|
SKIN TISSUE REARRANGEMENT 14020
|
Professional
|
Both
|
$1,032.00
|
|
|
Service Code
|
CPT 14020
|
| Hospital Charge Code |
3013621
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$363.86 |
| Max. Negotiated Rate |
$1,871.46 |
| Rate for Payer: Aetna Commercial |
$980.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$887.52
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cigna Commercial |
$980.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$363.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$619.20
|
| Rate for Payer: Health EOS Commercial |
$939.12
|
| Rate for Payer: HFN Commercial |
$980.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,871.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,871.46
|
| Rate for Payer: Multiplan Commercial |
$825.60
|
| Rate for Payer: Preferred Network Access Commercial |
$980.40
|
| Rate for Payer: Quartz Beloit One Network |
$454.08
|
| Rate for Payer: Quartz Commercial |
$588.24
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: United Healthcare Medicaid |
$363.86
|
| Rate for Payer: WEA Trust Commercial |
$567.60
|
| Rate for Payer: WPS Commercial |
$764.40
|
|
|
SKIN TISSUE REARRANGEMENT 14021
|
Professional
|
Both
|
$3,831.00
|
|
|
Service Code
|
CPT 14021
|
| Hospital Charge Code |
3013622
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$628.04 |
| Max. Negotiated Rate |
$3,639.45 |
| Rate for Payer: Aetna Commercial |
$3,639.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,294.66
|
| Rate for Payer: Cash Price |
$1,149.30
|
| Rate for Payer: Cash Price |
$1,149.30
|
| Rate for Payer: Cigna Commercial |
$3,639.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$628.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,298.60
|
| Rate for Payer: Health EOS Commercial |
$3,486.21
|
| Rate for Payer: HFN Commercial |
$3,639.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,349.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,349.71
|
| Rate for Payer: Multiplan Commercial |
$3,064.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,685.64
|
| Rate for Payer: Quartz Commercial |
$2,183.67
|
| Rate for Payer: The Alliance Commercial |
$1,915.50
|
| Rate for Payer: United Healthcare Medicaid |
$628.04
|
| Rate for Payer: WEA Trust Commercial |
$2,107.05
|
| Rate for Payer: WPS Commercial |
$2,837.62
|
|
|
SKIN TISSUE REARRANGEMENT 14040
|
Professional
|
Both
|
$3,302.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
3013623
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$389.77 |
| Max. Negotiated Rate |
$3,136.90 |
| Rate for Payer: Aetna Commercial |
$3,136.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,839.72
|
| Rate for Payer: Cash Price |
$990.60
|
| Rate for Payer: Cash Price |
$990.60
|
| Rate for Payer: Cigna Commercial |
$3,136.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$389.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,981.20
|
| Rate for Payer: Health EOS Commercial |
$3,004.82
|
| Rate for Payer: HFN Commercial |
$3,136.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,073.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,073.80
|
| Rate for Payer: Multiplan Commercial |
$2,641.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,136.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,452.88
|
| Rate for Payer: Quartz Commercial |
$1,882.14
|
| Rate for Payer: The Alliance Commercial |
$1,651.00
|
| Rate for Payer: United Healthcare Medicaid |
$389.77
|
| Rate for Payer: WEA Trust Commercial |
$1,816.10
|
| Rate for Payer: WPS Commercial |
$2,445.79
|
|
|
SKIN TISSUE REARRANGEMENT 14041
|
Professional
|
Both
|
$3,998.00
|
|
|
Service Code
|
CPT 14041
|
| Hospital Charge Code |
3013624
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$753.31 |
| Max. Negotiated Rate |
$3,798.10 |
| Rate for Payer: Aetna Commercial |
$3,798.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,438.28
|
| Rate for Payer: Cash Price |
$1,199.40
|
| Rate for Payer: Cash Price |
$1,199.40
|
| Rate for Payer: Cigna Commercial |
$3,798.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$753.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,398.80
|
| Rate for Payer: Health EOS Commercial |
$3,638.18
|
| Rate for Payer: HFN Commercial |
$3,798.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,537.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,537.51
|
| Rate for Payer: Multiplan Commercial |
$3,198.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,798.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,759.12
|
| Rate for Payer: Quartz Commercial |
$2,278.86
|
| Rate for Payer: The Alliance Commercial |
$1,999.00
|
| Rate for Payer: United Healthcare Medicaid |
$753.31
|
| Rate for Payer: WEA Trust Commercial |
$2,198.90
|
| Rate for Payer: WPS Commercial |
$2,961.32
|
|
|
SKIN TISSUE REARRANGEMENT 14060
|
Professional
|
Both
|
$4,193.00
|
|
|
Service Code
|
CPT 14060
|
| Hospital Charge Code |
3013625
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$390.81 |
| Max. Negotiated Rate |
$3,983.35 |
| Rate for Payer: Aetna Commercial |
$3,983.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,605.98
