|
PURAPLY AM 2X4 (8 SQ CM) PURAPLYAM-COM 2X4
|
Facility
|
IP
|
$7,181.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520549
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,659.44 |
| Max. Negotiated Rate |
$6,870.78 |
| Rate for Payer: Aetna Commercial |
$6,721.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,422.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,958.17
|
| Rate for Payer: Cash Price |
$2,154.30
|
| Rate for Payer: Cigna Commercial |
$6,870.78
|
| Rate for Payer: Health EOS Commercial |
$6,646.73
|
| Rate for Payer: HFN Commercial |
$6,870.78
|
| Rate for Payer: Multiplan Commercial |
$5,974.59
|
| Rate for Payer: Preferred Network Access Commercial |
$6,870.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,659.44
|
| Rate for Payer: Quartz Commercial |
$4,480.94
|
| Rate for Payer: WEA Trust Commercial |
$4,107.53
|
| Rate for Payer: WPS Commercial |
$5,531.52
|
|
|
PURAPLY AM 5X5 (25 SQ CM) PURAPLYAM-COM 5X5
|
Facility
|
OP
|
$13,829.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520546
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$13,231.59 |
| Rate for Payer: Aetna Commercial |
$12,943.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,368.66
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,348.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,191.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,903.44
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,622.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$4,148.70
|
| Rate for Payer: Cash Price |
$4,148.70
|
| Rate for Payer: Cigna Commercial |
$13,231.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$12,800.12
|
| Rate for Payer: HFN Commercial |
$13,231.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$11,505.73
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$13,231.59
|
| Rate for Payer: Quartz Beloit One Network |
$7,047.26
|
| Rate for Payer: Quartz Commercial |
$9,348.40
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$7,910.19
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$270.82
|
|
|
PURAPLY AM 5X5 (25 SQ CM) PURAPLYAM-COM 5X5
|
Facility
|
IP
|
$13,829.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520546
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,047.26 |
| Max. Negotiated Rate |
$13,231.59 |
| Rate for Payer: Aetna Commercial |
$12,943.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,368.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,622.54
|
| Rate for Payer: Cash Price |
$4,148.70
|
| Rate for Payer: Cigna Commercial |
$13,231.59
|
| Rate for Payer: Health EOS Commercial |
$12,800.12
|
| Rate for Payer: HFN Commercial |
$13,231.59
|
| Rate for Payer: Multiplan Commercial |
$11,505.73
|
| Rate for Payer: Preferred Network Access Commercial |
$13,231.59
|
| Rate for Payer: Quartz Beloit One Network |
$7,047.26
|
| Rate for Payer: Quartz Commercial |
$8,629.30
|
| Rate for Payer: WEA Trust Commercial |
$7,910.19
|
| Rate for Payer: WPS Commercial |
$10,652.48
|
|
|
PURAPLY AM 6X9 (54 SQ CM) PURAPLYAM-COM 6X9
|
Facility
|
IP
|
$26,236.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520551
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13,369.87 |
| Max. Negotiated Rate |
$25,102.60 |
| Rate for Payer: Aetna Commercial |
$24,556.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23,465.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,461.28
|
| Rate for Payer: Cash Price |
$7,870.80
|
| Rate for Payer: Cigna Commercial |
$25,102.60
|
| Rate for Payer: Health EOS Commercial |
$24,284.04
|
| Rate for Payer: HFN Commercial |
$25,102.60
|
| Rate for Payer: Multiplan Commercial |
$21,828.35
|
| Rate for Payer: Preferred Network Access Commercial |
$25,102.60
|
| Rate for Payer: Quartz Beloit One Network |
$13,369.87
|
| Rate for Payer: Quartz Commercial |
$16,371.26
|
| Rate for Payer: WEA Trust Commercial |
$15,006.99
|
| Rate for Payer: WPS Commercial |
$20,209.59
|
|
|
PURAPLY AM 6X9 (54 SQ CM) PURAPLYAM-COM 6X9
|
Facility
|
OP
|
$26,236.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520551
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$25,102.60 |
| Rate for Payer: Aetna Commercial |
$24,556.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23,465.48
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,735.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,642.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,097.01
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,461.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$7,870.80
|
| Rate for Payer: Cash Price |
$7,870.80
|
| Rate for Payer: Cigna Commercial |
$25,102.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$24,284.04
|
| Rate for Payer: HFN Commercial |
$25,102.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$21,828.35
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$25,102.60
|
| Rate for Payer: Quartz Beloit One Network |
$13,369.87
|
| Rate for Payer: Quartz Commercial |
$17,735.54
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$15,006.99
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$270.82
|
|
|
PURAPLY AM 8X16 (128 SQ CM) PURAPLYAM-COM 8X16
|
Facility
|
OP
|
$68,083.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
5107211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$65,141.81 |
| Rate for Payer: Aetna Commercial |
$63,725.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60,893.44
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46,024.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35,403.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33,987.03
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37,527.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$20,424.90
|
| Rate for Payer: Cash Price |
$20,424.90
|
| Rate for Payer: Cigna Commercial |
$65,141.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$63,017.62
|
