|
Yes - Mechanical Traction Charge
|
Facility
|
IP
|
$232.00
|
|
|
Service Code
|
CPT 97012 GP
|
| Hospital Charge Code |
2989810
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$118.23 |
| Max. Negotiated Rate |
$221.98 |
| Rate for Payer: Aetna Commercial |
$217.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.88
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$221.98
|
| Rate for Payer: Health EOS Commercial |
$214.74
|
| Rate for Payer: HFN Commercial |
$221.98
|
| Rate for Payer: Multiplan Commercial |
$193.02
|
| Rate for Payer: Preferred Network Access Commercial |
$221.98
|
| Rate for Payer: Quartz Beloit One Network |
$118.23
|
| Rate for Payer: Quartz Commercial |
$144.77
|
| Rate for Payer: WEA Trust Commercial |
$132.70
|
| Rate for Payer: WPS Commercial |
$178.71
|
|
|
Yes - Mechanical Traction Charge
|
Facility
|
OP
|
$232.00
|
|
|
Service Code
|
CPT 97012 GP
|
| Hospital Charge Code |
2989810
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$67.56 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$217.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.50
|
| Rate for Payer: Aetna Managed Medicare |
$67.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.88
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$221.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.02
|
| Rate for Payer: Health EOS Commercial |
$214.74
|
| Rate for Payer: HFN Commercial |
$221.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$193.02
|
| Rate for Payer: NAPHCARE Commercial |
$144.77
|
| Rate for Payer: Preferred Network Access Commercial |
$221.98
|
| Rate for Payer: Quartz Beloit One Network |
$118.23
|
| Rate for Payer: Quartz Commercial |
$156.83
|
| Rate for Payer: Quartz Medicare Advantage |
$144.77
|
| Rate for Payer: The Alliance Commercial |
$120.64
|
| Rate for Payer: United Healthcare PPO |
$180.96
|
| Rate for Payer: WEA Trust Commercial |
$132.70
|
| Rate for Payer: WPS Commercial |
$178.71
|
|
|
Yes - Mechanical Traction Charge
|
Professional
|
Both
|
$232.00
|
|
|
Service Code
|
CPT 97012 GP
|
| Hospital Charge Code |
2989810
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$106.16 |
| Max. Negotiated Rate |
$229.22 |
| Rate for Payer: Aetna Commercial |
$229.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.50
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$229.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.77
|
| Rate for Payer: Health EOS Commercial |
$219.56
|
| Rate for Payer: HFN Commercial |
$229.22
|
| Rate for Payer: Multiplan Commercial |
$193.02
|
| Rate for Payer: Preferred Network Access Commercial |
$229.22
|
| Rate for Payer: Quartz Beloit One Network |
$106.16
|
| Rate for Payer: Quartz Commercial |
$137.53
|
| Rate for Payer: The Alliance Commercial |
$120.64
|
| Rate for Payer: WEA Trust Commercial |
$132.70
|
| Rate for Payer: WPS Commercial |
$178.71
|
|
|
Yes - Medication Unit Dose Charge
|
Facility
|
OP
|
$21.00
|
|
| Hospital Charge Code |
3006960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Aetna Commercial |
$19.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.78
|
| Rate for Payer: Aetna Managed Medicare |
$6.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.58
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$20.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.22
|
| Rate for Payer: Health EOS Commercial |
$19.44
|
| Rate for Payer: HFN Commercial |
$20.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.38
|
| Rate for Payer: Multiplan Commercial |
$17.47
|
| Rate for Payer: NAPHCARE Commercial |
$13.10
|
| Rate for Payer: Preferred Network Access Commercial |
$20.09
|
| Rate for Payer: Quartz Beloit One Network |
$10.70
|
| Rate for Payer: Quartz Commercial |
$14.20
|
| Rate for Payer: Quartz Medicare Advantage |
$13.10
|
| Rate for Payer: The Alliance Commercial |
$10.92
|
| Rate for Payer: WEA Trust Commercial |
$12.01
|
| Rate for Payer: WPS Commercial |
$16.18
|
|
|
Yes - Medication Unit Dose Charge
|
Facility
|
IP
|
$21.00
|
|
| Hospital Charge Code |
3006960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.70 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Aetna Commercial |
$19.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.58
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$20.09
|
| Rate for Payer: Health EOS Commercial |
$19.44
|
| Rate for Payer: HFN Commercial |
$20.09
|
| Rate for Payer: Multiplan Commercial |
$17.47
|
| Rate for Payer: Preferred Network Access Commercial |
$20.09
|
| Rate for Payer: Quartz Beloit One Network |
$10.70
|
| Rate for Payer: Quartz Commercial |
$13.10
|
| Rate for Payer: WEA Trust Commercial |
$12.01
|
| Rate for Payer: WPS Commercial |
$16.18
|
|
|
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 |
$99.84 |
| Max. Negotiated Rate |
$921.81 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Aetna Managed Medicare |
$230.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$135.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$99.84
|
| Rate for Payer: Anthem Medicare Advantage |
$230.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| 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 |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$230.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$230.45