|
| Rate for Payer: Cash Price |
$1,257.90
|
| Rate for Payer: Cash Price |
$1,257.90
|
| Rate for Payer: Cigna Commercial |
$3,983.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$390.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,515.80
|
| Rate for Payer: Health EOS Commercial |
$3,815.63
|
| Rate for Payer: HFN Commercial |
$3,983.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,210.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,210.94
|
| Rate for Payer: Multiplan Commercial |
$3,354.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,983.35
|
| Rate for Payer: Quartz Beloit One Network |
$1,844.92
|
| Rate for Payer: Quartz Commercial |
$2,390.01
|
| Rate for Payer: The Alliance Commercial |
$2,096.50
|
| Rate for Payer: United Healthcare Medicaid |
$390.81
|
| Rate for Payer: WEA Trust Commercial |
$2,306.15
|
| Rate for Payer: WPS Commercial |
$3,105.76
|
|
|
SKIN TISSUE REARRANGEMENT 14061
|
Professional
|
Both
|
$5,111.00
|
|
|
Service Code
|
CPT 14061
|
| Hospital Charge Code |
3013626
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$523.35 |
| Max. Negotiated Rate |
$4,855.45 |
| Rate for Payer: Aetna Commercial |
$4,855.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,395.46
|
| Rate for Payer: Cash Price |
$1,533.30
|
| Rate for Payer: Cash Price |
$1,533.30
|
| Rate for Payer: Cigna Commercial |
$4,855.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$523.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,066.60
|
| Rate for Payer: Health EOS Commercial |
$4,651.01
|
| Rate for Payer: HFN Commercial |
$4,855.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,722.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,722.94
|
| Rate for Payer: Multiplan Commercial |
$4,088.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,855.45
|
| Rate for Payer: Quartz Beloit One Network |
$2,248.84
|
| Rate for Payer: Quartz Commercial |
$2,913.27
|
| Rate for Payer: The Alliance Commercial |
$2,555.50
|
| Rate for Payer: United Healthcare Medicaid |
$523.35
|
| Rate for Payer: WEA Trust Commercial |
$2,811.05
|
| Rate for Payer: WPS Commercial |
$3,785.72
|
|
|
SKIN ULCERS WITH CC
|
Facility
|
IP
|
$32,487.00
|
|
|
Service Code
|
MSDRG 593
|
| Min. Negotiated Rate |
$11,685.89 |
| Max. Negotiated Rate |
$32,487.00 |
| Rate for Payer: Aetna Managed Medicare |
$11,685.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,385.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,458.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,486.38
|
| Rate for Payer: Anthem Medicare Advantage |
$11,685.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,685.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,685.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,685.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,521.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,685.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,593.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,685.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,685.89
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,685.89
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,685.89
|
| Rate for Payer: NAPHCARE Commercial |
$17,528.84
|
| Rate for Payer: Quartz Medicare Advantage |
$11,685.89
|
| Rate for Payer: The Alliance Commercial |
$32,487.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,685.89
|
| Rate for Payer: United Healthcare PPO |
$18,367.49
|
| Rate for Payer: Wellcare Medicare |
$11,685.89
|
|
|
SKIN ULCERS WITH MCC
|
Facility
|
IP
|
$55,888.00
|
|
|
Service Code
|
MSDRG 592
|
| Min. Negotiated Rate |
$20,103.51 |
| Max. Negotiated Rate |
$55,888.00 |
| Rate for Payer: Aetna Managed Medicare |
$20,103.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43,848.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33,609.29
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31,931.02
|
| Rate for Payer: Anthem Medicare Advantage |
$20,103.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20,103.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20,103.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20,103.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35,446.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20,103.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40,756.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20,103.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20,103.51
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20,103.51
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20,103.51
|
| Rate for Payer: NAPHCARE Commercial |
$30,155.26
|
| Rate for Payer: Quartz Medicare Advantage |
$20,103.51
|
| Rate for Payer: The Alliance Commercial |
$55,888.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20,103.51
|
| Rate for Payer: United Healthcare PPO |
$31,729.81
|
| Rate for Payer: Wellcare Medicare |
$20,103.51
|
|
|
SKIN ULCERS WITHOUT CC/MCC
|
Facility
|
IP
|
$21,254.00
|
|
|
Service Code
|
MSDRG 594
|
| Min. Negotiated Rate |
$7,645.40 |
| Max. Negotiated Rate |
