|
Yes - OT TH Evaluation Low Complexity Chg
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
CPT 97165 GO,95
|
| Hospital Charge Code |
5585274
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$169.19 |
| Max. Negotiated Rate |
$317.66 |
| Rate for Payer: Aetna Commercial |
$310.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$183.00
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$317.66
|
| Rate for Payer: Health EOS Commercial |
$307.30
|
| Rate for Payer: HFN Commercial |
$317.66
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: Preferred Network Access Commercial |
$317.66
|
| Rate for Payer: Quartz Beloit One Network |
$169.19
|
| Rate for Payer: Quartz Commercial |
$207.17
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: WPS Commercial |
$255.74
|
|
|
Yes - OT TH Evaluation Low Complexity Chg
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
CPT 97165 GO,95
|
| Hospital Charge Code |
5585274
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$96.68 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$310.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Aetna Managed Medicare |
$96.68
|
| 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 |
$183.00
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$317.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.22
|
| Rate for Payer: Health EOS Commercial |
$307.30
|
| Rate for Payer: HFN Commercial |
$317.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: NAPHCARE Commercial |
$207.17
|
| Rate for Payer: Preferred Network Access Commercial |
$317.66
|
| Rate for Payer: Quartz Beloit One Network |
$169.19
|
| Rate for Payer: Quartz Commercial |
$224.43
|
| Rate for Payer: Quartz Medicare Advantage |
$207.17
|
| Rate for Payer: The Alliance Commercial |
$172.64
|
| Rate for Payer: United Healthcare PPO |
$258.96
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: WPS Commercial |
$255.74
|
|
|
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 |
$194.23 |
| Max. Negotiated Rate |
$638.19 |
| Rate for Payer: Aetna Commercial |
$624.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.56
|
| Rate for Payer: Aetna Managed Medicare |
$194.23
|
| 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 |
$367.65
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cigna Commercial |
$638.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$388.19
|
| Rate for Payer: Health EOS Commercial |
$617.38
|
| Rate for Payer: HFN Commercial |
$638.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$554.94
|
| Rate for Payer: NAPHCARE Commercial |
$416.21
|
| Rate for Payer: Preferred Network Access Commercial |
$638.19
|
| Rate for Payer: Quartz Beloit One Network |
$339.90
|
| Rate for Payer: Quartz Commercial |
$450.89
|
| Rate for Payer: Quartz Medicare Advantage |
$416.21
|
| Rate for Payer: The Alliance Commercial |
$346.84
|
| Rate for Payer: United Healthcare PPO |
$520.26
|
| Rate for Payer: WEA Trust Commercial |
$381.52
|
| Rate for Payer: WPS Commercial |
$513.79
|
|
|
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 |
$339.90 |
| Max. Negotiated Rate |
$638.19 |
| Rate for Payer: Aetna Commercial |
$624.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.65
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cigna Commercial |
$638.19
|
| Rate for Payer: Health EOS Commercial |
$617.38
|
| Rate for Payer: HFN Commercial |
$638.19
|
| Rate for Payer: Multiplan Commercial |
$554.94
|
| Rate for Payer: Preferred Network Access Commercial |
$638.19
|
| Rate for Payer: Quartz Beloit One Network |
$339.90
|
| Rate for Payer: Quartz Commercial |
$416.21
|
| Rate for Payer: WEA Trust Commercial |
$381.52
|
| Rate for Payer: WPS Commercial |
$513.79
|
|
|
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 |
$353.15 |
| Max. Negotiated Rate |
$663.06 |
| Rate for Payer: Aetna Commercial |
$648.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.98
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$663.06
|
| Rate for Payer: Health EOS Commercial |
$641.44
|
| Rate for Payer: HFN Commercial |
$663.06
|
| Rate for Payer: Multiplan Commercial |
$576.58
|
| Rate for Payer: Preferred Network Access Commercial |
$663.06
|
| Rate for Payer: Quartz Beloit One Network |
$353.15
|
| Rate for Payer: Quartz Commercial |
$432.43
|
| Rate for Payer: WEA Trust Commercial |
$396.40
|
| Rate for Payer: WPS Commercial |
$533.82
|
|
|
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 |
$201.80 |
| Max. Negotiated Rate |
$663.06 |
| Rate for Payer: Aetna Commercial |
$648.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.82
|
| Rate for Payer: Aetna Managed Medicare |
$201.80
|
| 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 |
$381.98
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$663.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$403.33
|
| Rate for Payer: Health EOS Commercial |
$641.44
|
| Rate for Payer: HFN Commercial |
$663.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$576.58
|
| Rate for Payer: NAPHCARE Commercial |
$432.43
|
| Rate for Payer: Preferred Network Access Commercial |
$663.06
|
| Rate for Payer: Quartz Beloit One Network |
$353.15
|
| Rate for Payer: Quartz Commercial |
$468.47
|
| Rate for Payer: Quartz Medicare Advantage |
$432.43
|
| Rate for Payer: The Alliance Commercial |
$360.36
|
| Rate for Payer: United Healthcare PPO |
$540.54
|
| Rate for Payer: WEA Trust Commercial |
$396.40
|
| Rate for Payer: WPS Commercial |
$533.82
|
|
|
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 |
$46.01 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Aetna Managed Medicare |
$46.01
|
| 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 |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.96
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: NAPHCARE Commercial |
$98.59
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$106.81
|
| Rate for Payer: Quartz Medicare Advantage |
$98.59
|