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| 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 |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$345.68
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$135.20
|
| 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 |
$156.00
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: Wellcare Medicare |
$230.45
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
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 |
$101.92 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
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 |
$903.73 |
| Max. Negotiated Rate |
$3,979.33 |
| Rate for Payer: Aetna Commercial |
$3,892.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,719.81
|
| Rate for Payer: Aetna Managed Medicare |
$903.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$903.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,292.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$903.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$903.73
|
| 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 |
$3,979.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$903.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,420.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$903.73
|
| Rate for Payer: Health EOS Commercial |
$3,849.57
|
| Rate for Payer: HFN Commercial |
$3,979.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,361.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$903.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$903.73
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$903.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$903.73
|
| Rate for Payer: Multiplan Commercial |
$3,460.29
|
| Rate for Payer: NAPHCARE Commercial |
$1,355.59
|
| Rate for Payer: Preferred Network Access Commercial |
$3,979.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,119.43
|
| Rate for Payer: Quartz Commercial |
$2,811.48
|
| Rate for Payer: Quartz Medicare Advantage |
$903.73
|
| Rate for Payer: The Alliance Commercial |
$3,614.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$903.73
|
| Rate for Payer: United Healthcare PPO |
$3,244.02
|
| Rate for Payer: WEA Trust Commercial |
$2,378.95
|
| Rate for Payer: Wellcare Medicare |
$903.73
|
| Rate for Payer: WPS Commercial |
$3,203.68
|
|
|
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 |
$2,119.43 |
| Max. Negotiated Rate |
$3,979.33 |
| Rate for Payer: Aetna Commercial |
$3,892.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,719.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,292.44
|
| Rate for Payer: Cash Price |
$1,247.70
|
| Rate for Payer: Cigna Commercial |
$3,979.33
|
| Rate for Payer: Health EOS Commercial |
$3,849.57
|
| Rate for Payer: HFN Commercial |
$3,979.33
|
| Rate for Payer: Multiplan Commercial |
$3,460.29
|
| Rate for Payer: Preferred Network Access Commercial |
$3,979.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,119.43
|
| Rate for Payer: Quartz Commercial |
$2,595.22
|
| Rate for Payer: WEA Trust Commercial |
$2,378.95
|
| Rate for Payer: WPS Commercial |
$3,203.68
|
|
|
Yes - Nasal Cannula(25ft) Charge
|
Facility
|
OP
|
$240.00
|
|
| Hospital Charge Code |
3006965
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$69.89 |
| Max. Negotiated Rate |
$229.63 |
| Rate for Payer: Aetna Commercial |
$224.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$214.66
|
| Rate for Payer: Aetna Managed Medicare |
$69.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$162.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$124.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$119.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.29
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$229.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$139.68
|
| Rate for Payer: Health EOS Commercial |
$222.14
|
| Rate for Payer: HFN Commercial |
$229.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.20
|
| Rate for Payer: Multiplan Commercial |
$199.68
|
| Rate for Payer: NAPHCARE Commercial |
$149.76
|
| Rate for Payer: Preferred Network Access Commercial |
$229.63
|
| Rate for Payer: Quartz Beloit One Network |
$122.30
|
| Rate for Payer: Quartz Commercial |
$162.24
|
| Rate for Payer: Quartz Medicare Advantage |
$149.76
|
| Rate for Payer: The Alliance Commercial |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$137.28
|
| Rate for Payer: WPS Commercial |
$184.87
|
|
|
Yes - Nasal Cannula(25ft) Charge
|
Facility
|
IP
|
$240.00
|
|
| Hospital Charge Code |
3006965
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$122.30 |
| Max. Negotiated Rate |
$229.63 |
| Rate for Payer: Aetna Commercial |
$224.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$214.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.29
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$229.63
|
| Rate for Payer: Health EOS Commercial |
$222.14
|
| Rate for Payer: HFN Commercial |
$229.63
|
| Rate for Payer: Multiplan Commercial |
$199.68
|
| Rate for Payer: Preferred Network Access Commercial |
