|
Yes - Tracheostomy Mask Charge
|
Facility
|
IP
|
$77.00
|
|
| Hospital Charge Code |
3006976
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$48.05
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Yes - Training ST Generating Device Charges
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
CPT 92609 GN
|
| Hospital Charge Code |
2989781
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$229.83 |
| Max. Negotiated Rate |
$431.52 |
| Rate for Payer: Aetna Commercial |
$422.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$403.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$248.59
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cigna Commercial |
$431.52
|
| Rate for Payer: Health EOS Commercial |
$417.45
|
| Rate for Payer: HFN Commercial |
$431.52
|
| Rate for Payer: Multiplan Commercial |
$375.23
|
| Rate for Payer: Preferred Network Access Commercial |
$431.52
|
| Rate for Payer: Quartz Beloit One Network |
$229.83
|
| Rate for Payer: Quartz Commercial |
$281.42
|
| Rate for Payer: WEA Trust Commercial |
$257.97
|
| Rate for Payer: WPS Commercial |
$347.41
|
|
|
Yes - Training ST Generating Device Charges
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
CPT 92609 GN
|
| Hospital Charge Code |
2989781
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$131.33 |
| Max. Negotiated Rate |
$431.52 |
| Rate for Payer: Aetna Commercial |
$422.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$403.37
|
| Rate for Payer: Aetna Managed Medicare |
$131.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$248.59
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cigna Commercial |
$431.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$262.48
|
| Rate for Payer: Health EOS Commercial |
$417.45
|
| Rate for Payer: HFN Commercial |
$431.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$375.23
|
| Rate for Payer: NAPHCARE Commercial |
$281.42
|
| Rate for Payer: Preferred Network Access Commercial |
$431.52
|
| Rate for Payer: Quartz Beloit One Network |
$229.83
|
| Rate for Payer: Quartz Commercial |
$304.88
|
| Rate for Payer: Quartz Medicare Advantage |
$281.42
|
| Rate for Payer: The Alliance Commercial |
$234.52
|
| Rate for Payer: United Healthcare PPO |
$351.78
|
| Rate for Payer: WEA Trust Commercial |
$257.97
|
| Rate for Payer: WPS Commercial |
$347.41
|
|
|
Yes - Ventilator Circuit Charge
|
Facility
|
OP
|
$121.00
|
|
| Hospital Charge Code |
3006978
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$35.24 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Aetna Managed Medicare |
$35.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.42
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.38
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: NAPHCARE Commercial |
$75.50
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$81.80
|
| Rate for Payer: Quartz Medicare Advantage |
$75.50
|
| Rate for Payer: The Alliance Commercial |
$62.92
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
Yes - Ventilator Circuit Charge
|
Facility
|
IP
|
$121.00
|
|
| Hospital Charge Code |
3006978
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$61.66 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
Yes - Venti-Mask Charge
|
Facility
|
IP
|
$77.00
|
|
| Hospital Charge Code |
3006977
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$48.05
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Yes - Venti-Mask Charge
|
Facility
|
OP
|
$77.00
|
|
| Hospital Charge Code |
3006977
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Aetna Managed Medicare |
$22.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.81
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.06
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: NAPHCARE Commercial |
$48.05
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$52.05
|
| Rate for Payer: Quartz Medicare Advantage |
$48.05
|
| Rate for Payer: The Alliance Commercial |
$40.04
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Yes - Video Swallow Eval Charge (Motion)
|
Facility
|
IP
|
$745.00
|
|
|
Service Code
|
CPT 92611 GN
|
| Hospital Charge Code |
4075915
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$379.65 |
| Max. Negotiated Rate |
$712.82 |
| Rate for Payer: Aetna Commercial |
$697.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$666.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$410.64
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$712.82
|