$21,254.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,645.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,574.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,703.99
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,069.62
|
| Rate for Payer: Anthem Medicare Advantage |
$7,645.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,645.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,645.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,645.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,398.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,645.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,354.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,645.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,645.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,645.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,645.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,468.10
|
| Rate for Payer: Quartz Medicare Advantage |
$7,645.40
|
| Rate for Payer: The Alliance Commercial |
$21,254.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,645.40
|
| Rate for Payer: United Healthcare PPO |
$11,953.52
|
| Rate for Payer: Wellcare Medicare |
$7,645.40
|
|
|
SKN SPLT A-GRFT FAC/NCK/HF/G 15120
|
Professional
|
Both
|
$3,886.00
|
|
|
Service Code
|
CPT 15120
|
| Hospital Charge Code |
3013636
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$784.10 |
| Max. Negotiated Rate |
$3,691.70 |
| Rate for Payer: Aetna Commercial |
$3,691.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,341.96
|
| Rate for Payer: Cash Price |
$1,165.80
|
| Rate for Payer: Cash Price |
$1,165.80
|
| Rate for Payer: Cigna Commercial |
$3,691.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$784.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,331.60
|
| Rate for Payer: Health EOS Commercial |
$3,536.26
|
| Rate for Payer: HFN Commercial |
$3,691.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,285.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,285.15
|
| Rate for Payer: Multiplan Commercial |
$3,108.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,691.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,709.84
|
| Rate for Payer: Quartz Commercial |
$2,215.02
|
| Rate for Payer: The Alliance Commercial |
$1,943.00
|
| Rate for Payer: United Healthcare Medicaid |
$784.10
|
| Rate for Payer: WEA Trust Commercial |
$2,137.30
|
| Rate for Payer: WPS Commercial |
$2,878.36
|
|
|
SLEEP APNEA CPAP
|
Facility
|
IP
|
$7,668.00
|
|
|
Service Code
|
CPT 95811
|
| Hospital Charge Code |
3059529
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$3,757.32 |
| Max. Negotiated Rate |
$7,054.56 |
| Rate for Payer: Aetna Commercial |
$6,901.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,594.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,064.04
|
| Rate for Payer: Cash Price |
$2,300.40
|
| Rate for Payer: Cigna Commercial |
$7,054.56
|
| Rate for Payer: Health EOS Commercial |
$6,824.52
|
| Rate for Payer: HFN Commercial |
$7,054.56
|
| Rate for Payer: Multiplan Commercial |
$6,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,600.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,054.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,757.32
|
| Rate for Payer: Quartz Commercial |
$4,600.80
|
| Rate for Payer: WEA Trust Commercial |
$4,217.40
|
| Rate for Payer: WPS Commercial |
$5,679.69
|
|
|
SLEEP APNEA CPAP
|
Facility
|
OP
|
$7,668.00
|
|
|
Service Code
|
CPT 95811
|
| Hospital Charge Code |
3059529
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$1,033.42 |
| Max. Negotiated Rate |
$7,054.56 |
| Rate for Payer: Aetna Commercial |
$6,901.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,594.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,033.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,033.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,064.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,033.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,033.42
|
| Rate for Payer: Cash Price |
$2,300.40
|
| Rate for Payer: Cash Price |
$2,300.40
|
| Rate for Payer: Cash Price |
$2,300.40
|
| Rate for Payer: Cigna Commercial |
$7,054.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,033.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,291.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,033.42
|
| Rate for Payer: Health EOS Commercial |
$6,824.52
|
| Rate for Payer: HFN Commercial |
$7,054.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,844.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,033.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,033.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,033.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,033.42
|
| Rate for Payer: Multiplan Commercial |
$6,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,550.13
|
| Rate for Payer: Preferred Network Access Commercial |
$7,054.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,757.32
|
| Rate for Payer: Quartz Commercial |
$4,984.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,033.42
|
| Rate for Payer: The Alliance Commercial |
$4,133.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,033.42
