|
Speech Audiometry Threshold
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
CPT 92555
|
| Hospital Charge Code |
1230803
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$60.46 |
| Max. Negotiated Rate |
$241.84 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.44
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.63
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$83.20
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: The Alliance Commercial |
$241.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Speech Audiometry Threshold
|
Professional
|
Both
|
$128.00
|
|
|
Service Code
|
CPT 92555
|
| Hospital Charge Code |
1230803
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$56.32 |
| Max. Negotiated Rate |
$121.60 |
| Rate for Payer: Aetna Commercial |
$121.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$121.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$64.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.80
|
| Rate for Payer: Health EOS Commercial |
$116.48
|
| Rate for Payer: HFN Commercial |
$121.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$82.74
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: Preferred Network Access Commercial |
$121.60
|
| Rate for Payer: Quartz Beloit One Network |
$56.32
|
| Rate for Payer: Quartz Commercial |
$72.96
|
| Rate for Payer: The Alliance Commercial |
$64.00
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Speech Audiometry Threshold W/ Speech Recognition
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
CPT 92556
|
| Hospital Charge Code |
1230804
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$60.72 |
| Max. Negotiated Rate |
$131.49 |
| Rate for Payer: Aetna Commercial |
$131.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$131.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$125.58
|
| Rate for Payer: HFN Commercial |
$131.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$131.49
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$131.10
|
| Rate for Payer: Quartz Beloit One Network |
$60.72
|
| Rate for Payer: Quartz Commercial |
$78.66
|
| Rate for Payer: The Alliance Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Speech Audiometry Threshold W/ Speech Recognition
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
CPT 92556
|
| Hospital Charge Code |
1230804
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$67.62 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$82.80
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Speech Audiometry Threshold W/ Speech Recognition
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
CPT 92556
|
| Hospital Charge Code |
1230804
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$60.46 |
| Max. Negotiated Rate |
$241.84 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$89.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.24
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$89.70
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: The Alliance Commercial |
$241.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$103.50
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Speech Language Therapy
|
Facility
|
IP
|
$574.00
|
|
|
Service Code
|
CPT 92507 GN
|
| Hospital Charge Code |
5313692
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$281.26 |
| Max. Negotiated Rate |
$528.08 |
| Rate for Payer: Aetna Commercial |
$516.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$493.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.22
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cigna Commercial |
$528.08
|
| Rate for Payer: Health EOS Commercial |
$510.86
|
| Rate for Payer: HFN Commercial |
$528.08
|
| Rate for Payer: Multiplan Commercial |
$459.20
|
| Rate for Payer: NAPHCARE Commercial |
$344.40
|
| Rate for Payer: Preferred Network Access Commercial |
$528.08
|
| Rate for Payer: Quartz Beloit One Network |
$281.26
|
| Rate for Payer: Quartz Commercial |
$344.40
|
| Rate for Payer: WEA Trust Commercial |
$315.70
|
| Rate for Payer: WPS Commercial |
$425.16
|
|
|
Speech Language Therapy
|
Facility
|
OP
|
$574.00
|
|
|
Service Code
|
CPT 92507 GN
|
| Hospital Charge Code |
5313692
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$160.72 |
| Max. Negotiated Rate |
$2,296.00 |
| Rate for Payer: Aetna Commercial |
$516.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$493.64
|
| Rate for Payer: Aetna Managed Medicare |
$160.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.22
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cigna Commercial |
$528.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$321.21
|
| Rate for Payer: Health EOS Commercial |
$510.86
|
| Rate for Payer: HFN Commercial |
$528.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$459.20
|
| Rate for Payer: NAPHCARE Commercial |
$344.40
|
| Rate for Payer: Preferred Network Access Commercial |
$528.08
|
| Rate for Payer: Quartz Beloit One Network |
$281.26
|
| Rate for Payer: Quartz Commercial |
$373.10
|
| Rate for Payer: Quartz Medicare Advantage |
$344.40
|
| Rate for Payer: The Alliance Commercial |
$2,296.00
|
| Rate for Payer: United Healthcare PPO |
$430.50
|
| Rate for Payer: WEA Trust Commercial |
$315.70
|
| Rate for Payer: WPS Commercial |