| Rate for Payer: Health EOS Commercial |
$689.57
|
| Rate for Payer: HFN Commercial |
$712.82
|
| Rate for Payer: Multiplan Commercial |
$619.84
|
| Rate for Payer: Preferred Network Access Commercial |
$712.82
|
| Rate for Payer: Quartz Beloit One Network |
$379.65
|
| Rate for Payer: Quartz Commercial |
$464.88
|
| Rate for Payer: WEA Trust Commercial |
$426.14
|
| Rate for Payer: WPS Commercial |
$573.87
|
|
|
Yes - Video Swallow Eval Charge (Motion)
|
Facility
|
OP
|
$745.00
|
|
|
Service Code
|
CPT 92611 GN
|
| Hospital Charge Code |
4075915
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$210.08 |
| Max. Negotiated Rate |
$712.82 |
| Rate for Payer: Aetna Commercial |
$697.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$666.33
|
| Rate for Payer: Aetna Managed Medicare |
$216.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$410.64
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$712.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$433.59
|
| Rate for Payer: Health EOS Commercial |
$689.57
|
| Rate for Payer: HFN Commercial |
$712.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$619.84
|
| Rate for Payer: NAPHCARE Commercial |
$464.88
|
| Rate for Payer: Preferred Network Access Commercial |
$712.82
|
| Rate for Payer: Quartz Beloit One Network |
$379.65
|
| Rate for Payer: Quartz Commercial |
$503.62
|
| Rate for Payer: Quartz Medicare Advantage |
$464.88
|
| Rate for Payer: The Alliance Commercial |
$387.40
|
| Rate for Payer: United Healthcare PPO |
$581.10
|
| Rate for Payer: WEA Trust Commercial |
$426.14
|
| Rate for Payer: WPS Commercial |
$573.87
|
|
|
Yes - Video Swallow Eval (Flexible Fiberoptic)
|
Facility
|
OP
|
$646.00
|
|
|
Service Code
|
CPT 92611 GN
|
| Hospital Charge Code |
2989780
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$188.12 |
| Max. Negotiated Rate |
$618.09 |
| Rate for Payer: Aetna Commercial |
$604.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| Rate for Payer: Aetna Managed Medicare |
$188.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$356.08
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$618.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$375.97
|
| Rate for Payer: Health EOS Commercial |
$597.94
|
| Rate for Payer: HFN Commercial |
$618.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: NAPHCARE Commercial |
$403.10
|
| Rate for Payer: Preferred Network Access Commercial |
$618.09
|
| Rate for Payer: Quartz Beloit One Network |
$329.20
|
| Rate for Payer: Quartz Commercial |
$436.70
|
| Rate for Payer: Quartz Medicare Advantage |
$403.10
|
| Rate for Payer: The Alliance Commercial |
$335.92
|
| Rate for Payer: United Healthcare PPO |
$503.88
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: WPS Commercial |
$497.61
|
|
|
Yes - Video Swallow Eval (Flexible Fiberoptic)
|
Facility
|
IP
|
$646.00
|
|
|
Service Code
|
CPT 92611 GN
|
| Hospital Charge Code |
2989780
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$329.20 |
| Max. Negotiated Rate |
$618.09 |
| Rate for Payer: Aetna Commercial |
$604.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$356.08
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$618.09
|
| Rate for Payer: Health EOS Commercial |
$597.94
|
| Rate for Payer: HFN Commercial |
$618.09
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: Preferred Network Access Commercial |
$618.09
|
| Rate for Payer: Quartz Beloit One Network |
$329.20
|
| Rate for Payer: Quartz Commercial |
$403.10
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: WPS Commercial |
$497.61
|
|
|
Yes - Wound Care Non-Selective Debride Charge
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
3554169
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$54.53 |
| Max. Negotiated Rate |
$102.38 |
| Rate for Payer: Aetna Commercial |
$100.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.98
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$102.38
|
| Rate for Payer: Health EOS Commercial |
$99.04
|
| Rate for Payer: HFN Commercial |
$102.38
|
| Rate for Payer: Multiplan Commercial |
$89.02
|
| Rate for Payer: Preferred Network Access Commercial |
$102.38
|
| Rate for Payer: Quartz Beloit One Network |
$54.53
|
| Rate for Payer: Quartz Commercial |
$66.77
|
| Rate for Payer: WEA Trust Commercial |
$61.20
|
| Rate for Payer: WPS Commercial |
$82.42
|
|
|
Yes - Wound Care Non-Selective Debride Charge
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
3554169
