|
PURAPLY AM 2X4 (8 SQ CM) PURAPLYAM-COM 2X4
|
Facility
|
OP
|
$7,181.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520549
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.81 |
| Max. Negotiated Rate |
$28,724.00 |
| Rate for Payer: Aetna Commercial |
$6,462.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,175.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,010.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,667.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,590.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,446.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,805.93
|
| Rate for Payer: Cash Price |
$2,154.30
|
| Rate for Payer: Cash Price |
$2,154.30
|
| Rate for Payer: Cigna Commercial |
$6,606.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.81
|
| Rate for Payer: Health EOS Commercial |
$6,391.09
|
| Rate for Payer: HFN Commercial |
$6,606.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,385.75
|
| Rate for Payer: Multiplan Commercial |
$5,744.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,308.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,606.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,518.69
|
| Rate for Payer: Quartz Commercial |
$4,667.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4,308.60
|
| Rate for Payer: The Alliance Commercial |
$28,724.00
|
| Rate for Payer: WEA Trust Commercial |
$3,949.55
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
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 |
$137.81 |
| Max. Negotiated Rate |
$55,316.00 |
| Rate for Payer: Aetna Commercial |
$12,446.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,892.94
|
| Rate for Payer: Aetna Managed Medicare |
$3,872.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,988.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,914.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,637.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,329.37
|
| Rate for Payer: Cash Price |
$4,148.70
|
| Rate for Payer: Cash Price |
$4,148.70
|
| Rate for Payer: Cigna Commercial |
$12,722.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.81
|
| Rate for Payer: Health EOS Commercial |
$12,307.81
|
| Rate for Payer: HFN Commercial |
$12,722.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,371.75
|
| Rate for Payer: Multiplan Commercial |
$11,063.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,297.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,722.68
|
| Rate for Payer: Quartz Beloit One Network |
$6,776.21
|
| Rate for Payer: Quartz Commercial |
$8,988.85
|
| Rate for Payer: Quartz Medicare Advantage |
$8,297.40
|
| Rate for Payer: The Alliance Commercial |
$55,316.00
|
| Rate for Payer: WEA Trust Commercial |
$7,605.95
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
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 |
$6,776.21 |
| Max. Negotiated Rate |
$12,722.68 |
| Rate for Payer: Aetna Commercial |
$12,446.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,892.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,329.37
|
| Rate for Payer: Cash Price |
$4,148.70
|
| Rate for Payer: Cigna Commercial |
$12,722.68
|
| Rate for Payer: Health EOS Commercial |
$12,307.81
|
| Rate for Payer: HFN Commercial |
$12,722.68
|
| Rate for Payer: Multiplan Commercial |
$11,063.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,297.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,722.68
|
| Rate for Payer: Quartz Beloit One Network |
$6,776.21
|
| Rate for Payer: Quartz Commercial |
$8,297.40
|
| Rate for Payer: WEA Trust Commercial |
$7,605.95
|
| Rate for Payer: WPS Commercial |
$10,243.14
|
|
|
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 |
$137.81 |
| Max. Negotiated Rate |
$104,944.00 |
| Rate for Payer: Aetna Commercial |
$23,612.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,562.96
|
| Rate for Payer: Aetna Managed Medicare |
$7,346.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,053.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,118.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,593.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,905.08
|
| Rate for Payer: Cash Price |
$7,870.80
|
| Rate for Payer: Cash Price |
$7,870.80
|
| Rate for Payer: Cigna Commercial |
$24,137.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.81
|
| Rate for Payer: Health EOS Commercial |
$23,350.04
|
| Rate for Payer: HFN Commercial |
$24,137.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,677.00
|
| Rate for Payer: Multiplan Commercial |
$20,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$15,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$24,137.12
|
| Rate for Payer: Quartz Beloit One Network |
$12,855.64
|
| Rate for Payer: Quartz Commercial |
$17,053.40
|
| Rate for Payer: Quartz Medicare Advantage |
$15,741.60
|
| Rate for Payer: The Alliance Commercial |
$104,944.00
|
| Rate for Payer: WEA Trust Commercial |
$14,429.80
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
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 |
$12,855.64 |
| Max. Negotiated Rate |
$24,137.12 |
| Rate for Payer: Aetna Commercial |
$23,612.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,562.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,905.08
|
| Rate for Payer: Cash Price |
$7,870.80
|
