|
Yes - Pentamidine Treatment Charge
|
Facility
|
OP
|
$249.00
|
|
|
Service Code
|
CPT 94642
|
| Hospital Charge Code |
3006936
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$124.30 |
| Max. Negotiated Rate |
$921.81 |
| Rate for Payer: Aetna Commercial |
$233.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$222.71
|
| Rate for Payer: Aetna Managed Medicare |
$230.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$168.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$129.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$124.30
|
| Rate for Payer: Anthem Medicare Advantage |
$230.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$137.25
|
| 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 |
$74.70
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna Commercial |
$238.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$230.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$230.45
|
| Rate for Payer: Health EOS Commercial |
$230.47
|
| Rate for Payer: HFN Commercial |
$238.24
|
| 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 |
$207.17
|
| Rate for Payer: NAPHCARE Commercial |
$345.68
|
| Rate for Payer: Preferred Network Access Commercial |
$238.24
|
| Rate for Payer: Quartz Beloit One Network |
$126.89
|
| Rate for Payer: Quartz Commercial |
$168.32
|
| 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 |
$194.22
|
| Rate for Payer: WEA Trust Commercial |
$142.43
|
| Rate for Payer: Wellcare Medicare |
$230.45
|
| Rate for Payer: WPS Commercial |
$191.80
|
|
|
Yes - Polysomnogram Charge
|
Facility
|
IP
|
$6,863.00
|
|
|
Service Code
|
CPT 94811
|
| Hospital Charge Code |
2990211
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$3,497.38 |
| Max. Negotiated Rate |
$6,566.52 |
| Rate for Payer: Aetna Commercial |
$6,423.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,138.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,782.89
|
| Rate for Payer: Cash Price |
$2,058.90
|
| Rate for Payer: Cigna Commercial |
$6,566.52
|
| Rate for Payer: Health EOS Commercial |
$6,352.39
|
| Rate for Payer: HFN Commercial |
$6,566.52
|
| Rate for Payer: Multiplan Commercial |
$5,710.02
|
| Rate for Payer: Preferred Network Access Commercial |
$6,566.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,497.38
|
| Rate for Payer: Quartz Commercial |
$4,282.51
|
| Rate for Payer: WEA Trust Commercial |
$3,925.64
|
| Rate for Payer: WPS Commercial |
$5,286.57
|
|
|
Yes - Polysomnogram Charge
|
Facility
|
OP
|
$6,863.00
|
|
|
Service Code
|
CPT 94811
|
| Hospital Charge Code |
2990211
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$210.08 |
| Max. Negotiated Rate |
$6,566.52 |
| Rate for Payer: Aetna Commercial |
$6,423.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,138.27
|
| Rate for Payer: Aetna Managed Medicare |
$1,998.51
|
| 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 |
$3,782.89
|
| Rate for Payer: Cash Price |
$2,058.90
|
| Rate for Payer: Cash Price |
$2,058.90
|
| Rate for Payer: Cigna Commercial |
$6,566.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,994.27
|
| Rate for Payer: Health EOS Commercial |
$6,352.39
|
| Rate for Payer: HFN Commercial |
$6,566.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$5,710.02
|
| Rate for Payer: NAPHCARE Commercial |
$4,282.51
|
| Rate for Payer: Preferred Network Access Commercial |
$6,566.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,497.38
|
| Rate for Payer: Quartz Commercial |
$4,639.39
|
| Rate for Payer: Quartz Medicare Advantage |
$4,282.51
|
| Rate for Payer: The Alliance Commercial |
$3,568.76
|
| Rate for Payer: United Healthcare PPO |
$5,353.14
|
| Rate for Payer: WEA Trust Commercial |
$3,925.64
|
| Rate for Payer: WPS Commercial |
$5,286.57
|
|
|
Yes - Polysomnogram CPAP Charge
|
Facility
|
IP
|
$6,863.00
|
|
|
Service Code
|
CPT 94811
|
| Hospital Charge Code |
2990212
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$3,497.38 |
| Max. Negotiated Rate |
$6,566.52 |
| Rate for Payer: Aetna Commercial |
$6,423.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,138.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,782.89
|
| Rate for Payer: Cash Price |
$2,058.90
|
| Rate for Payer: Cigna Commercial |
$6,566.52
|
| Rate for Payer: Health EOS Commercial |
$6,352.39
|
| Rate for Payer: HFN Commercial |
$6,566.52
|
| Rate for Payer: Multiplan Commercial |
$5,710.02
|
| Rate for Payer: Preferred Network Access Commercial |
$6,566.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,497.38
|
| Rate for Payer: Quartz Commercial |
$4,282.51
|
| Rate for Payer: WEA Trust Commercial |
$3,925.64
|
| Rate for Payer: WPS Commercial |
$5,286.57
|
|
|
Yes - Polysomnogram CPAP Charge
|
Facility
|
OP
|
