|
Motor&/sens 1-2 nrv cndj tst 95907
|
Professional
|
Both
|
$1,220.00
|
|
|
Service Code
|
CPT 95907
|
| Hospital Charge Code |
3119366
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.73 |
| Max. Negotiated Rate |
$1,159.00 |
| Rate for Payer: Aetna Commercial |
$1,159.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,049.20
|
| Rate for Payer: Cash Price |
$366.00
|
| Rate for Payer: Cash Price |
$366.00
|
| Rate for Payer: Cash Price |
$366.00
|
| Rate for Payer: Cigna Commercial |
$1,159.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$732.00
|
| Rate for Payer: Health EOS Commercial |
$1,110.20
|
| Rate for Payer: HFN Commercial |
$1,159.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$325.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$325.71
|
| Rate for Payer: Multiplan Commercial |
$976.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.00
|
| Rate for Payer: Quartz Beloit One Network |
$536.80
|
| Rate for Payer: Quartz Commercial |
$695.40
|
| Rate for Payer: The Alliance Commercial |
$610.00
|
| Rate for Payer: United Healthcare Medicaid |
$72.73
|
| Rate for Payer: WEA Trust Commercial |
$671.00
|
| Rate for Payer: WPS Commercial |
$903.65
|
|
|
Motor&/sens 1-2 nrv cndj tst 9590726
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
CPT 95907 26
|
| Hospital Charge Code |
3333546
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.73 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Aetna Commercial |
$470.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$470.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$297.00
|
| Rate for Payer: Health EOS Commercial |
$450.45
|
| Rate for Payer: HFN Commercial |
$470.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$183.81
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: Preferred Network Access Commercial |
$470.25
|
| Rate for Payer: Quartz Beloit One Network |
$217.80
|
| Rate for Payer: Quartz Commercial |
$282.15
|
| Rate for Payer: The Alliance Commercial |
$247.50
|
| Rate for Payer: United Healthcare Medicaid |
$72.73
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
Motor&/sens 3-4 nrv cndj tst 95908
|
Professional
|
Both
|
$497.00
|
|
|
Service Code
|
CPT 95908
|
| Hospital Charge Code |
3103304
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$89.80 |
| Max. Negotiated Rate |
$472.15 |
| Rate for Payer: Aetna Commercial |
$472.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$427.42
|
| Rate for Payer: Cash Price |
$149.10
|
| Rate for Payer: Cash Price |
$149.10
|
| Rate for Payer: Cash Price |
$149.10
|
| Rate for Payer: Cigna Commercial |
$472.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$298.20
|
| Rate for Payer: Health EOS Commercial |
$452.27
|
| Rate for Payer: HFN Commercial |
$472.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$411.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$411.42
|
| Rate for Payer: Multiplan Commercial |
$397.60
|
| Rate for Payer: Preferred Network Access Commercial |
$472.15
|
| Rate for Payer: Quartz Beloit One Network |
$218.68
|
| Rate for Payer: Quartz Commercial |
$283.29
|
| Rate for Payer: The Alliance Commercial |
$248.50
|
| Rate for Payer: United Healthcare Medicaid |
$89.80
|
| Rate for Payer: WEA Trust Commercial |
$273.35
|
| Rate for Payer: WPS Commercial |
$368.13
|
|
|
Motor&/sens 3-4 nrv cndj tst 9590826
|
Professional
|
Both
|
$497.00
|
|
|
Service Code
|
CPT 95908 26
|
| Hospital Charge Code |
3147573
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$89.80 |
| Max. Negotiated Rate |
$472.15 |
| Rate for Payer: Aetna Commercial |
$472.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$427.42
|
| Rate for Payer: Cash Price |
$149.10
|
| Rate for Payer: Cash Price |
$149.10
|
| Rate for Payer: Cash Price |
$149.10
|
| Rate for Payer: Cigna Commercial |
$472.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$298.20
|
| Rate for Payer: Health EOS Commercial |
$452.27
|
| Rate for Payer: HFN Commercial |
$472.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$230.05
|
| Rate for Payer: Multiplan Commercial |
$397.60
|
| Rate for Payer: Preferred Network Access Commercial |
$472.15
|
| Rate for Payer: Quartz Beloit One Network |
$218.68
|
| Rate for Payer: Quartz Commercial |
$283.29
|
| Rate for Payer: The Alliance Commercial |
$248.50
|
| Rate for Payer: United Healthcare Medicaid |
$89.80
|
| Rate for Payer: WEA Trust Commercial |
$273.35
|
| Rate for Payer: WPS Commercial |
$368.13
|
|
|
Motor&/sens 5-6 nrv cndj tst 95909
|
Professional
|
Both
|
$1,572.00
|
|
|
Service Code
|
CPT 95909
|
| Hospital Charge Code |
3127524
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$107.53 |
| Max. Negotiated Rate |
$1,493.40 |
| Rate for Payer: Aetna Commercial |
$1,493.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,351.92
|
| Rate for Payer: Cash Price |
$471.60
|
| Rate for Payer: Cash Price |
$471.60
|
