|
Yes - Infant Cannulaide Charge
|
Facility
|
OP
|
$10.00
|
|
| Hospital Charge Code |
3006982
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Aetna Managed Medicare |
$2.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.82
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.80
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: NAPHCARE Commercial |
$6.24
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.76
|
| Rate for Payer: Quartz Medicare Advantage |
$6.24
|
| Rate for Payer: The Alliance Commercial |
$5.20
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
Yes - Infant Mini Whiskers Charge
|
Facility
|
IP
|
$19.00
|
|
| Hospital Charge Code |
3006959
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$18.18 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.47
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$18.18
|
| Rate for Payer: Health EOS Commercial |
$17.59
|
| Rate for Payer: HFN Commercial |
$18.18
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: Preferred Network Access Commercial |
$18.18
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$11.86
|
| Rate for Payer: WEA Trust Commercial |
$10.87
|
| Rate for Payer: WPS Commercial |
$14.64
|
|
|
Yes - Infant Mini Whiskers Charge
|
Facility
|
OP
|
$19.00
|
|
| Hospital Charge Code |
3006959
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$18.18 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.99
|
| Rate for Payer: Aetna Managed Medicare |
$5.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.47
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$18.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.06
|
| Rate for Payer: Health EOS Commercial |
$17.59
|
| Rate for Payer: HFN Commercial |
$18.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.82
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: NAPHCARE Commercial |
$11.86
|
| Rate for Payer: Preferred Network Access Commercial |
$18.18
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.84
|
| Rate for Payer: Quartz Medicare Advantage |
$11.86
|
| Rate for Payer: The Alliance Commercial |
$9.88
|
| Rate for Payer: WEA Trust Commercial |
$10.87
|
| Rate for Payer: WPS Commercial |
$14.64
|
|
|
Yes - In-line Suction Catheter 24 hr Charge
|
Facility
|
IP
|
$326.00
|
|
| Hospital Charge Code |
3006957
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$166.13 |
| Max. Negotiated Rate |
$311.92 |
| Rate for Payer: Aetna Commercial |
$305.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.69
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$311.92
|
| Rate for Payer: Health EOS Commercial |
$301.75
|
| Rate for Payer: HFN Commercial |
$311.92
|
| Rate for Payer: Multiplan Commercial |
$271.23
|
| Rate for Payer: Preferred Network Access Commercial |
$311.92
|
| Rate for Payer: Quartz Beloit One Network |
$166.13
|
| Rate for Payer: Quartz Commercial |
$203.42
|
| Rate for Payer: WEA Trust Commercial |
$186.47
|
| Rate for Payer: WPS Commercial |
$251.12
|
|
|
Yes - In-line Suction Catheter 24 hr Charge
|
Facility
|
OP
|
$326.00
|
|
| Hospital Charge Code |
3006957
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$94.93 |
| Max. Negotiated Rate |
$311.92 |
| Rate for Payer: Aetna Commercial |
$305.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.57
|
| Rate for Payer: Aetna Managed Medicare |
$94.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$220.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$169.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$162.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.69
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$311.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.73
|
| Rate for Payer: Health EOS Commercial |
$301.75
|
| Rate for Payer: HFN Commercial |
$311.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$254.28
|
| Rate for Payer: Multiplan Commercial |
$271.23
|
| Rate for Payer: NAPHCARE Commercial |
$203.42
|
| Rate for Payer: Preferred Network Access Commercial |
$311.92
|
| Rate for Payer: Quartz Beloit One Network |
$166.13
|
| Rate for Payer: Quartz Commercial |
$220.38
|
| Rate for Payer: Quartz Medicare Advantage |
$203.42
|
| Rate for Payer: The Alliance Commercial |
$169.52
|
| Rate for Payer: WEA Trust Commercial |
$186.47
|
| Rate for Payer: WPS Commercial |
$251.12
|
|
|
Yes - In-line Suction Catheter 72 hr Charge
|
Facility
|
IP
|
$396.00
|
|
| Hospital Charge Code |
3006958
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$201.80 |
| Max. Negotiated Rate |
$378.89 |
| Rate for Payer: Aetna Commercial |
$370.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$354.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.28
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$378.89
|
| Rate for Payer: Health EOS Commercial |
$366.54
|
| Rate for Payer: HFN Commercial |
$378.89
|
| Rate for Payer: Multiplan Commercial |
$329.47
|
| Rate for Payer: Preferred Network Access Commercial |
$378.89
|
| Rate for Payer: Quartz Beloit One Network |
$201.80
|
| Rate for Payer: Quartz Commercial |
$247.10
|
| Rate for Payer: WEA Trust Commercial |
$226.51
|
| Rate for Payer: WPS Commercial |
$305.04
|
|
|
Yes - In-line Suction Catheter 72 hr Charge
|
Facility
|
OP
|
$396.00
|
|
| Hospital Charge Code |
3006958
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$115.32 |
| Max. Negotiated Rate |
$378.89 |
| Rate for Payer: Aetna Commercial |
$370.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$354.18
|
| Rate for Payer: Aetna Managed Medicare |
$115.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$267.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$205.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$197.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.28
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$378.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.47
|
| Rate for Payer: Health EOS Commercial |
$366.54
|
| Rate for Payer: HFN Commercial |
$378.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$308.88
|
| Rate for Payer: Multiplan Commercial |
$329.47
|
| Rate for Payer: NAPHCARE Commercial |
$247.10
|
| Rate for Payer: Preferred Network Access Commercial |
$378.89
|
| Rate for Payer: Quartz Beloit One Network |
$201.80
|
| Rate for Payer: Quartz Commercial |
$267.70
|
| Rate for Payer: Quartz Medicare Advantage |
$247.10
|
| Rate for Payer: The Alliance Commercial |
$205.92
|
| Rate for Payer: WEA Trust Commercial |
$226.51
|
| Rate for Payer: WPS Commercial |