|
| Rate for Payer: United Healthcare PPO |
$5,751.00
|
| Rate for Payer: WEA Trust Commercial |
$4,217.40
|
| Rate for Payer: Wellcare Medicare |
$1,033.42
|
| Rate for Payer: WPS Commercial |
$5,679.69
|
|
|
SLEEP APNEA PROCEDURE
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960378
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
SLEEP APNEA PROCEDURE
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960378
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATT 9580626
|
Professional
|
Both
|
$1,023.00
|
|
|
Service Code
|
CPT 95806 26
|
| Hospital Charge Code |
6172223
|
|
Hospital Revenue Code
|
511
|
| Min. Negotiated Rate |
$154.30 |
| Max. Negotiated Rate |
$971.85 |
| Rate for Payer: Aetna Commercial |
$971.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$879.78
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cigna Commercial |
$971.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$511.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$613.80
|
| Rate for Payer: Health EOS Commercial |
$930.93
|
| Rate for Payer: HFN Commercial |
$971.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$154.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.30
|
| Rate for Payer: Multiplan Commercial |
$818.40
|
| Rate for Payer: Preferred Network Access Commercial |
$971.85
|
| Rate for Payer: Quartz Beloit One Network |
$450.12
|
| Rate for Payer: Quartz Commercial |
$583.11
|
| Rate for Payer: The Alliance Commercial |
$511.50
|
| Rate for Payer: WEA Trust Commercial |
$562.65
|
| Rate for Payer: WPS Commercial |
$757.74
|
|
|
SLEEVE COMPRESSION LARGE
|
Facility
|
IP
|
$465.00
|
|
| Hospital Charge Code |
2963056
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$227.85 |
| Max. Negotiated Rate |
$427.80 |
| Rate for Payer: Aetna Commercial |
$418.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$399.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.45
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$427.80
|
| Rate for Payer: Health EOS Commercial |
$413.85
|
| Rate for Payer: HFN Commercial |
$427.80
|
| Rate for Payer: Multiplan Commercial |
$372.00
|
| Rate for Payer: NAPHCARE Commercial |
$279.00
|
| Rate for Payer: Preferred Network Access Commercial |
$427.80
|
| Rate for Payer: Quartz Beloit One Network |
$227.85
|
| Rate for Payer: Quartz Commercial |
$279.00
|
| Rate for Payer: WEA Trust Commercial |
$255.75
|
| Rate for Payer: WPS Commercial |
$344.43
|
|
|
SLEEVE COMPRESSION LARGE
|
Facility
|
OP
|
$465.00
|
|
| Hospital Charge Code |
2963056
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$130.20 |
| Max. Negotiated Rate |
$1,860.00 |
| Rate for Payer: Aetna Commercial |
$418.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$399.90
|
| Rate for Payer: Aetna Managed Medicare |
$130.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$302.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$232.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$223.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.45
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$427.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$260.21
|
| Rate for Payer: Health EOS Commercial |
$413.85
|
| Rate for Payer: HFN Commercial |
$427.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$348.75
|
| Rate for Payer: Multiplan Commercial |
$372.00
|
| Rate for Payer: NAPHCARE Commercial |
$279.00
|
| Rate for Payer: Preferred Network Access Commercial |
$427.80
|
| Rate for Payer: Quartz Beloit One Network |
$227.85
|
| Rate for Payer: Quartz Commercial |
$302.25
|
| Rate for Payer: Quartz Medicare Advantage |
$279.00
|
| Rate for Payer: The Alliance Commercial |
$1,860.00
|
| Rate for Payer: WEA Trust Commercial |
$255.75
|
| Rate for Payer: WPS Commercial |
$344.43
|
|
|
SLEEVE COMPRESSION MEDIUM
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2963266
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$1,140.00 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Aetna Managed Medicare |
$79.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$142.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$136.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.49
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$185.25
|
| Rate for Payer: Quartz Medicare Advantage |
$171.00
|
| Rate for Payer: The Alliance Commercial |
$1,140.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
SLEEVE COMPRESSION MEDIUM
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2963266
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$139.65 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
SLEEVE COMPRESSION-XL
|
Facility
|
IP
|
$915.00
|
|
| Hospital Charge Code |
2975049
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$448.35 |
| Max. Negotiated Rate |
$841.80 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$549.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
SLEEVE COMPRESSION-XL
|
Facility
|
OP
|
$915.00
|
|
| Hospital Charge Code |
2975049
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$256.20 |
| Max. Negotiated Rate |