| Rate for Payer: Cigna Commercial |
$24,137.12
|
| Rate for Payer: Health EOS Commercial |
$23,350.04
|
| Rate for Payer: HFN Commercial |
$24,137.12
|
| Rate for Payer: Multiplan Commercial |
$20,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$15,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$24,137.12
|
| Rate for Payer: Quartz Beloit One Network |
$12,855.64
|
| Rate for Payer: Quartz Commercial |
$15,741.60
|
| Rate for Payer: WEA Trust Commercial |
$14,429.80
|
| Rate for Payer: WPS Commercial |
$19,433.01
|
|
|
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 |
$137.81 |
| Max. Negotiated Rate |
$272,332.00 |
| Rate for Payer: Aetna Commercial |
$61,274.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$58,551.38
|
| Rate for Payer: Aetna Managed Medicare |
$19,063.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44,253.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34,041.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32,679.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36,083.99
|
| Rate for Payer: Cash Price |
$20,424.90
|
| Rate for Payer: Cash Price |
$20,424.90
|
| Rate for Payer: Cigna Commercial |
$62,636.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.81
|
| Rate for Payer: Health EOS Commercial |
$60,593.87
|
| Rate for Payer: HFN Commercial |
$62,636.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51,062.25
|
| Rate for Payer: Multiplan Commercial |
$54,466.40
|
| Rate for Payer: NAPHCARE Commercial |
$40,849.80
|
| Rate for Payer: Preferred Network Access Commercial |
$62,636.36
|
| Rate for Payer: Quartz Beloit One Network |
$33,360.67
|
| Rate for Payer: Quartz Commercial |
$44,253.95
|
| Rate for Payer: Quartz Medicare Advantage |
$40,849.80
|
| Rate for Payer: The Alliance Commercial |
$272,332.00
|
| Rate for Payer: WEA Trust Commercial |
$37,445.65
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
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 |
$33,360.67 |
| Max. Negotiated Rate |
$62,636.36 |
| Rate for Payer: Aetna Commercial |
$61,274.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$58,551.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36,083.99
|
| Rate for Payer: Cash Price |
$20,424.90
|
| Rate for Payer: Cigna Commercial |
$62,636.36
|
| Rate for Payer: Health EOS Commercial |
$60,593.87
|
| Rate for Payer: HFN Commercial |
$62,636.36
|
| Rate for Payer: Multiplan Commercial |
$54,466.40
|
| Rate for Payer: NAPHCARE Commercial |
$40,849.80
|
| Rate for Payer: Preferred Network Access Commercial |
$62,636.36
|
| Rate for Payer: Quartz Beloit One Network |
$33,360.67
|
| Rate for Payer: Quartz Commercial |
$40,849.80
|
| Rate for Payer: WEA Trust Commercial |
$37,445.65
|
| Rate for Payer: WPS Commercial |
$50,429.08
|
|
|
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 |
$261.66 |
| Max. Negotiated Rate |
$491.28 |
| Rate for Payer: Aetna Commercial |
$480.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$459.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.02
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$491.28
|
| Rate for Payer: Health EOS Commercial |
$475.26
|
| Rate for Payer: HFN Commercial |
$491.28
|
| Rate for Payer: Multiplan Commercial |
$427.20
|
| Rate for Payer: NAPHCARE Commercial |
$320.40
|
| Rate for Payer: Preferred Network Access Commercial |
$491.28
|
| Rate for Payer: Quartz Beloit One Network |
$261.66
|
| Rate for Payer: Quartz Commercial |
$320.40
|
| Rate for Payer: WEA Trust Commercial |
$293.70
|
| Rate for Payer: WPS Commercial |
$395.53
|
|
|
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 |
$137.81 |
| Max. Negotiated Rate |
$2,136.00 |
| Rate for Payer: Aetna Commercial |
$480.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$459.24
|
| Rate for Payer: Aetna Managed Medicare |
$149.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$347.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$267.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$256.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.02
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$491.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.81
|
| Rate for Payer: Health EOS Commercial |
$475.26
|
| Rate for Payer: HFN Commercial |
$491.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$400.50
|
| Rate for Payer: Multiplan Commercial |
$427.20
|
| Rate for Payer: NAPHCARE Commercial |
$320.40
|
| Rate for Payer: Preferred Network Access Commercial |
$491.28
|
| Rate for Payer: Quartz Beloit One Network |
$261.66
|
| Rate for Payer: Quartz Commercial |
$347.10
|
| Rate for Payer: Quartz Medicare Advantage |
$320.40
|
| Rate for Payer: The Alliance Commercial |
$2,136.00
|
| Rate for Payer: WEA Trust Commercial |
$293.70
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
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 |
$104.16 |
| Max. Negotiated Rate |
$507.30 |
| Rate for Payer: Aetna Commercial |
$507.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$459.24
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$507.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$267.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.16
|
| Rate for Payer: Health EOS Commercial |
$485.94
|
| Rate for Payer: HFN Commercial |