$6,863.00
|
|
|
Service Code
|
CPT 94811
|
| Hospital Charge Code |
2990212
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$210.08 |
| Max. Negotiated Rate |
$6,566.52 |
| Rate for Payer: Aetna Commercial |
$6,423.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,138.27
|
| Rate for Payer: Aetna Managed Medicare |
$1,998.51
|
| 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 |
$3,782.89
|
| Rate for Payer: Cash Price |
$2,058.90
|
| Rate for Payer: Cash Price |
$2,058.90
|
| Rate for Payer: Cigna Commercial |
$6,566.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,994.27
|
| Rate for Payer: Health EOS Commercial |
$6,352.39
|
| Rate for Payer: HFN Commercial |
$6,566.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$5,710.02
|
| Rate for Payer: NAPHCARE Commercial |
$4,282.51
|
| Rate for Payer: Preferred Network Access Commercial |
$6,566.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,497.38
|
| Rate for Payer: Quartz Commercial |
$4,639.39
|
| Rate for Payer: Quartz Medicare Advantage |
$4,282.51
|
| Rate for Payer: The Alliance Commercial |
$3,568.76
|
| Rate for Payer: United Healthcare PPO |
$5,353.14
|
| Rate for Payer: WEA Trust Commercial |
$3,925.64
|
| Rate for Payer: WPS Commercial |
$5,286.57
|
|
|
Yes - Polysomnogram CPAP With Titration Charge
|
Facility
|
IP
|
$6,863.00
|
|
|
Service Code
|
CPT 94811
|
| Hospital Charge Code |
2990213
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$3,497.38 |
| Max. Negotiated Rate |
$6,566.52 |
| Rate for Payer: Aetna Commercial |
$6,423.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,138.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,782.89
|
| Rate for Payer: Cash Price |
$2,058.90
|
| Rate for Payer: Cigna Commercial |
$6,566.52
|
| Rate for Payer: Health EOS Commercial |
$6,352.39
|
| Rate for Payer: HFN Commercial |
$6,566.52
|
| Rate for Payer: Multiplan Commercial |
$5,710.02
|
| Rate for Payer: Preferred Network Access Commercial |
$6,566.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,497.38
|
| Rate for Payer: Quartz Commercial |
$4,282.51
|
| Rate for Payer: WEA Trust Commercial |
$3,925.64
|
| Rate for Payer: WPS Commercial |
$5,286.57
|
|
|
Yes - Polysomnogram CPAP With Titration Charge
|
Facility
|
OP
|
$6,863.00
|
|
|
Service Code
|
CPT 94811
|
| Hospital Charge Code |
2990213
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$210.08 |
| Max. Negotiated Rate |
$6,566.52 |
| Rate for Payer: Aetna Commercial |
$6,423.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,138.27
|
| Rate for Payer: Aetna Managed Medicare |
$1,998.51
|
| 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 |
$3,782.89
|
| Rate for Payer: Cash Price |
$2,058.90
|
| Rate for Payer: Cash Price |
$2,058.90
|
| Rate for Payer: Cigna Commercial |
$6,566.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,994.27
|
| Rate for Payer: Health EOS Commercial |
$6,352.39
|
| Rate for Payer: HFN Commercial |
$6,566.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$5,710.02
|
| Rate for Payer: NAPHCARE Commercial |
$4,282.51
|
| Rate for Payer: Preferred Network Access Commercial |
$6,566.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,497.38
|
| Rate for Payer: Quartz Commercial |
$4,639.39
|
| Rate for Payer: Quartz Medicare Advantage |
$4,282.51
|
| Rate for Payer: The Alliance Commercial |
$3,568.76
|
| Rate for Payer: United Healthcare PPO |
$5,353.14
|
| Rate for Payer: WEA Trust Commercial |
$3,925.64
|
| Rate for Payer: WPS Commercial |
$5,286.57
|
|
|
Yes - Portable 02 Tank Charge
|
Facility
|
IP
|
$182.00
|
|
| Hospital Charge Code |
3006969
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$92.75 |
| Max. Negotiated Rate |
$174.14 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$113.57
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$140.19
|
|
|
Yes - Portable 02 Tank Charge
|
Facility
|
OP
|
$182.00
|
|
| Hospital Charge Code |
3006969
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$53.00 |
| Max. Negotiated Rate |
$174.14 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Aetna Managed Medicare |
$53.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$123.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$94.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$90.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.92
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.96
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: NAPHCARE Commercial |
$113.57
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$123.03
|
| Rate for Payer: Quartz Medicare Advantage |
$113.57
|
| Rate for Payer: The Alliance Commercial |
$94.64
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$140.19
|
|
|