| Rate for Payer: Cash Price |
$471.60
|
| Rate for Payer: Cigna Commercial |
$1,493.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$943.20
|
| Rate for Payer: Health EOS Commercial |
$1,430.52
|
| Rate for Payer: HFN Commercial |
$1,493.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$492.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$492.12
|
| Rate for Payer: Multiplan Commercial |
$1,257.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,493.40
|
| Rate for Payer: Quartz Beloit One Network |
$691.68
|
| Rate for Payer: Quartz Commercial |
$896.04
|
| Rate for Payer: The Alliance Commercial |
$786.00
|
| Rate for Payer: United Healthcare Medicaid |
$107.53
|
| Rate for Payer: WEA Trust Commercial |
$864.60
|
| Rate for Payer: WPS Commercial |
$1,164.38
|
|
|
Motor&/sens 5-6 nrv cndj tst 9590926
|
Professional
|
Both
|
$639.00
|
|
|
Service Code
|
CPT 95909 26
|
| Hospital Charge Code |
3127529
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$107.53 |
| Max. Negotiated Rate |
$607.05 |
| Rate for Payer: Aetna Commercial |
$607.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$549.54
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cigna Commercial |
$607.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$383.40
|
| Rate for Payer: Health EOS Commercial |
$581.49
|
| Rate for Payer: HFN Commercial |
$607.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$274.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$274.78
|
| Rate for Payer: Multiplan Commercial |
$511.20
|
| Rate for Payer: Preferred Network Access Commercial |
$607.05
|
| Rate for Payer: Quartz Beloit One Network |
$281.16
|
| Rate for Payer: Quartz Commercial |
$364.23
|
| Rate for Payer: The Alliance Commercial |
$319.50
|
| Rate for Payer: United Healthcare Medicaid |
$107.53
|
| Rate for Payer: WEA Trust Commercial |
$351.45
|
| Rate for Payer: WPS Commercial |
$473.31
|
|
|
Motor&/sens 7-8 nrv cndj tst 95910
|
Professional
|
Both
|
$2,373.00
|
|
|
Service Code
|
CPT 95910
|
| Hospital Charge Code |
3147572
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$141.54 |
| Max. Negotiated Rate |
$2,254.35 |
| Rate for Payer: Aetna Commercial |
$2,254.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,040.78
|
| Rate for Payer: Cash Price |
$711.90
|
| Rate for Payer: Cash Price |
$711.90
|
| Rate for Payer: Cash Price |
$711.90
|
| Rate for Payer: Cigna Commercial |
$2,254.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$141.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,423.80
|
| Rate for Payer: Health EOS Commercial |
$2,159.43
|
| Rate for Payer: HFN Commercial |
$2,254.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$645.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$645.64
|
| Rate for Payer: Multiplan Commercial |
$1,898.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,254.35
|
| Rate for Payer: Quartz Beloit One Network |
$1,044.12
|
| Rate for Payer: Quartz Commercial |
$1,352.61
|
| Rate for Payer: The Alliance Commercial |
$1,186.50
|
| Rate for Payer: United Healthcare Medicaid |
$141.54
|
| Rate for Payer: WEA Trust Commercial |
$1,305.15
|
| Rate for Payer: WPS Commercial |
$1,757.68
|
|
|
Motor&/sens 7-8 nrv cndj tst 9591026
|
Professional
|
Both
|
$2,373.00
|
|
|
Service Code
|
CPT 95910 26
|
| Hospital Charge Code |
3571509
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$141.54 |
| Max. Negotiated Rate |
$2,254.35 |
| Rate for Payer: Aetna Commercial |
$2,254.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,040.78
|
| Rate for Payer: Cash Price |
$711.90
|
| Rate for Payer: Cash Price |
$711.90
|
| Rate for Payer: Cash Price |
$711.90
|
| Rate for Payer: Cigna Commercial |
$2,254.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$141.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,423.80
|
| Rate for Payer: Health EOS Commercial |
$2,159.43
|
| Rate for Payer: HFN Commercial |
$2,254.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$367.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$367.97
|
| Rate for Payer: Multiplan Commercial |
$1,898.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,254.35
|
| Rate for Payer: Quartz Beloit One Network |
$1,044.12
|
| Rate for Payer: Quartz Commercial |
$1,352.61
|
| Rate for Payer: The Alliance Commercial |
$1,186.50
|
| Rate for Payer: United Healthcare Medicaid |
$141.54
|
| Rate for Payer: WEA Trust Commercial |
$1,305.15
|
| Rate for Payer: WPS Commercial |
$1,757.68
|
|
|
Motor&/sens 9-10 nrv cndj test 95911
|
Professional
|
Both
|
$2,784.00
|
|
|
Service Code
|
CPT 95911
|
| Hospital Charge Code |
3165562
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$171.11 |
| Max. Negotiated Rate |
$2,644.80 |
| Rate for Payer: Aetna Commercial |
$2,644.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,394.24
|
| Rate for Payer: Cash Price |
$835.20
|
| Rate for Payer: Cash Price |
$835.20
|
| Rate for Payer: Cash Price |