$507.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$372.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$372.91
|
| Rate for Payer: Multiplan Commercial |
$427.20
|
| Rate for Payer: Preferred Network Access Commercial |
$507.30
|
| Rate for Payer: Quartz Beloit One Network |
$234.96
|
| Rate for Payer: Quartz Commercial |
$304.38
|
| Rate for Payer: The Alliance Commercial |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$293.70
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
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 |
$84.92 |
| Max. Negotiated Rate |
$304.06 |
| Rate for Payer: Aetna Commercial |
$183.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$183.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$96.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.63
|
| Rate for Payer: Health EOS Commercial |
$175.63
|
| Rate for Payer: HFN Commercial |
$183.35
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: Preferred Network Access Commercial |
$183.35
|
| Rate for Payer: Quartz Beloit One Network |
$84.92
|
| Rate for Payer: Quartz Commercial |
$110.01
|
| Rate for Payer: The Alliance Commercial |
$96.50
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$304.06
|
|
|
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 |
$54.04 |
| Max. Negotiated Rate |
$772.00 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Aetna Managed Medicare |
$54.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$125.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.91
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.75
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$125.45
|
| Rate for Payer: Quartz Medicare Advantage |
$115.80
|
| Rate for Payer: The Alliance Commercial |
$772.00
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$304.06
|
|
|
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 |
$94.57 |
| Max. Negotiated Rate |
$177.56 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$115.80
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
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 |
$97.02 |
| Max. Negotiated Rate |
$182.16 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.94
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$182.16
|
| Rate for Payer: Health EOS Commercial |
$176.22
|
| Rate for Payer: HFN Commercial |
$182.16
|
| Rate for Payer: Multiplan Commercial |
$158.40
|
| Rate for Payer: NAPHCARE Commercial |
$118.80
|
| Rate for Payer: Preferred Network Access Commercial |
$182.16
|
| Rate for Payer: Quartz Beloit One Network |
$97.02
|
| Rate for Payer: Quartz Commercial |
$118.80
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
|
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 |
$87.12 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna Commercial |
$188.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$188.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$99.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$118.80
|
| Rate for Payer: Health EOS Commercial |
$180.18
|
| Rate for Payer: HFN Commercial |
$188.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$132.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$132.62
|
| Rate for Payer: Multiplan Commercial |
$158.40
|
| Rate for Payer: Preferred Network Access Commercial |
$188.10
|
| Rate for Payer: Quartz Beloit One Network |
$87.12
|
| Rate for Payer: Quartz Commercial |
$112.86
|
| Rate for Payer: The Alliance Commercial |
$99.00
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
|
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 |
$95.04 |
| Max. Negotiated Rate |
$617.56 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Aetna Managed Medicare |
$154.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$128.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.04
|
| Rate for Payer: Anthem Medicare Advantage |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$154.39
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$182.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$154.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$154.39
|
| Rate for Payer: Health EOS Commercial |
$176.22
|
| Rate for Payer: HFN Commercial |
$182.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$154.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$154.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$154.39
|
| Rate for Payer: Multiplan Commercial |
$158.40
|
| Rate for Payer: NAPHCARE Commercial |
$231.58
|
| Rate for Payer: Preferred Network Access Commercial |
$182.16
|
| Rate for Payer: Quartz Beloit One Network |
$97.02
|
| Rate for Payer: Quartz Commercial |
$128.70
|
| Rate for Payer: Quartz Medicare Advantage |
$154.39
|
| Rate for Payer: The Alliance Commercial |
$617.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.39
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: Wellcare Medicare |
$154.39
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
|
Pure Tone Audio; Air Only
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
1152816
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$53.40
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pure Tone Audio; Air Only
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
1152816
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.72 |
| Max. Negotiated Rate |
$505.04 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.72
