetna Commercial |
$2,280.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,178.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,342.72
|
| Rate for Payer: Cash Price |
$730.80
|
| Rate for Payer: Cigna Commercial |
$2,330.76
|
| Rate for Payer: Health EOS Commercial |
$2,254.76
|
| Rate for Payer: HFN Commercial |
$2,330.76
|
| Rate for Payer: Multiplan Commercial |
$2,026.75
|
| Rate for Payer: Preferred Network Access Commercial |
$2,330.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,241.39
|
| Rate for Payer: Quartz Commercial |
$1,520.06
|
| Rate for Payer: WEA Trust Commercial |
$1,393.39
|
| Rate for Payer: WPS Commercial |
$1,876.45
|
|
|
Yes - Disposable EBUS Needle 22g
|
Facility
|
OP
|
$2,436.00
|
|
| Hospital Charge Code |
5476743
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$709.36 |
| Max. Negotiated Rate |
$2,330.76 |
| Rate for Payer: Aetna Commercial |
$2,280.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,178.76
|
| Rate for Payer: Aetna Managed Medicare |
$709.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,646.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,266.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,216.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,342.72
|
| Rate for Payer: Cash Price |
$730.80
|
| Rate for Payer: Cigna Commercial |
$2,330.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,417.75
|
| Rate for Payer: Health EOS Commercial |
$2,254.76
|
| Rate for Payer: HFN Commercial |
$2,330.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,900.08
|
| Rate for Payer: Multiplan Commercial |
$2,026.75
|
| Rate for Payer: NAPHCARE Commercial |
$1,520.06
|
| Rate for Payer: Preferred Network Access Commercial |
$2,330.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,241.39
|
| Rate for Payer: Quartz Commercial |
$1,646.74
|
| Rate for Payer: Quartz Medicare Advantage |
$1,520.06
|
| Rate for Payer: The Alliance Commercial |
$1,266.72
|
| Rate for Payer: WEA Trust Commercial |
$1,393.39
|
| Rate for Payer: WPS Commercial |
$1,876.45
|
|
|
Yes - Disposable EBUS Needle 22g - Procore
|
Facility
|
IP
|
$2,953.00
|
|
| Hospital Charge Code |
5476744
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,504.85 |
| Max. Negotiated Rate |
$2,825.43 |
| Rate for Payer: Aetna Commercial |
$2,764.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,641.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,627.69
|
| Rate for Payer: Cash Price |
$885.90
|
| Rate for Payer: Cigna Commercial |
$2,825.43
|
| Rate for Payer: Health EOS Commercial |
$2,733.30
|
| Rate for Payer: HFN Commercial |
$2,825.43
|
| Rate for Payer: Multiplan Commercial |
$2,456.90
|
| Rate for Payer: Preferred Network Access Commercial |
$2,825.43
|
| Rate for Payer: Quartz Beloit One Network |
$1,504.85
|
| Rate for Payer: Quartz Commercial |
$1,842.67
|
| Rate for Payer: WEA Trust Commercial |
$1,689.12
|
| Rate for Payer: WPS Commercial |
$2,274.70
|
|
|
Yes - Disposable EBUS Needle 22g - Procore
|
Facility
|
OP
|
$2,953.00
|
|
| Hospital Charge Code |
5476744
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$859.91 |
| Max. Negotiated Rate |
$2,825.43 |
| Rate for Payer: Aetna Commercial |
$2,764.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,641.16
|
| Rate for Payer: Aetna Managed Medicare |
$859.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,996.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,535.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,474.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,627.69
|
| Rate for Payer: Cash Price |
$885.90
|
| Rate for Payer: Cigna Commercial |
$2,825.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,718.65
|
| Rate for Payer: Health EOS Commercial |
$2,733.30
|
| Rate for Payer: HFN Commercial |
$2,825.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,303.34
|
| Rate for Payer: Multiplan Commercial |
$2,456.90
|
| Rate for Payer: NAPHCARE Commercial |
$1,842.67
|
| Rate for Payer: Preferred Network Access Commercial |
$2,825.43
|
| Rate for Payer: Quartz Beloit One Network |
$1,504.85
|
| Rate for Payer: Quartz Commercial |
$1,996.23
|
| Rate for Payer: Quartz Medicare Advantage |
$1,842.67
|
| Rate for Payer: The Alliance Commercial |
$1,535.56
|
| Rate for Payer: WEA Trust Commercial |
$1,689.12
|
| Rate for Payer: WPS Commercial |
$2,274.70
|
|
|
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 |
$1,402.74 |
| Max. Negotiated Rate |
$5,610.97 |
| Rate for Payer: Aetna Commercial |
$3,731.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,565.97
|
| Rate for Payer: Aetna Managed Medicare |
$1,402.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,695.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,073.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,990.31
|
| Rate for Payer: Anthem Medicare Advantage |
$1,402.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,197.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,402.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,402.74
|
| Rate for Payer: Cash Price |
$1,196.10
|
| Rate for Payer: Cash Price |
$1,196.10
|
| Rate for Payer: Cigna Commercial |
$3,814.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,402.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,320.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,402.74
|
| Rate for Payer: Health EOS Commercial |
$3,690.37
|
| Rate for Payer: HFN Commercial |
$3,814.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,218.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,402.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,402.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,402.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,402.74
|
| Rate for Payer: Multiplan Commercial |
$3,317.18
|
| Rate for Payer: NAPHCARE Commercial |
$2,104.11
|
| Rate for Payer: Preferred Network Access Commercial |
$3,814.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,031.78
|
| Rate for Payer: Quartz Commercial |
$2,695.21
|
| Rate for Payer: Quartz Medicare Advantage |
$1,402.74
|
| Rate for Payer: The Alliance Commercial |
$5,610.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,402.74
|
| Rate for Payer: WEA Trust Commercial |
$2,280.56
|
| Rate for Payer: Wellcare Medicare |
$1,402.74
|
| Rate for Payer: WPS Commercial |
$3,071.19
|
|
|
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 |
$2,031.78 |
| Max. Negotiated Rate |
$3,814.76 |
| Rate for Payer: Aetna Commercial |
$3,731.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,565.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,197.63
|
| Rate for Payer: Cash Price |
$1,196.10
|
| Rate for Payer: Cigna Commercial |
$3,814.76
|
| Rate for Payer: Health EOS Commercial |
$3,690.37
|
| Rate for Payer: HFN Commercial |
$3,814.76
|
| Rate for Payer: Multiplan Commercial |
$3,317.18
|
| Rate for Payer: Preferred Network Access Commercial |
$3,814.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,031.78
|
| Rate for Payer: Quartz Commercial |
$2,487.89
|
| Rate for Payer: WEA Trust Commercial |
$2,280.56
|
| Rate for Payer: WPS Commercial |
$3,071.19
|
|