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$54.53 |
| Max. Negotiated Rate |
$844.56 |
| Rate for Payer: Aetna Commercial |
$100.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.70
|
| Rate for Payer: Aetna Managed Medicare |
$211.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Anthem Medicare Advantage |
$211.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$211.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$211.14
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$102.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$211.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$211.14
|
| Rate for Payer: Health EOS Commercial |
$99.04
|
| Rate for Payer: HFN Commercial |
$102.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$211.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$211.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$211.14
|
| Rate for Payer: Multiplan Commercial |
$89.02
|
| Rate for Payer: NAPHCARE Commercial |
$316.71
|
| Rate for Payer: Preferred Network Access Commercial |
$102.38
|
| Rate for Payer: Quartz Beloit One Network |
$54.53
|
| Rate for Payer: Quartz Commercial |
$72.33
|
| Rate for Payer: Quartz Medicare Advantage |
$211.14
|
| Rate for Payer: The Alliance Commercial |
$844.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$211.14
|
| Rate for Payer: United Healthcare PPO |
$83.46
|
| Rate for Payer: WEA Trust Commercial |
$61.20
|
| Rate for Payer: Wellcare Medicare |
$211.14
|
| Rate for Payer: WPS Commercial |
$82.42
|
|
|
Yes - Wound Care Non-Selective Debride Charge
|
Professional
|
Both
|
$107.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
3554169
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$48.96 |
| Max. Negotiated Rate |
$105.72 |
| Rate for Payer: Aetna Commercial |
$105.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.70
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$105.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.77
|
| Rate for Payer: Health EOS Commercial |
$101.26
|
| Rate for Payer: HFN Commercial |
$105.72
|
| Rate for Payer: Multiplan Commercial |
$89.02
|
| Rate for Payer: Preferred Network Access Commercial |
$105.72
|
| Rate for Payer: Quartz Beloit One Network |
$48.96
|
| Rate for Payer: Quartz Commercial |
$63.43
|
| Rate for Payer: The Alliance Commercial |
$55.64
|
| Rate for Payer: WEA Trust Commercial |
$61.20
|
| Rate for Payer: WPS Commercial |
$82.42
|
|
|
Yes - Wound Vac 50 sq cm Charges
|
Professional
|
Both
|
$317.00
|
|
|
Service Code
|
CPT 97605 GP
|
| Hospital Charge Code |
2989816
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$29.98 |
| Max. Negotiated Rate |
$313.20 |
| Rate for Payer: Aetna Commercial |
$313.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$313.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$164.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.81
|
| Rate for Payer: Health EOS Commercial |
$300.01
|
| Rate for Payer: HFN Commercial |
$313.20
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: Preferred Network Access Commercial |
$313.20
|
| Rate for Payer: Quartz Beloit One Network |
$145.06
|
| Rate for Payer: Quartz Commercial |
$187.92
|
| Rate for Payer: The Alliance Commercial |
$164.84
|
| Rate for Payer: United Healthcare Medicaid |
$29.98
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$244.19
|
|
|
Yes - Wound Vac 50 sq cm Charges
|
Facility
|
OP
|
$317.00
|
|
|
Service Code
|
CPT 97605 GP
|
| Hospital Charge Code |
2989816
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$92.31 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$296.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Aetna Managed Medicare |
$92.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.73
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$303.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$184.49
|
| Rate for Payer: Health EOS Commercial |
$293.42
|
| Rate for Payer: HFN Commercial |
$303.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: NAPHCARE Commercial |
$197.81
|
| Rate for Payer: Preferred Network Access Commercial |
$303.31
|
| Rate for Payer: Quartz Beloit One Network |
$161.54
|
| Rate for Payer: Quartz Commercial |
$214.29
|
| Rate for Payer: Quartz Medicare Advantage |
$197.81
|
| Rate for Payer: The Alliance Commercial |
$164.84
|
| Rate for Payer: United Healthcare PPO |
$247.26
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$244.19
|
|
|
Yes - Wound Vac 50 sq cm Charges