| Rate for Payer: HFN Commercial |
$65,141.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$56,645.06
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$65,141.81
|
| Rate for Payer: Quartz Beloit One Network |
$34,695.10
|
| Rate for Payer: Quartz Commercial |
$46,024.11
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$38,943.48
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$270.82
|
|
|
PURAPLY AM 8X16 (128 SQ CM) PURAPLYAM-COM 8X16
|
Facility
|
IP
|
$68,083.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
5107211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34,695.10 |
| Max. Negotiated Rate |
$65,141.81 |
| Rate for Payer: Aetna Commercial |
$63,725.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60,893.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37,527.35
|
| Rate for Payer: Cash Price |
$20,424.90
|
| Rate for Payer: Cigna Commercial |
$65,141.81
|
| Rate for Payer: Health EOS Commercial |
$63,017.62
|
| Rate for Payer: HFN Commercial |
$65,141.81
|
| Rate for Payer: Multiplan Commercial |
$56,645.06
|
| Rate for Payer: Preferred Network Access Commercial |
$65,141.81
|
| Rate for Payer: Quartz Beloit One Network |
$34,695.10
|
| Rate for Payer: Quartz Commercial |
$42,483.79
|
| Rate for Payer: WEA Trust Commercial |
$38,943.48
|
| Rate for Payer: WPS Commercial |
$52,444.33
|
|
|
PuraPly AM per sq cm Q4196
|
Facility
|
IP
|
$534.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
5455196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$272.13 |
| Max. Negotiated Rate |
$510.93 |
| Rate for Payer: Aetna Commercial |
$499.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$477.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.34
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$510.93
|
| Rate for Payer: Health EOS Commercial |
$494.27
|
| Rate for Payer: HFN Commercial |
$510.93
|
| Rate for Payer: Multiplan Commercial |
$444.29
|
| Rate for Payer: Preferred Network Access Commercial |
$510.93
|
| Rate for Payer: Quartz Beloit One Network |
$272.13
|
| Rate for Payer: Quartz Commercial |
$333.22
|
| Rate for Payer: WEA Trust Commercial |
$305.45
|
| Rate for Payer: WPS Commercial |
$411.34
|
|
|
PuraPly AM per sq cm Q4196
|
Professional
|
Both
|
$534.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
5455196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.33 |
| Max. Negotiated Rate |
$527.59 |
| Rate for Payer: Aetna Commercial |
$527.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$477.61
|
| Rate for Payer: Aetna Managed Medicare |
$126.79
|
| Rate for Payer: Anthem Medicare Advantage |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.79
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$527.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$277.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.33
|
| Rate for Payer: Health EOS Commercial |
$505.38
|
| Rate for Payer: HFN Commercial |
$527.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$387.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$387.83
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$444.29
|
| Rate for Payer: NAPHCARE Commercial |
$190.18
|
| Rate for Payer: Preferred Network Access Commercial |
$527.59
|
| Rate for Payer: Quartz Beloit One Network |
$244.36
|
| Rate for Payer: Quartz Commercial |
$316.56
|
| Rate for Payer: Quartz Medicare Advantage |
$126.79
|
| Rate for Payer: The Alliance Commercial |
$348.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.79
|
| Rate for Payer: WEA Trust Commercial |
$305.45
|
| Rate for Payer: WPS Commercial |
$270.82
|
|
|
PuraPly AM per sq cm Q4196
|
Facility
|
OP
|
$534.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
5455196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$499.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$477.61
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$360.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$277.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.57
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$510.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$494.27
|
| Rate for Payer: HFN Commercial |
$510.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$444.29
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$510.93
|
| Rate for Payer: Quartz Beloit One Network |
$272.13
|
| Rate for Payer: Quartz Commercial |
$360.98
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$305.45
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$270.82
|
|
|
PuraPly XT, 1 sq cm Q4197
|
Professional
|
Both
|
$193.00
|
|
|
Service Code
|
HCPCS Q4197
|
| Hospital Charge Code |
6195787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.32 |
| Max. Negotiated Rate |
$348.66 |
| Rate for Payer: Aetna Commercial |
$190.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$126.79
|
| Rate for Payer: Anthem Medicare Advantage |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.79
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$190.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$100.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$126.49
|
| Rate for Payer: Health EOS Commercial |
$182.66
|
| Rate for Payer: HFN Commercial |
$190.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$190.18
|
| Rate for Payer: Preferred Network Access Commercial |
$190.68
|
| Rate for Payer: Quartz Beloit One Network |
$88.32
|
| Rate for Payer: Quartz Commercial |
$114.41
|
| Rate for Payer: Quartz Medicare Advantage |
$126.79
|
| Rate for Payer: The Alliance Commercial |
$348.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.79
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$316.23
|
|
|
PuraPly XT, 1 sq cm Q4197
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
HCPCS Q4197
|
| Hospital Charge Code |
6195787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.35 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$130.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.35