$229.63
|
| Rate for Payer: Quartz Beloit One Network |
$122.30
|
| Rate for Payer: Quartz Commercial |
$149.76
|
| Rate for Payer: WEA Trust Commercial |
$137.28
|
| Rate for Payer: WPS Commercial |
$184.87
|
|
|
Yes - Nasal Cannula Holder Charge
|
Facility
|
IP
|
$29.00
|
|
| Hospital Charge Code |
2990208
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.98
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.75
|
| Rate for Payer: Health EOS Commercial |
$26.84
|
| Rate for Payer: HFN Commercial |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: Preferred Network Access Commercial |
$27.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.78
|
| Rate for Payer: Quartz Commercial |
$18.10
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$22.34
|
|
|
Yes - Nasal Cannula Holder Charge
|
Facility
|
OP
|
$29.00
|
|
| Hospital Charge Code |
2990208
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Aetna Managed Medicare |
$8.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.98
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.88
|
| Rate for Payer: Health EOS Commercial |
$26.84
|
| Rate for Payer: HFN Commercial |
$27.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.62
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: NAPHCARE Commercial |
$18.10
|
| Rate for Payer: Preferred Network Access Commercial |
$27.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.78
|
| Rate for Payer: Quartz Commercial |
$19.60
|
| Rate for Payer: Quartz Medicare Advantage |
$18.10
|
| Rate for Payer: The Alliance Commercial |
$15.08
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$22.34
|
|
|
Yes - Nasal Cannula(std) Charge
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
3006964
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$30.58
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Yes - Nasal Cannula(std) Charge
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
3006964
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Aetna Managed Medicare |
$14.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.22
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: NAPHCARE Commercial |
$30.58
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$33.12
|
| Rate for Payer: Quartz Medicare Advantage |
$30.58
|
| Rate for Payer: The Alliance Commercial |
$25.48
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Yes - Nebulizer Setup Charge
|
Facility
|
OP
|
$453.00
|
|
| Hospital Charge Code |
3006961
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$131.91 |
| Max. Negotiated Rate |
$433.43 |
| Rate for Payer: Aetna Commercial |
$424.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.16
|
| Rate for Payer: Aetna Managed Medicare |
$131.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$306.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$235.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$226.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.69
|
| Rate for Payer: Cash Price |
$135.90
|
| Rate for Payer: Cigna Commercial |
$433.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$263.65
|
| Rate for Payer: Health EOS Commercial |
$419.30
|
| Rate for Payer: HFN Commercial |
$433.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$353.34
|
| Rate for Payer: Multiplan Commercial |
$376.90
|
| Rate for Payer: NAPHCARE Commercial |
$282.67
|
| Rate for Payer: Preferred Network Access Commercial |
$433.43
|
| Rate for Payer: Quartz Beloit One Network |
$230.85
|
| Rate for Payer: Quartz Commercial |
$306.23
|
| Rate for Payer: Quartz Medicare Advantage |
$282.67
|
| Rate for Payer: The Alliance Commercial |
$235.56
|
| Rate for Payer: WEA Trust Commercial |
$259.12
|
| Rate for Payer: WPS Commercial |
$348.95
|
|
|
Yes - Nebulizer Setup Charge
|
Facility
|
IP
|
$453.00
|
|
| Hospital Charge Code |
3006961
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$230.85 |
| Max. Negotiated Rate |
$433.43 |
| Rate for Payer: Aetna Commercial |
$424.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.69
|
| Rate for Payer: Cash Price |
$135.90
|
| Rate for Payer: Cigna Commercial |
$433.43
|
| Rate for Payer: Health EOS Commercial |
$419.30
|
| Rate for Payer: HFN Commercial |
$433.43
|
| Rate for Payer: Multiplan Commercial |
$376.90
|
| Rate for Payer: Preferred Network Access Commercial |
$433.43
|
| Rate for Payer: Quartz Beloit One Network |
$230.85
|
| Rate for Payer: Quartz Commercial |
$282.67
|
| Rate for Payer: WEA Trust Commercial |
$259.12
|
| Rate for Payer: WPS Commercial |
$348.95
|
|
|
Yes - Nebulizer T-Adapter Charge
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
3006962
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Aetna Managed Medicare |
$3.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.40
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.58
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: NAPHCARE Commercial |
$6.86
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$7.44
|
| Rate for Payer: Quartz Medicare Advantage |
$6.86
|
| Rate for Payer: The Alliance Commercial |
$5.72
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
Yes - Nebulizer T-Adapter Charge
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