$305.04
|
|
|
Yes - Inspiratory Muscle Trainer Charge
|
Facility
|
IP
|
$128.00
|
|
| Hospital Charge Code |
3006956
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$122.47 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$79.87
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Yes - Inspiratory Muscle Trainer Charge
|
Facility
|
OP
|
$128.00
|
|
| Hospital Charge Code |
3006956
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.27 |
| Max. Negotiated Rate |
$122.47 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Aetna Managed Medicare |
$37.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$86.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$66.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$63.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.50
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$99.84
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: NAPHCARE Commercial |
$79.87
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$86.53
|
| Rate for Payer: Quartz Medicare Advantage |
$79.87
|
| Rate for Payer: The Alliance Commercial |
$66.56
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Yes - Laryngeal Video Stroboscopy Charges
|
Facility
|
IP
|
$643.00
|
|
|
Service Code
|
CPT 31579 GN
|
| Hospital Charge Code |
2987978
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$327.67 |
| Max. Negotiated Rate |
$615.22 |
| Rate for Payer: Aetna Commercial |
$601.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.42
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cigna Commercial |
$615.22
|
| Rate for Payer: Health EOS Commercial |
$595.16
|
| Rate for Payer: HFN Commercial |
$615.22
|
| Rate for Payer: Multiplan Commercial |
$534.98
|
| Rate for Payer: Preferred Network Access Commercial |
$615.22
|
| Rate for Payer: Quartz Beloit One Network |
$327.67
|
| Rate for Payer: Quartz Commercial |
$401.23
|
| Rate for Payer: WEA Trust Commercial |
$367.80
|
| Rate for Payer: WPS Commercial |
$495.30
|
|
|
Yes - Laryngeal Video Stroboscopy Charges
|
Facility
|
OP
|
$643.00
|
|
|
Service Code
|
CPT 31579 GN
|
| Hospital Charge Code |
2987978
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$187.24 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$601.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.10
|
| Rate for Payer: Aetna Managed Medicare |
$187.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.42
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cigna Commercial |
$615.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$595.16
|
| Rate for Payer: HFN Commercial |
$615.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$501.54
|
| Rate for Payer: Multiplan Commercial |
$534.98
|
| Rate for Payer: NAPHCARE Commercial |
$401.23
|
| Rate for Payer: Preferred Network Access Commercial |
$615.22
|
| Rate for Payer: Quartz Beloit One Network |
$327.67
|
| Rate for Payer: Quartz Commercial |
$434.67
|
| Rate for Payer: Quartz Medicare Advantage |
$401.23
|
| Rate for Payer: The Alliance Commercial |
$334.36
|
| Rate for Payer: United Healthcare PPO |
$2,347.28
|
| Rate for Payer: WEA Trust Commercial |
$367.80
|
| Rate for Payer: WPS Commercial |
$495.30
|
|
|
Yes - Maintenance Of Wakefullness Test Charge
|
Facility
|
OP
|
$3,781.00
|
|
|
Service Code
|
CPT 95805
|
| Hospital Charge Code |
3004223
|
| Min. Negotiated Rate |
$903.73 |
| Max. Negotiated Rate |
$3,617.66 |
| Rate for Payer: Aetna Commercial |
$3,539.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,381.73
|
| Rate for Payer: Aetna Managed Medicare |
$903.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,555.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,966.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,887.48
|
| Rate for Payer: Anthem Medicare Advantage |
$903.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,084.09
|
| 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 |
$1,134.30
|
| Rate for Payer: Cash Price |
$1,134.30
|
| Rate for Payer: Cigna Commercial |
$3,617.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$903.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,200.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$903.73
|
| Rate for Payer: Health EOS Commercial |
$3,499.69
|
| Rate for Payer: HFN Commercial |
$3,617.66
|
| 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 |
$3,145.79
|
| Rate for Payer: NAPHCARE Commercial |
$1,355.59
|
| Rate for Payer: Preferred Network Access Commercial |
$3,617.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,926.80
|
| Rate for Payer: Quartz Commercial |
$2,555.96
|
| 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: WEA Trust Commercial |
$2,162.73
|
| Rate for Payer: Wellcare Medicare |
$903.73
|
| Rate for Payer: WPS Commercial |
$2,912.50
|
|
|
Yes - Maintenance Of Wakefullness Test Charge
|
Facility
|
IP
|
$3,781.00
|
|
|
Service Code
|
CPT 95805
|
| Hospital Charge Code |
3004223
|
| Min. Negotiated Rate |
$1,926.80 |
| Max. Negotiated Rate |
$3,617.66 |
| Rate for Payer: Aetna Commercial |
$3,539.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,381.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,084.09
|
| Rate for Payer: Cash Price |
$1,134.30
|
| Rate for Payer: Cigna Commercial |
$3,617.66
|
| Rate for Payer: Health EOS Commercial |
$3,499.69
|
| Rate for Payer: HFN Commercial |
$3,617.66
|
| Rate for Payer: Multiplan Commercial |
$3,145.79
|
| Rate for Payer: Preferred Network Access Commercial |
$3,617.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,926.80
|
| Rate for Payer: Quartz Commercial |
$2,359.34
|
| Rate for Payer: WEA Trust Commercial |
$2,162.73
|
| Rate for Payer: WPS Commercial |
$2,912.50
|
|
|
Yes - Mechanical Traction Charge
|
Professional
|
Both
|
$232.00
|
|
|
Service Code
|
CPT 97012 GP
|
| Hospital Charge Code |
2989810
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$52.90 |
| 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$52.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.90
|
| 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 - 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 - 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
|
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 - 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 - 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
|
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(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 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
|
|