$835.20
|
| Rate for Payer: Cigna Commercial |
$2,644.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$171.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,670.40
|
| Rate for Payer: Health EOS Commercial |
$2,533.44
|
| Rate for Payer: HFN Commercial |
$2,644.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$776.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$776.07
|
| Rate for Payer: Multiplan Commercial |
$2,227.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,644.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,224.96
|
| Rate for Payer: Quartz Commercial |
$1,586.88
|
| Rate for Payer: The Alliance Commercial |
$1,392.00
|
| Rate for Payer: United Healthcare Medicaid |
$171.11
|
| Rate for Payer: WEA Trust Commercial |
$1,531.20
|
| Rate for Payer: WPS Commercial |
$2,062.11
|
|
|
Motor&/sens 9-10 nrv cndj test 9591126
|
Professional
|
Both
|
$1,129.00
|
|
|
Service Code
|
CPT 95911 26
|
| Hospital Charge Code |
3245494
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$171.11 |
| Max. Negotiated Rate |
$1,072.55 |
| Rate for Payer: Aetna Commercial |
$1,072.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.94
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,072.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$171.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$677.40
|
| Rate for Payer: Health EOS Commercial |
$1,027.39
|
| Rate for Payer: HFN Commercial |
$1,072.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$457.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$457.77
|
| Rate for Payer: Multiplan Commercial |
$903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,072.55
|
| Rate for Payer: Quartz Beloit One Network |
$496.76
|
| Rate for Payer: Quartz Commercial |
$643.53
|
| Rate for Payer: The Alliance Commercial |
$564.50
|
| Rate for Payer: United Healthcare Medicaid |
$171.11
|
| Rate for Payer: WEA Trust Commercial |
$620.95
|
| Rate for Payer: WPS Commercial |
$836.25
|
|
|
MOUTHPIECE ACAPELLA DH BLUE
|
Facility
|
OP
|
$936.00
|
|
| Hospital Charge Code |
2973630
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$262.08 |
| Max. Negotiated Rate |
$3,744.00 |
| Rate for Payer: Aetna Commercial |
$842.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$804.96
|
| Rate for Payer: Aetna Managed Medicare |
$262.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$608.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$468.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$449.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$496.08
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Cigna Commercial |
$861.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$523.79
|
| Rate for Payer: Health EOS Commercial |
$833.04
|
| Rate for Payer: HFN Commercial |
$861.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$702.00
|
| Rate for Payer: Multiplan Commercial |
$748.80
|
| Rate for Payer: NAPHCARE Commercial |
$561.60
|
| Rate for Payer: Preferred Network Access Commercial |
$861.12
|
| Rate for Payer: Quartz Beloit One Network |
$458.64
|
| Rate for Payer: Quartz Commercial |
$608.40
|
| Rate for Payer: Quartz Medicare Advantage |
$561.60
|
| Rate for Payer: The Alliance Commercial |
$3,744.00
|
| Rate for Payer: WEA Trust Commercial |
$514.80
|
| Rate for Payer: WPS Commercial |
$693.30
|
|
|
MOUTHPIECE ACAPELLA DH BLUE
|
Facility
|
IP
|
$936.00
|
|
| Hospital Charge Code |
2973630
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$458.64 |
| Max. Negotiated Rate |
$861.12 |
| Rate for Payer: Aetna Commercial |
$842.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$804.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$496.08
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Cigna Commercial |
$861.12
|
| Rate for Payer: Health EOS Commercial |
$833.04
|
| Rate for Payer: HFN Commercial |
$861.12
|
| Rate for Payer: Multiplan Commercial |
$748.80
|
| Rate for Payer: NAPHCARE Commercial |
$561.60
|
| Rate for Payer: Preferred Network Access Commercial |
$861.12
|
| Rate for Payer: Quartz Beloit One Network |
$458.64
|
| Rate for Payer: Quartz Commercial |
$561.60
|
| Rate for Payer: WEA Trust Commercial |
$514.80
|
| Rate for Payer: WPS Commercial |
$693.30
|
|
|
MOUTHPIECE ACAPELLA DH GREEN FLUTTER
|
Facility
|
IP
|
$947.00
|
|
| Hospital Charge Code |
2973614
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$464.03 |
| Max. Negotiated Rate |
$871.24 |
| Rate for Payer: Aetna Commercial |
$852.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$814.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$501.91
|
| Rate for Payer: Cash Price |
$284.10
|
| Rate for Payer: Cigna Commercial |
$871.24
|
| Rate for Payer: Health EOS Commercial |
$842.83
|
| Rate for Payer: HFN Commercial |
$871.24
|
| Rate for Payer: Multiplan Commercial |
$757.60
|
| Rate for Payer: NAPHCARE Commercial |
$568.20
|