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$167.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$130.47
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$316.23
|
|
|
PuraPly XT, 1 sq cm Q4197
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
HCPCS Q4197
|
| Hospital Charge Code |
6195787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.35 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$120.43
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
Pure Tone Audio; Air and Bone
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
CPT 92553
|
| Hospital Charge Code |
1152817
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$100.90 |
| Max. Negotiated Rate |
$189.45 |
| Rate for Payer: Aetna Commercial |
$185.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.14
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$189.45
|
| Rate for Payer: Health EOS Commercial |
$183.27
|
| Rate for Payer: HFN Commercial |
$189.45
|
| Rate for Payer: Multiplan Commercial |
$164.74
|
| Rate for Payer: Preferred Network Access Commercial |
$189.45
|
| Rate for Payer: Quartz Beloit One Network |
$100.90
|
| Rate for Payer: Quartz Commercial |
$123.55
|
| Rate for Payer: WEA Trust Commercial |
$113.26
|
| Rate for Payer: WPS Commercial |
$152.52
|
|
|
Pure Tone Audio; Air and Bone
|
Professional
|
Both
|
$198.00
|
|
|
Service Code
|
CPT 92553
|
| Hospital Charge Code |
1152817
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.69 |
| Max. Negotiated Rate |
$195.62 |
| Rate for Payer: Aetna Commercial |
$195.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.09
|
| Rate for Payer: Aetna Managed Medicare |
$48.69
|
| Rate for Payer: Anthem Medicare Advantage |
$48.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$48.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$48.69
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$195.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$102.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.69
|
| Rate for Payer: Health EOS Commercial |
$187.39
|
| Rate for Payer: HFN Commercial |
$195.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$137.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$48.69
|
| Rate for Payer: Multiplan Commercial |
$164.74
|
| Rate for Payer: NAPHCARE Commercial |
$73.04
|
| Rate for Payer: Preferred Network Access Commercial |
$195.62
|
| Rate for Payer: Quartz Beloit One Network |
$90.60
|
| Rate for Payer: Quartz Commercial |
$117.37
|
| Rate for Payer: Quartz Medicare Advantage |
$48.69
|
| Rate for Payer: The Alliance Commercial |
$121.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.69
|
| Rate for Payer: WEA Trust Commercial |
$113.26
|
| Rate for Payer: WPS Commercial |
$194.77
|
|
|
Pure Tone Audio; Air and Bone
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
CPT 92553
|
| Hospital Charge Code |
1152817
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$98.84 |
| Max. Negotiated Rate |
$541.67 |
| Rate for Payer: Aetna Commercial |
$185.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.09
|
| Rate for Payer: Aetna Managed Medicare |
$135.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$133.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$102.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$98.84
|
| Rate for Payer: Anthem Medicare Advantage |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.14
|
| 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 |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$189.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$135.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.24
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$135.42
|
| Rate for Payer: Health EOS Commercial |
$183.27
|
| Rate for Payer: HFN Commercial |
$189.45
|
| 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 |
$164.74
|
| Rate for Payer: NAPHCARE Commercial |
$203.13
|
| Rate for Payer: Preferred Network Access Commercial |
$189.45
|
| Rate for Payer: Quartz Beloit One Network |
$100.90
|
| Rate for Payer: Quartz Commercial |
$133.85
|
| 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: WEA Trust Commercial |
$113.26
|
| Rate for Payer: Wellcare Medicare |
$135.42
|
| Rate for Payer: WPS Commercial |
$152.52
|
|
|
Pure Tone Audio; Air Only
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
1152816
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.43 |
| Max. Negotiated Rate |
$560.06 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.43
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$60.16
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
Pure Tone Audio; Air Only
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
1152816
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$45.35 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$55.54
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
Pure Tone Audio; Air Only
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
1152816
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$40.04 |
| Max. Negotiated Rate |
$160.16 |
| Rate for Payer: Aetna Commercial |
$87.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$40.04
|
| Rate for Payer: Anthem Medicare Advantage |
$40.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$40.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$40.04
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$87.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.04
|
| Rate for Payer: Health EOS Commercial |
$84.23
|
| Rate for Payer: HFN Commercial |
$87.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$40.04
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$60.06
|
| Rate for Payer: Preferred Network Access Commercial |
$87.93
|
| Rate for Payer: Quartz Beloit One Network |
$40.73
|
| Rate for Payer: Quartz Commercial |
$52.76
