|
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
|
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 - 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 - 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
|
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 - 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 - 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 - 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 - 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 - 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: WPS Commercial |
$191.80
|
| 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
|
|
|
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 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 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 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 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 - 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 - 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
|
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
|
|