| Rate for Payer: Preferred Network Access Commercial |
$871.24
|
| Rate for Payer: Quartz Beloit One Network |
$464.03
|
| Rate for Payer: Quartz Commercial |
$568.20
|
| Rate for Payer: WEA Trust Commercial |
$520.85
|
| Rate for Payer: WPS Commercial |
$701.44
|
|
|
MOUTHPIECE ACAPELLA DH GREEN FLUTTER
|
Facility
|
OP
|
$947.00
|
|
| Hospital Charge Code |
2973614
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$265.16 |
| Max. Negotiated Rate |
$3,788.00 |
| Rate for Payer: Aetna Commercial |
$852.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$814.42
|
| Rate for Payer: Aetna Managed Medicare |
$265.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$615.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$473.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$454.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$501.91
|
| Rate for Payer: Cash Price |
$284.10
|
| Rate for Payer: Cigna Commercial |
$871.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$529.94
|
| Rate for Payer: Health EOS Commercial |
$842.83
|
| Rate for Payer: HFN Commercial |
$871.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$710.25
|
| Rate for Payer: Multiplan Commercial |
$757.60
|
| Rate for Payer: NAPHCARE Commercial |
$568.20
|
| Rate for Payer: Preferred Network Access Commercial |
$871.24
|
| Rate for Payer: Quartz Beloit One Network |
$464.03
|
| Rate for Payer: Quartz Commercial |
$615.55
|
| Rate for Payer: Quartz Medicare Advantage |
$568.20
|
| Rate for Payer: The Alliance Commercial |
$3,788.00
|
| Rate for Payer: WEA Trust Commercial |
$520.85
|
| Rate for Payer: WPS Commercial |
$701.44
|
|
|
MOUTHPIECE ENDOSCOPIC SNGL USE
|
Facility
|
IP
|
$125.00
|
|
| Hospital Charge Code |
2973196
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$75.00
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
MOUTHPIECE ENDOSCOPIC SNGL USE
|
Facility
|
OP
|
$125.00
|
|
| Hospital Charge Code |
2973196
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Aetna Managed Medicare |
$35.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.95
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.75
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$75.00
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$81.25
|
| Rate for Payer: Quartz Medicare Advantage |
$75.00
|
| Rate for Payer: The Alliance Commercial |
$500.00
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
MOUTHPIECE EZ GUARD ADULT 710101
|
Facility
|
IP
|
$75.00
|
|
| Hospital Charge Code |
2971976
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$67.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.75
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$69.00
|
| Rate for Payer: Health EOS Commercial |
$66.75
|
| Rate for Payer: HFN Commercial |
$69.00
|
| Rate for Payer: Multiplan Commercial |
$60.00
|
| Rate for Payer: NAPHCARE Commercial |
$45.00
|
| Rate for Payer: Preferred Network Access Commercial |
$69.00
|
| Rate for Payer: Quartz Beloit One Network |
$36.75
|
| Rate for Payer: Quartz Commercial |
$45.00
|
| Rate for Payer: WEA Trust Commercial |
$41.25
|
| Rate for Payer: WPS Commercial |
$55.55
|
|
|
MOUTHPIECE EZ GUARD ADULT 710101
|
Facility
|
OP
|
$75.00
|
|
| Hospital Charge Code |
2971976
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$67.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.50
|
| Rate for Payer: Aetna Managed Medicare |
$21.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.75
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$69.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.97
|
| Rate for Payer: Health EOS Commercial |
$66.75
|
| Rate for Payer: HFN Commercial |
$69.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.25
|
| Rate for Payer: Multiplan Commercial |
$60.00
|
| Rate for Payer: NAPHCARE Commercial |
$45.00
|
| Rate for Payer: Preferred Network Access Commercial |
$69.00
|
| Rate for Payer: Quartz Beloit One Network |
$36.75
|
| Rate for Payer: Quartz Commercial |
$48.75
|
| Rate for Payer: Quartz Medicare Advantage |
$45.00
|
| Rate for Payer: The Alliance Commercial |
$300.00
|
| Rate for Payer: WEA Trust Commercial |
$41.25
|
| Rate for Payer: WPS Commercial |
$55.55
|
|
|
MOUTHPIECE EZ PAP #26-23-0747
|
Facility
|
IP
|
$430.00
|
|
| Hospital Charge Code |
2973090
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$210.70 |
| Max. Negotiated Rate |
$395.60 |
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$258.00
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$258.00
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
MOUTHPIECE EZ PAP #26-23-0747
|
Facility
|
OP
|
$430.00
|
|
| Hospital Charge Code |
2973090
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$120.40 |
| Max. Negotiated Rate |
$1,720.00 |
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.80
|
| Rate for Payer: Aetna Managed Medicare |