| Rate for Payer: The Alliance Commercial |
$82.16
|
| Rate for Payer: United Healthcare PPO |
$123.24
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
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 |
$80.52 |
| Max. Negotiated Rate |
$151.17 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$98.59
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
Yes - OT Vasopneumatic Charge
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
CPT 97016 GO
|
| Hospital Charge Code |
2989879
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$56.20
|
| 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 |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.33
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$120.43
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$130.47
|
| Rate for Payer: Quartz Medicare Advantage |
$120.43
|
| Rate for Payer: The Alliance Commercial |
$100.36
|
| Rate for Payer: United Healthcare PPO |
$150.54
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
Yes - OT Vasopneumatic Charge
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
CPT 97016 GO
|
| Hospital Charge Code |
2989879
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$98.35 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$120.43
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
Yes - OT Whirlpool Charge
|
Facility
|
IP
|
$296.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2987961
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$150.84 |
| Max. Negotiated Rate |
$283.21 |
| Rate for Payer: Aetna Commercial |
$277.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$163.16
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$283.21
|
| Rate for Payer: Health EOS Commercial |
$273.98
|
| Rate for Payer: HFN Commercial |
$283.21
|
| Rate for Payer: Multiplan Commercial |
$246.27
|
| Rate for Payer: Preferred Network Access Commercial |
$283.21
|
| Rate for Payer: Quartz Beloit One Network |
$150.84
|
| Rate for Payer: Quartz Commercial |
$184.70
|
| Rate for Payer: WEA Trust Commercial |
$169.31
|
| Rate for Payer: WPS Commercial |
$228.01
|
|
|
Yes - OT Whirlpool Charge
|
Facility
|
OP
|
$296.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2987961
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$86.20 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$277.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.74
|
| Rate for Payer: Aetna Managed Medicare |
$86.20
|
| 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 |
$163.16
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$283.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$172.27
|
| Rate for Payer: Health EOS Commercial |
$273.98
|
| Rate for Payer: HFN Commercial |
$283.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$246.27
|
| Rate for Payer: NAPHCARE Commercial |
$184.70
|
| Rate for Payer: Preferred Network Access Commercial |
$283.21
|
| Rate for Payer: Quartz Beloit One Network |
$150.84
|
| Rate for Payer: Quartz Commercial |
$200.10
|
| Rate for Payer: Quartz Medicare Advantage |
$184.70
|
| Rate for Payer: The Alliance Commercial |
$153.92
|
| Rate for Payer: United Healthcare PPO |
$230.88
|
| Rate for Payer: WEA Trust Commercial |
$169.31
|
| Rate for Payer: WPS Commercial |
$228.01
|
|
|
Yes - Oximeter Probe Charge
|
Facility
|
OP
|
$287.00
|
|
| Hospital Charge Code |
3006967
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$83.57 |
| Max. Negotiated Rate |
$274.60 |
| Rate for Payer: Aetna Commercial |
$268.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$256.69
|
| Rate for Payer: Aetna Managed Medicare |
$83.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$194.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$149.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$143.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$158.19
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$274.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$167.03
|
| Rate for Payer: Health EOS Commercial |
$265.65
|
| Rate for Payer: HFN Commercial |
$274.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$223.86
|
| Rate for Payer: Multiplan Commercial |
$238.78
|
| Rate for Payer: NAPHCARE Commercial |
$179.09
|
| Rate for Payer: Preferred Network Access Commercial |
$274.60
|
| Rate for Payer: Quartz Beloit One Network |
$146.26
|
| Rate for Payer: Quartz Commercial |
$194.01
|
| Rate for Payer: Quartz Medicare Advantage |
$179.09
|
| Rate for Payer: The Alliance Commercial |
$149.24
|
| Rate for Payer: WEA Trust Commercial |
$164.16
|
| Rate for Payer: WPS Commercial |
$221.08
|
|
|
Yes - Oximeter Probe Charge
|
Facility
|
IP
|
$287.00
|
|
| Hospital Charge Code |
3006967
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$146.26 |
| Max. Negotiated Rate |
$274.60 |
| Rate for Payer: Aetna Commercial |
$268.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$256.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$158.19
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$274.60
|
| Rate for Payer: Health EOS Commercial |
$265.65
|
| Rate for Payer: HFN Commercial |
$274.60
|
| Rate for Payer: Multiplan Commercial |
$238.78
|
| Rate for Payer: Preferred Network Access Commercial |
$274.60
|
| Rate for Payer: Quartz Beloit One Network |
$146.26
|
| Rate for Payer: Quartz Commercial |
$179.09
|
| Rate for Payer: WEA Trust Commercial |
$164.16
|
| Rate for Payer: WPS Commercial |
$221.08
|
|
|
Yes - Oxygen Extension Tubing(7ft) Charge
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
3006952
|
|
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 - Oxygen Extension Tubing(7ft) Charge
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
3006952
|
|
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 - Oxymask
|
Facility
|
OP
|
$126.00
|
|
| Hospital Charge Code |
5543173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.69 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna Commercial |