Yes - Posey Trach Tie Charge
|
Facility
|
IP
|
$28.00
|
|
| Hospital Charge Code |
2990209
|
|
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 - Posey Trach Tie Charge
|
Facility
|
OP
|
$28.00
|
|
| Hospital Charge Code |
2990209
|
|
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 - Post-Op Oxygen Charge
|
Facility
|
OP
|
$453.00
|
|
| Hospital Charge Code |
2990191
|
|
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 - Post-Op Oxygen Charge
|
Facility
|
IP
|
$453.00
|
|
| Hospital Charge Code |
2990191
|
|
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 - Procedural Oxygen Charge
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
3511518
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Aetna Managed Medicare |
$11.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.12
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.64
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: NAPHCARE Commercial |
$23.71
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$25.69
|
| Rate for Payer: Quartz Medicare Advantage |
$23.71
|
| Rate for Payer: The Alliance Commercial |
$19.76
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
Yes - Procedural Oxygen Charge
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
3511518
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$19.36 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$23.71
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
Yes - PTA E-Stim Attended Charges
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
CPT 97032 GP,CQ
|
| Hospital Charge Code |
5568940
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$85.10 |
| Max. Negotiated Rate |
$159.79 |
| Rate for Payer: Aetna Commercial |
$156.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.05
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$159.79
|
| Rate for Payer: Health EOS Commercial |
$154.58
|
| Rate for Payer: HFN Commercial |
$159.79
|
| Rate for Payer: Multiplan Commercial |
$138.94
|
| Rate for Payer: Preferred Network Access Commercial |
$159.79
|
| Rate for Payer: Quartz Beloit One Network |
$85.10
|
| Rate for Payer: Quartz Commercial |
$104.21
|
| Rate for Payer: WEA Trust Commercial |
$95.52
|
| Rate for Payer: WPS Commercial |
$128.64
|
|
|
Yes - PTA E-Stim Attended Charges
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
CPT 97032 GP,CQ
|
| Hospital Charge Code |
5568940
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$48.63 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$156.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.36
|
| Rate for Payer: Aetna Managed Medicare |
$48.63
|
| 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 |
$92.05
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$159.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.19
|
| Rate for Payer: Health EOS Commercial |
$154.58
|
| Rate for Payer: HFN Commercial |
$159.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$138.94
|
| Rate for Payer: NAPHCARE Commercial |
$104.21
|
| Rate for Payer: Preferred Network Access Commercial |
$159.79
|
| Rate for Payer: Quartz Beloit One Network |
$85.10
|
| Rate for Payer: Quartz Commercial |
$112.89
|
| Rate for Payer: Quartz Medicare Advantage |
$104.21
|
| Rate for Payer: The Alliance Commercial |
$86.84
|
| Rate for Payer: United Healthcare PPO |
$130.26
|
| Rate for Payer: WEA Trust Commercial |
$95.52
|
| Rate for Payer: WPS Commercial |
$128.64
|
|
|
Yes - PTA E-Stim Unattended Charge
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
CPT 97014 GP,CQ
|
| Hospital Charge Code |
5569114
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$85.10 |
| Max. Negotiated Rate |
$159.79 |
| Rate for Payer: Aetna Commercial |
$156.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.05
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$159.79
|
| Rate for Payer: Health EOS Commercial |
$154.58
|
| Rate for Payer: HFN Commercial |
$159.79
|
| Rate for Payer: Multiplan Commercial |
$138.94
|
| Rate for Payer: Preferred Network Access Commercial |
$159.79
|
| Rate for Payer: Quartz Beloit One Network |
$85.10
|
| Rate for Payer: Quartz Commercial |
$104.21
|
| Rate for Payer: WEA Trust Commercial |
$95.52
|
| Rate for Payer: WPS Commercial |
$128.64
|
|
|
Yes - PTA E-Stim Unattended Charge
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
CPT 97014 GP,CQ
|
| Hospital Charge Code |
5569114
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$48.63 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$156.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.36
|
| Rate for Payer: Aetna Managed Medicare |
$48.63
|
| 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 |
$92.05