$120.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$279.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$215.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$206.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.63
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$322.50
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$258.00
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$279.50
|
| Rate for Payer: Quartz Medicare Advantage |
$258.00
|
| Rate for Payer: The Alliance Commercial |
$1,720.00
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
MOUTHPIECE IQSPIRO 2-100-1205
|
Facility
|
OP
|
$72.00
|
|
| Hospital Charge Code |
2974645
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Aetna Managed Medicare |
$20.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.29
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: Quartz Medicare Advantage |
$43.20
|
| Rate for Payer: The Alliance Commercial |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
MOUTHPIECE IQSPIRO 2-100-1205
|
Facility
|
IP
|
$72.00
|
|
| Hospital Charge Code |
2974645
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$35.28 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$43.20
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
MOUTH PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$40,324.00
|
|
|
Service Code
|
MSDRG 137
|
| Min. Negotiated Rate |
$14,505.16 |
| Max. Negotiated Rate |
$40,324.00 |
| Rate for Payer: Aetna Managed Medicare |
$14,505.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31,470.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,121.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22,917.00
|
| Rate for Payer: Anthem Medicare Advantage |
$14,505.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,505.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,505.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,505.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25,439.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,505.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,341.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,505.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,505.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,505.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,505.16
|
| Rate for Payer: NAPHCARE Commercial |
$21,757.74
|
| Rate for Payer: Quartz Medicare Advantage |
$14,505.16
|
| Rate for Payer: The Alliance Commercial |
$40,324.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,505.16
|
| Rate for Payer: United Healthcare PPO |
$22,842.85
|
| Rate for Payer: Wellcare Medicare |
$14,505.16
|
|
|
MOUTH PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$23,336.00
|
|
|
Service Code
|
MSDRG 138
|
| Min. Negotiated Rate |
$8,394.20 |
| Max. Negotiated Rate |
$23,336.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,394.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,252.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,990.47
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,291.86
|
| Rate for Payer: Anthem Medicare Advantage |
$8,394.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,394.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,394.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,394.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,755.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,394.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,881.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,394.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,394.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,394.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,394.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,591.30
|
| Rate for Payer: Quartz Medicare Advantage |
$8,394.20
|
| Rate for Payer: The Alliance Commercial |
$23,336.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,394.20
|
| Rate for Payer: United Healthcare PPO |
$13,142.19
|
| Rate for Payer: Wellcare Medicare |
$8,394.20
|
|
|
M-PACI HAND-SCORING STARTER
|
Facility
|
IP
|
$3,795.00
|
|
| Hospital Charge Code |
2973439
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,859.55 |
| Max. Negotiated Rate |
$3,491.40 |
| Rate for Payer: Aetna Commercial |
$3,415.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,263.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,011.35
|
| Rate for Payer: Cash Price |
$1,138.50
|
| Rate for Payer: Cigna Commercial |
$3,491.40
|
| Rate for Payer: Health EOS Commercial |
$3,377.55
|
| Rate for Payer: HFN Commercial |
$3,491.40
|
| Rate for Payer: Multiplan Commercial |
$3,036.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,277.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,491.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,859.55
|
| Rate for Payer: Quartz Commercial |
$2,277.00
|
| Rate for Payer: WEA Trust Commercial |
$2,087.25
|
| Rate for Payer: WPS Commercial |
$2,810.96
|
|