|
Facility
|
IP
|
$317.00
|
|
|
Service Code
|
CPT 97605 GP
|
| Hospital Charge Code |
2989816
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$161.54 |
| Max. Negotiated Rate |
$303.31 |
| Rate for Payer: Aetna Commercial |
$296.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.73
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$303.31
|
| Rate for Payer: Health EOS Commercial |
$293.42
|
| Rate for Payer: HFN Commercial |
$303.31
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: Preferred Network Access Commercial |
$303.31
|
| Rate for Payer: Quartz Beloit One Network |
$161.54
|
| Rate for Payer: Quartz Commercial |
$197.81
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$244.19
|
|
|
Yes - Wound Vac Addit. 50 sq cm Charges
|
Professional
|
Both
|
$330.00
|
|
|
Service Code
|
CPT 97606 GP
|
| Hospital Charge Code |
2989817
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$32.39 |
| Max. Negotiated Rate |
$326.04 |
| Rate for Payer: Aetna Commercial |
$326.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.15
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$326.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$171.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$205.92
|
| Rate for Payer: Health EOS Commercial |
$312.31
|
| Rate for Payer: HFN Commercial |
$326.04
|
| Rate for Payer: Multiplan Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$326.04
|
| Rate for Payer: Quartz Beloit One Network |
$151.01
|
| Rate for Payer: Quartz Commercial |
$195.62
|
| Rate for Payer: The Alliance Commercial |
$171.60
|
| Rate for Payer: United Healthcare Medicaid |
$32.39
|
| Rate for Payer: WEA Trust Commercial |
$188.76
|
| Rate for Payer: WPS Commercial |
$254.20
|
|
|
Yes - Wound Vac Addit. 50 sq cm Charges
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
CPT 97606 GP
|
| Hospital Charge Code |
2989817
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$96.10 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$308.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.15
|
| Rate for Payer: Aetna Managed Medicare |
$96.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$181.90
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$315.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.06
|
| Rate for Payer: Health EOS Commercial |
$305.45
|
| Rate for Payer: HFN Commercial |
$315.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$274.56
|
| Rate for Payer: NAPHCARE Commercial |
$205.92
|
| Rate for Payer: Preferred Network Access Commercial |
$315.74
|
| Rate for Payer: Quartz Beloit One Network |
$168.17
|
| Rate for Payer: Quartz Commercial |
$223.08
|
| Rate for Payer: Quartz Medicare Advantage |
$205.92
|
| Rate for Payer: The Alliance Commercial |
$171.60
|
| Rate for Payer: United Healthcare PPO |
$257.40
|
| Rate for Payer: WEA Trust Commercial |
$188.76
|
| Rate for Payer: WPS Commercial |
$254.20
|
|
|
Yes - Wound Vac Addit. 50 sq cm Charges
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
CPT 97606 GP
|
| Hospital Charge Code |
2989817
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$168.17 |
| Max. Negotiated Rate |
$315.74 |
| Rate for Payer: Aetna Commercial |
$308.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$181.90
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$315.74
|
| Rate for Payer: Health EOS Commercial |
$305.45
|
| Rate for Payer: HFN Commercial |
$315.74
|
| Rate for Payer: Multiplan Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$315.74
|
| Rate for Payer: Quartz Beloit One Network |
$168.17
|
| Rate for Payer: Quartz Commercial |
$205.92
|
| Rate for Payer: WEA Trust Commercial |
$188.76
|
| Rate for Payer: WPS Commercial |
$254.20
|
|
|
Yes - Wound Vac Disposable Charges >50 sq cm
|
Facility
|
IP
|
$457.00
|
|
|
Service Code
|
CPT 97608 GP
|
| Hospital Charge Code |
5364681
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$232.89 |
| Max. Negotiated Rate |
$437.26 |
| Rate for Payer: Aetna Commercial |
$427.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$408.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.90
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$437.26
|
| Rate for Payer: Health EOS Commercial |
$423.00
|
| Rate for Payer: HFN Commercial |
$437.26
|
| Rate for Payer: Multiplan Commercial |
$380.22
|
| Rate for Payer: Preferred Network Access Commercial |
$437.26
|
| Rate for Payer: Quartz Beloit One Network |
$232.89
|