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$57.85
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pure Tone Audio; Air Only
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
1152816
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$39.16 |
| Max. Negotiated Rate |
$108.27 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.40
|
| Rate for Payer: Health EOS Commercial |
$80.99
|
| Rate for Payer: HFN Commercial |
$84.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.27
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.55
|
| Rate for Payer: Quartz Beloit One Network |
$39.16
|
| Rate for Payer: Quartz Commercial |
$50.73
|
| Rate for Payer: The Alliance Commercial |
$44.50
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pure Tone Audiometry Air
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
3203498
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$53.40
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pure Tone Audiometry Air
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
3203498
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$42.72 |
| Max. Negotiated Rate |
$505.04 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.72
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$57.85
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$66.75
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pure Tone Audiometry Air
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
3203498
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$39.16 |
| Max. Negotiated Rate |
$108.27 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.40
|
| Rate for Payer: Health EOS Commercial |
$80.99
|
| Rate for Payer: HFN Commercial |
$84.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.27
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.55
|
| Rate for Payer: Quartz Beloit One Network |
$39.16
|
| Rate for Payer: Quartz Commercial |
$50.73
|
| Rate for Payer: The Alliance Commercial |
$44.50
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pure Tone Audiometry Air/Bone
|
Professional
|
Both
|
$198.00
|
|
|
Service Code
|
CPT 92553
|
| Hospital Charge Code |
3203499
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$87.12 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna Commercial |
$188.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$188.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$99.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$118.80
|
| Rate for Payer: Health EOS Commercial |
$180.18
|
| Rate for Payer: HFN Commercial |
$188.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$132.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$132.62
|
| Rate for Payer: Multiplan Commercial |
$158.40
|
| Rate for Payer: Preferred Network Access Commercial |
$188.10
|
| Rate for Payer: Quartz Beloit One Network |
$87.12
|
| Rate for Payer: Quartz Commercial |
$112.86
|
| Rate for Payer: The Alliance Commercial |
$99.00
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
|
Pure Tone Audiometry Air/Bone
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
CPT 92553
|
| Hospital Charge Code |
3203499
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$95.04 |
| Max. Negotiated Rate |
$617.56 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Aetna Managed Medicare |
$154.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$128.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.04
|
| Rate for Payer: Anthem Medicare Advantage |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$154.39
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$182.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$154.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$154.39
|
| Rate for Payer: Health EOS Commercial |
$176.22
|
| Rate for Payer: HFN Commercial |
$182.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$154.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$154.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$154.39
|
| Rate for Payer: Multiplan Commercial |
$158.40
|
| Rate for Payer: NAPHCARE Commercial |
$231.58
|
| Rate for Payer: Preferred Network Access Commercial |
$182.16
|
| Rate for Payer: Quartz Beloit One Network |
$97.02
|
| Rate for Payer: Quartz Commercial |
$128.70
|
| Rate for Payer: Quartz Medicare Advantage |
$154.39
|
| Rate for Payer: The Alliance Commercial |
$617.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare PPO |
$148.50
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: Wellcare Medicare |
$154.39
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
|
Pure Tone Audiometry Air/Bone
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
CPT 92553
|
| Hospital Charge Code |
3203499
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$97.02 |
| Max. Negotiated Rate |
$182.16 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.94
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$182.16
|
| Rate for Payer: Health EOS Commercial |
$176.22
|
| Rate for Payer: HFN Commercial |
$182.16
|
| Rate for Payer: Multiplan Commercial |
$158.40
|
| Rate for Payer: NAPHCARE Commercial |
$118.80
|
| Rate for Payer: Preferred Network Access Commercial |
$182.16
|
| Rate for Payer: Quartz Beloit One Network |
$97.02
|
| Rate for Payer: Quartz Commercial |
$118.80
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