$117.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$112.69
|
| Rate for Payer: Aetna Managed Medicare |
$36.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$85.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$65.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$62.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$69.45
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$120.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$73.33
|
| Rate for Payer: Health EOS Commercial |
$116.63
|
| Rate for Payer: HFN Commercial |
$120.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$98.28
|
| Rate for Payer: Multiplan Commercial |
$104.83
|
| Rate for Payer: NAPHCARE Commercial |
$78.62
|
| Rate for Payer: Preferred Network Access Commercial |
$120.56
|
| Rate for Payer: Quartz Beloit One Network |
$64.21
|
| Rate for Payer: Quartz Commercial |
$85.18
|
| Rate for Payer: Quartz Medicare Advantage |
$78.62
|
| Rate for Payer: The Alliance Commercial |
$65.52
|
| Rate for Payer: WEA Trust Commercial |
$72.07
|
| Rate for Payer: WPS Commercial |
$97.06
|
|
|
Yes - Oxymask
|
Facility
|
IP
|
$126.00
|
|
| Hospital Charge Code |
5543173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$64.21 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna Commercial |
$117.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$112.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$69.45
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$120.56
|
| Rate for Payer: Health EOS Commercial |
$116.63
|
| Rate for Payer: HFN Commercial |
$120.56
|
| Rate for Payer: Multiplan Commercial |
$104.83
|
| Rate for Payer: Preferred Network Access Commercial |
$120.56
|
| Rate for Payer: Quartz Beloit One Network |
$64.21
|
| Rate for Payer: Quartz Commercial |
$78.62
|
| Rate for Payer: WEA Trust Commercial |
$72.07
|
| Rate for Payer: WPS Commercial |
$97.06
|
|
|
Yes - Peak Flow Measurement Charge
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 94150
|
| Hospital Charge Code |
2990197
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$80.52 |
| Max. Negotiated Rate |
$151.17 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$98.59
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
Yes - Peak Flow Measurement Charge
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 94150
|
| Hospital Charge Code |
2990197
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$78.87 |
| Max. Negotiated Rate |
$541.67 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Aetna Managed Medicare |
$135.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.87
|
| Rate for Payer: Anthem Medicare Advantage |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| 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 |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$135.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$135.42
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| 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 |
$131.46
|
| Rate for Payer: NAPHCARE Commercial |
$203.13
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$106.81
|
| 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 |
$123.24
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: Wellcare Medicare |
$135.42
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
Yes - Peak Flow Meter Charge
|
Facility
|
IP
|
$243.00
|
|
| Hospital Charge Code |
3006968
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$123.83 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$151.63
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
Yes - Peak Flow Meter Charge
|
Facility
|
OP
|
$243.00
|
|
| Hospital Charge Code |
3006968
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.76 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Aetna Managed Medicare |
$70.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$164.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$126.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$121.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.43
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.54
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: NAPHCARE Commercial |
$151.63
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$164.27
|
| Rate for Payer: Quartz Medicare Advantage |
$151.63
|
| Rate for Payer: The Alliance Commercial |
$126.36
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
Yes - PEEP Valve Adjustable Charge
|
Facility
|
OP
|
$50.00
|
|
| Hospital Charge Code |
2990205
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Aetna Managed Medicare |
$14.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.10
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$31.20
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$33.80
|
| Rate for Payer: Quartz Medicare Advantage |
$31.20
|
| Rate for Payer: The Alliance Commercial |
$26.00
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Yes - PEEP Valve Adjustable Charge
|
Facility
|
IP
|
$50.00
|
|
| Hospital Charge Code |
2990205
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Yes - Pentamidine Treatment Charge
|
Facility
|
IP
|
$249.00
|
|
|
Service Code
|
CPT 94642
|
| Hospital Charge Code |
3006936
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$126.89 |
| Max. Negotiated Rate |
$238.24 |
| Rate for Payer: Aetna Commercial |
$233.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$222.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$137.25
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna Commercial |
$238.24
|
| Rate for Payer: Health EOS Commercial |
$230.47
|
| Rate for Payer: HFN Commercial |
$238.24
|
| Rate for Payer: Multiplan Commercial |
$207.17
|
| Rate for Payer: Preferred Network Access Commercial |
$238.24
|
| Rate for Payer: Quartz Beloit One Network |
$126.89
|
| Rate for Payer: Quartz Commercial |
$155.38
|
| Rate for Payer: WEA Trust Commercial |
$142.43
|
| Rate for Payer: WPS Commercial |
$191.80
|
|