| Rate for Payer: Quartz Commercial |
$285.17
|
| Rate for Payer: WEA Trust Commercial |
$261.40
|
| Rate for Payer: WPS Commercial |
$352.03
|
|
|
Yes - Wound Vac Disposable Charges >50 sq cm
|
Facility
|
OP
|
$457.00
|
|
|
Service Code
|
CPT 97608 GP
|
| Hospital Charge Code |
5364681
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$133.08 |
| Max. Negotiated Rate |
$437.26 |
| Rate for Payer: Aetna Commercial |
$427.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$408.74
|
| Rate for Payer: Aetna Managed Medicare |
$133.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.90
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$437.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$265.97
|
| Rate for Payer: Health EOS Commercial |
$423.00
|
| Rate for Payer: HFN Commercial |
$437.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$380.22
|
| Rate for Payer: NAPHCARE Commercial |
$285.17
|
| Rate for Payer: Preferred Network Access Commercial |
$437.26
|
| Rate for Payer: Quartz Beloit One Network |
$232.89
|
| Rate for Payer: Quartz Commercial |
$308.93
|
| Rate for Payer: Quartz Medicare Advantage |
$285.17
|
| Rate for Payer: The Alliance Commercial |
$237.64
|
| Rate for Payer: United Healthcare PPO |
$356.46
|
| Rate for Payer: WEA Trust Commercial |
$261.40
|
| Rate for Payer: WPS Commercial |
$352.03
|
|
|
Yes - Wound Vac Disposable Charges 50 sq cm
|
Facility
|
IP
|
$457.00
|
|
|
Service Code
|
CPT 97607 GP
|
| Hospital Charge Code |
5364671
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$232.89 |
| Max. Negotiated Rate |
$437.26 |
| Rate for Payer: Aetna Commercial |
$427.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$408.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.90
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$437.26
|
| Rate for Payer: Health EOS Commercial |
$423.00
|
| Rate for Payer: HFN Commercial |
$437.26
|
| Rate for Payer: Multiplan Commercial |
$380.22
|
| Rate for Payer: Preferred Network Access Commercial |
$437.26
|
| Rate for Payer: Quartz Beloit One Network |
$232.89
|
| Rate for Payer: Quartz Commercial |
$285.17
|
| Rate for Payer: WEA Trust Commercial |
$261.40
|
| Rate for Payer: WPS Commercial |
$352.03
|
|
|
Yes - Wound Vac Disposable Charges 50 sq cm
|
Professional
|
Both
|
$457.00
|
|
|
Service Code
|
CPT 97607 GP
|
| Hospital Charge Code |
5364671
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$32.39 |
| Max. Negotiated Rate |
$451.52 |
| Rate for Payer: Aetna Commercial |
$451.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$408.74
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$451.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$237.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$285.17
|
| Rate for Payer: Health EOS Commercial |
$432.50
|
| Rate for Payer: HFN Commercial |
$451.52
|
| Rate for Payer: Multiplan Commercial |
$380.22
|
| Rate for Payer: Preferred Network Access Commercial |
$451.52
|
| Rate for Payer: Quartz Beloit One Network |
$209.12
|
| Rate for Payer: Quartz Commercial |
$270.91
|
| Rate for Payer: The Alliance Commercial |
$237.64
|
| Rate for Payer: United Healthcare Medicaid |
$32.39
|
| Rate for Payer: WEA Trust Commercial |
$261.40
|
| Rate for Payer: WPS Commercial |
$352.03
|
|
|
Yes - Wound Vac Disposable Charges 50 sq cm
|
Facility
|
OP
|
$457.00
|
|
|
Service Code
|
CPT 97607 GP
|
| Hospital Charge Code |
5364671
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$133.08 |
| Max. Negotiated Rate |
$437.26 |
| Rate for Payer: Aetna Commercial |
$427.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$408.74
|
| Rate for Payer: Aetna Managed Medicare |
$133.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.90
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$437.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$265.97
|
| Rate for Payer: Health EOS Commercial |
$423.00
|
| Rate for Payer: HFN Commercial |
$437.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$380.22
|
| Rate for Payer: NAPHCARE Commercial |
$285.17
|
| Rate for Payer: Preferred Network Access Commercial |
$437.26
|
| Rate for Payer: Quartz Beloit One Network |
$232.89
|
| Rate for Payer: Quartz Commercial |
$308.93
|
| Rate for Payer: Quartz Medicare Advantage |
$285.17
|
| Rate for Payer: The Alliance Commercial |
$237.64
|
| Rate for Payer: United Healthcare PPO |
$356.46
|
| Rate for Payer: WEA Trust Commercial |
$261.40
|
| Rate for Payer: WPS Commercial |
$352.03
|
|