|
| Rate for Payer: Quartz Medicare Advantage |
$40.04
|
| Rate for Payer: The Alliance Commercial |
$100.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.04
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$160.16
|
|
|
Pure Tone Audiometry Air
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
3203498
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$40.04 |
| Max. Negotiated Rate |
$160.16 |
| Rate for Payer: Aetna Commercial |
$87.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$40.04
|
| Rate for Payer: Anthem Medicare Advantage |
$40.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$40.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$40.04
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$87.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.04
|
| Rate for Payer: Health EOS Commercial |
$84.23
|
| Rate for Payer: HFN Commercial |
$87.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$40.04
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$60.06
|
| Rate for Payer: Preferred Network Access Commercial |
$87.93
|
| Rate for Payer: Quartz Beloit One Network |
$40.73
|
| Rate for Payer: Quartz Commercial |
$52.76
|
| Rate for Payer: Quartz Medicare Advantage |
$40.04
|
| Rate for Payer: The Alliance Commercial |
$100.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.04
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$160.16
|
|
|
Pure Tone Audiometry Air
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
3203498
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$45.35 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$55.54
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
Pure Tone Audiometry Air
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
3203498
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$44.43 |
| Max. Negotiated Rate |
$560.06 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.43
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$60.16
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$69.42
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
Pure Tone Audiometry Air/Bone
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
CPT 92553
|
| Hospital Charge Code |
3203499
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$100.90 |
| Max. Negotiated Rate |
$189.45 |
| Rate for Payer: Aetna Commercial |
$185.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.14
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$189.45
|
| Rate for Payer: Health EOS Commercial |
$183.27
|
| Rate for Payer: HFN Commercial |
$189.45
|
| Rate for Payer: Multiplan Commercial |
$164.74
|
| Rate for Payer: Preferred Network Access Commercial |
$189.45
|
| Rate for Payer: Quartz Beloit One Network |
$100.90
|
| Rate for Payer: Quartz Commercial |
$123.55
|
| Rate for Payer: WEA Trust Commercial |
$113.26
|
| Rate for Payer: WPS Commercial |
$152.52
|
|
|
Pure Tone Audiometry Air/Bone
|
Professional
|
Both
|
$198.00
|
|
|
Service Code
|
CPT 92553
|
| Hospital Charge Code |
3203499
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$48.69 |
| Max. Negotiated Rate |
$195.62 |
| Rate for Payer: Aetna Commercial |
$195.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.09
|
| Rate for Payer: Aetna Managed Medicare |
$48.69
|
| Rate for Payer: Anthem Medicare Advantage |
$48.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$48.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$48.69
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$195.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$102.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.69
|
| Rate for Payer: Health EOS Commercial |
$187.39
|
| Rate for Payer: HFN Commercial |
$195.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$137.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$48.69
|
| Rate for Payer: Multiplan Commercial |
$164.74
|
| Rate for Payer: NAPHCARE Commercial |
$73.04
|
| Rate for Payer: Preferred Network Access Commercial |
$195.62
|
| Rate for Payer: Quartz Beloit One Network |
$90.60
|
| Rate for Payer: Quartz Commercial |
$117.37
|
| Rate for Payer: Quartz Medicare Advantage |
$48.69
|
| Rate for Payer: The Alliance Commercial |
$121.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.69
|
| Rate for Payer: WEA Trust Commercial |
$113.26
|
| Rate for Payer: WPS Commercial |
$194.77
|
|
|
Pure Tone Audiometry Air/Bone
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
CPT 92553
|
| Hospital Charge Code |
3203499
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$98.84 |
| Max. Negotiated Rate |
$541.67 |
| Rate for Payer: Aetna Commercial |
$185.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.09
|
| Rate for Payer: Aetna Managed Medicare |
$135.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$133.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$102.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$98.84
|
| Rate for Payer: Anthem Medicare Advantage |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.14
|
| 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 |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$189.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$135.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.24
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$135.42
|
| Rate for Payer: Health EOS Commercial |
$183.27
|
| Rate for Payer: HFN Commercial |
$189.45
|
| 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 |
$164.74
|
| Rate for Payer: NAPHCARE Commercial |
$203.13
|
| Rate for Payer: Preferred Network Access Commercial |
$189.45
|
| Rate for Payer: Quartz Beloit One Network |
$100.90
|
| Rate for Payer: Quartz Commercial |
$133.85
|
| 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 |
$154.44
|
| Rate for Payer: WEA Trust Commercial |
$113.26
|
| Rate for Payer: Wellcare Medicare |
$135.42
|
| Rate for Payer: WPS Commercial |
$152.52
|
|