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$159.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.19
|
| Rate for Payer: Health EOS Commercial |
$154.58
|
| Rate for Payer: HFN Commercial |
$159.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$138.94
|
| Rate for Payer: NAPHCARE Commercial |
$104.21
|
| Rate for Payer: Preferred Network Access Commercial |
$159.79
|
| Rate for Payer: Quartz Beloit One Network |
$85.10
|
| Rate for Payer: Quartz Commercial |
$112.89
|
| Rate for Payer: Quartz Medicare Advantage |
$104.21
|
| Rate for Payer: The Alliance Commercial |
$86.84
|
| Rate for Payer: United Healthcare PPO |
$130.26
|
| Rate for Payer: WEA Trust Commercial |
$95.52
|
| Rate for Payer: WPS Commercial |
$128.64
|
|
|
Yes - PTA Fluidotherapy Charge
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP,CQ
|
| Hospital Charge Code |
5565415
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$94.79 |
| Max. Negotiated Rate |
$177.96 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$116.06
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Yes - PTA Fluidotherapy Charge
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP,CQ
|
| Hospital Charge Code |
5565415
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$85.11 |
| Max. Negotiated Rate |
$183.77 |
| Rate for Payer: Aetna Commercial |
$183.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$183.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$96.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.06
|
| Rate for Payer: Health EOS Commercial |
$176.03
|
| Rate for Payer: HFN Commercial |
$183.77
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$183.77
|
| Rate for Payer: Quartz Beloit One Network |
$85.11
|
| Rate for Payer: Quartz Commercial |
$110.26
|
| Rate for Payer: The Alliance Commercial |
$96.72
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Yes - PTA Fluidotherapy Charge
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP,CQ
|
| Hospital Charge Code |
5565415
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$54.16 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Aetna Managed Medicare |
$54.16
|
| 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 |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.25
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: NAPHCARE Commercial |
$116.06
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$125.74
|
| Rate for Payer: Quartz Medicare Advantage |
$116.06
|
| Rate for Payer: The Alliance Commercial |
$96.72
|
| Rate for Payer: United Healthcare PPO |
$145.08
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Yes - PTA Group Therapy Charge
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 97150 GP,CQ
|
| Hospital Charge Code |
5569052
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$66.39 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: HFN Commercial |
$218.15
|
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.92
|
| Rate for Payer: Aetna Managed Medicare |
$66.39
|
| 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 |
$125.67
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$218.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.70
|
| Rate for Payer: Health EOS Commercial |
$211.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$189.70
|
| Rate for Payer: NAPHCARE Commercial |
$142.27
|
| Rate for Payer: Preferred Network Access Commercial |
$218.15
|
| Rate for Payer: Quartz Beloit One Network |
$116.19
|
| Rate for Payer: Quartz Commercial |
$154.13
|
| Rate for Payer: Quartz Medicare Advantage |
$142.27
|
| Rate for Payer: The Alliance Commercial |
$118.56
|
| Rate for Payer: United Healthcare PPO |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$130.42
|
| Rate for Payer: WPS Commercial |
$175.63
|
|
|
Yes - PTA Group Therapy Charge
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 97150 GP,CQ
|
| Hospital Charge Code |
5569052
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$116.19 |
| Max. Negotiated Rate |
$218.15 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.67
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$218.15
|
| Rate for Payer: Health EOS Commercial |
$211.04
|
| Rate for Payer: HFN Commercial |
$218.15
|
| Rate for Payer: Multiplan Commercial |
$189.70
|
| Rate for Payer: Preferred Network Access Commercial |
$218.15
|
| Rate for Payer: Quartz Beloit One Network |
$116.19
|
| Rate for Payer: Quartz Commercial |
$142.27
|
| Rate for Payer: WEA Trust Commercial |
$130.42
|
| Rate for Payer: WPS Commercial |
$175.63
|
|
|
Yes - PTA Iontophoresis Charge
|
Facility
|
OP
|
$296.00
|
|
|
Service Code
|
CPT 97033 GP,CQ
|
| Hospital Charge Code |
5569141
|
|
Hospital Revenue Code
|
420
|
| 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
|
|