$3,660.00 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Aetna Managed Medicare |
$256.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$594.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$457.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$439.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.03
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.25
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$594.75
|
| Rate for Payer: Quartz Medicare Advantage |
$549.00
|
| Rate for Payer: The Alliance Commercial |
$3,660.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
SLEEVE RESORBABLE FOR 5.0 ANGU
|
Facility
|
OP
|
$2,608.00
|
|
| Hospital Charge Code |
2966584
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$730.24 |
| Max. Negotiated Rate |
$10,432.00 |
| Rate for Payer: Aetna Commercial |
$2,347.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,242.88
|
| Rate for Payer: Aetna Managed Medicare |
$730.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,695.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,304.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,251.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,382.24
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,399.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,459.44
|
| Rate for Payer: Health EOS Commercial |
$2,321.12
|
| Rate for Payer: HFN Commercial |
$2,399.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,956.00
|
| Rate for Payer: Multiplan Commercial |
$2,086.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,564.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,399.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,277.92
|
| Rate for Payer: Quartz Commercial |
$1,695.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,564.80
|
| Rate for Payer: The Alliance Commercial |
$10,432.00
|
| Rate for Payer: WEA Trust Commercial |
$1,434.40
|
| Rate for Payer: WPS Commercial |
$1,931.75
|
|
|
SLEEVE RESORBABLE FOR 5.0 ANGU
|
Facility
|
IP
|
$2,608.00
|
|
| Hospital Charge Code |
2966584
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,277.92 |
| Max. Negotiated Rate |
$2,399.36 |
| Rate for Payer: Aetna Commercial |
$2,347.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,242.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,382.24
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,399.36
|
| Rate for Payer: Health EOS Commercial |
$2,321.12
|
| Rate for Payer: HFN Commercial |
$2,399.36
|
| Rate for Payer: Multiplan Commercial |
$2,086.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,564.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,399.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,277.92
|
| Rate for Payer: Quartz Commercial |
$1,564.80
|
| Rate for Payer: WEA Trust Commercial |
$1,434.40
|
| Rate for Payer: WPS Commercial |
$1,931.75
|
|
|
SLEEVE REVISION METAPHYSEAL POROUS M.B.T. 29MM 1294-54-000
|
Facility
|
IP
|
$14,721.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,213.29 |
| Max. Negotiated Rate |
$13,543.32 |
| Rate for Payer: Aetna Commercial |
$13,248.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,660.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,802.13
|
| Rate for Payer: Cash Price |
$4,416.30
|
| Rate for Payer: Cigna Commercial |
$13,543.32
|
| Rate for Payer: Health EOS Commercial |
$13,101.69
|
| Rate for Payer: HFN Commercial |
$13,543.32
|
| Rate for Payer: Multiplan Commercial |
$11,776.80
|
| Rate for Payer: NAPHCARE Commercial |
$8,832.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,543.32
|
| Rate for Payer: Quartz Beloit One Network |
$7,213.29
|
| Rate for Payer: Quartz Commercial |
$8,832.60
|
| Rate for Payer: WEA Trust Commercial |
$8,096.55
|
| Rate for Payer: WPS Commercial |
$10,903.84
|
|
|
SLEEVE REVISION METAPHYSEAL POROUS M.B.T. 29MM 1294-54-000
|
Facility
|
OP
|
$14,721.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,121.88 |
| Max. Negotiated Rate |
$58,884.00 |
| Rate for Payer: Aetna Commercial |
$13,248.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,660.06
|
| Rate for Payer: Aetna Managed Medicare |
$4,121.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,568.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,360.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,066.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,802.13
|
| Rate for Payer: Cash Price |
$4,416.30
|
| Rate for Payer: Cigna Commercial |
$13,543.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,237.87
|
| Rate for Payer: Health EOS Commercial |
$13,101.69
|
| Rate for Payer: HFN Commercial |
$13,543.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,040.75
|
| Rate for Payer: Multiplan Commercial |
$11,776.80
|
| Rate for Payer: NAPHCARE Commercial |
$8,832.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,543.32
|
| Rate for Payer: Quartz Beloit One Network |
$7,213.29
|
| Rate for Payer: Quartz Commercial |
$9,568.65
|
| Rate for Payer: Quartz Medicare Advantage |
$8,832.60
|
| Rate for Payer: The Alliance Commercial |
$58,884.00
|
| Rate for Payer: WEA Trust Commercial |
$8,096.55
|
| Rate for Payer: WPS Commercial |
$10,903.84
|
|