3006962
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$6.86
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
Yes - Nocturnal Oximetry Study Charge
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
3026389
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$226.26 |
| Max. Negotiated Rate |
$424.82 |
| Rate for Payer: Aetna Commercial |
$415.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$397.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.73
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cigna Commercial |
$424.82
|
| Rate for Payer: Health EOS Commercial |
$410.97
|
| Rate for Payer: HFN Commercial |
$424.82
|
| Rate for Payer: Multiplan Commercial |
$369.41
|
| Rate for Payer: Preferred Network Access Commercial |
$424.82
|
| Rate for Payer: Quartz Beloit One Network |
$226.26
|
| Rate for Payer: Quartz Commercial |
$277.06
|
| Rate for Payer: WEA Trust Commercial |
$253.97
|
| Rate for Payer: WPS Commercial |
$342.01
|
|
|
Yes - Nocturnal Oximetry Study Charge
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
3026389
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$135.42 |
| Max. Negotiated Rate |
$541.67 |
| Rate for Payer: Aetna Commercial |
$415.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$397.11
|
| Rate for Payer: Aetna Managed Medicare |
$135.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$300.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$230.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$221.64
|
| Rate for Payer: Anthem Medicare Advantage |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$135.42
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cigna Commercial |
$424.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$135.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$135.42
|
| Rate for Payer: Health EOS Commercial |
$410.97
|
| Rate for Payer: HFN Commercial |
$424.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$503.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$135.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$135.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$135.42
|
| Rate for Payer: Multiplan Commercial |
$369.41
|
| Rate for Payer: NAPHCARE Commercial |
$203.13
|
| Rate for Payer: Preferred Network Access Commercial |
$424.82
|
| Rate for Payer: Quartz Beloit One Network |
$226.26
|
| Rate for Payer: Quartz Commercial |
$300.14
|
| Rate for Payer: Quartz Medicare Advantage |
$135.42
|
| Rate for Payer: The Alliance Commercial |
$541.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$135.42
|
| Rate for Payer: United Healthcare PPO |
$346.32
|
| Rate for Payer: WEA Trust Commercial |
$253.97
|
| Rate for Payer: Wellcare Medicare |
$135.42
|
| Rate for Payer: WPS Commercial |
$342.01
|
|
|
Yes - Non-Rebeather Mask Charge
|
Facility
|
OP
|
$77.00
|
|
| Hospital Charge Code |
3006963
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Aetna Managed Medicare |
$22.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.81
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.06
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: NAPHCARE Commercial |
$48.05
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$52.05
|
| Rate for Payer: Quartz Medicare Advantage |
$48.05
|
| Rate for Payer: The Alliance Commercial |
$40.04
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Yes - Non-Rebeather Mask Charge
|
Facility
|
IP
|
$77.00
|
|
| Hospital Charge Code |
3006963
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$48.05
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Yes - Noturnal Oximetry Charge
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
2990180
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$181.42 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$222.14
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
Yes - Noturnal Oximetry Charge
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
2990180
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$135.42 |
| Max. Negotiated Rate |
$541.67 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Aetna Managed Medicare |
$135.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$240.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.72
|
| Rate for Payer: Anthem Medicare Advantage |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$135.42
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$135.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$135.42
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$503.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$135.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$135.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$135.42
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$203.13
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$240.66
|
| Rate for Payer: Quartz Medicare Advantage |
$135.42
|
| Rate for Payer: The Alliance Commercial |
$541.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$135.42
|
| Rate for Payer: United Healthcare PPO |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: Wellcare Medicare |
$135.42
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