$425.16
|
|
|
SPEEDBRIDGE ACHILLES IMPLANT SYSTEM PEEK WITH JUMPSTART AR-8928PJ-CP
|
Facility
|
OP
|
$15,159.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,244.52 |
| Max. Negotiated Rate |
$60,636.00 |
| Rate for Payer: Aetna Commercial |
$13,643.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,036.74
|
| Rate for Payer: Aetna Managed Medicare |
$4,244.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,853.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,579.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,276.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,034.27
|
| Rate for Payer: Cash Price |
$4,547.70
|
| Rate for Payer: Cigna Commercial |
$13,946.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,482.98
|
| Rate for Payer: Health EOS Commercial |
$13,491.51
|
| Rate for Payer: HFN Commercial |
$13,946.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,369.25
|
| Rate for Payer: Multiplan Commercial |
$12,127.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,095.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,946.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,427.91
|
| Rate for Payer: Quartz Commercial |
$9,853.35
|
| Rate for Payer: Quartz Medicare Advantage |
$9,095.40
|
| Rate for Payer: The Alliance Commercial |
$60,636.00
|
| Rate for Payer: WEA Trust Commercial |
$8,337.45
|
| Rate for Payer: WPS Commercial |
$11,228.27
|
|
|
SPEEDBRIDGE ACHILLES IMPLANT SYSTEM PEEK WITH JUMPSTART AR-8928PJ-CP
|
Facility
|
IP
|
$15,159.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,427.91 |
| Max. Negotiated Rate |
$13,946.28 |
| Rate for Payer: Aetna Commercial |
$13,643.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,036.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,034.27
|
| Rate for Payer: Cash Price |
$4,547.70
|
| Rate for Payer: Cigna Commercial |
$13,946.28
|
| Rate for Payer: Health EOS Commercial |
$13,491.51
|
| Rate for Payer: HFN Commercial |
$13,946.28
|
| Rate for Payer: Multiplan Commercial |
$12,127.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,095.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,946.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,427.91
|
| Rate for Payer: Quartz Commercial |
$9,095.40
|
| Rate for Payer: WEA Trust Commercial |
$8,337.45
|
| Rate for Payer: WPS Commercial |
$11,228.27
|
|
|
SPEEDBRIDGE ACHILLES IMPLANT SYSTEM WITH JUMPSTART AR-8928BCJ-CP
|
Facility
|
IP
|
$15,159.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415175
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,427.91 |
| Max. Negotiated Rate |
$13,946.28 |
| Rate for Payer: Aetna Commercial |
$13,643.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,036.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,034.27
|
| Rate for Payer: Cash Price |
$4,547.70
|
| Rate for Payer: Cigna Commercial |
$13,946.28
|
| Rate for Payer: Health EOS Commercial |
$13,491.51
|
| Rate for Payer: HFN Commercial |
$13,946.28
|
| Rate for Payer: Multiplan Commercial |
$12,127.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,095.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,946.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,427.91
|
| Rate for Payer: Quartz Commercial |
$9,095.40
|
| Rate for Payer: WEA Trust Commercial |
$8,337.45
|
| Rate for Payer: WPS Commercial |
$11,228.27
|
|
|
SPEEDBRIDGE ACHILLES IMPLANT SYSTEM WITH JUMPSTART AR-8928BCJ-CP
|
Facility
|
OP
|
$15,159.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415175
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,244.52 |
| Max. Negotiated Rate |
$60,636.00 |
| Rate for Payer: Aetna Commercial |
$13,643.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,036.74
|
| Rate for Payer: Aetna Managed Medicare |
$4,244.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,853.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,579.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,276.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,034.27
|
| Rate for Payer: Cash Price |
$4,547.70
|
| Rate for Payer: Cigna Commercial |
$13,946.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,482.98
|
| Rate for Payer: Health EOS Commercial |
$13,491.51
|
| Rate for Payer: HFN Commercial |
$13,946.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,369.25
|
| Rate for Payer: Multiplan Commercial |
$12,127.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,095.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,946.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,427.91
|
| Rate for Payer: Quartz Commercial |
$9,853.35
|
| Rate for Payer: Quartz Medicare Advantage |
$9,095.40
|
| Rate for Payer: The Alliance Commercial |
$60,636.00
|
| Rate for Payer: WEA Trust Commercial |
$8,337.45
|
| Rate for Payer: WPS Commercial |
$11,228.27
|
|
|
SPEEDBRIDGE BIO-COMP ACHILLES IMPLANT SYS AR-8928BC-CP
|
Facility
|
IP
|
$13,223.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4167706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,479.27 |
| Max. Negotiated Rate |
$12,165.16 |
| Rate for Payer: Aetna Commercial |
$11,900.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,371.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,008.19
|
| Rate for Payer: Cash Price |
$3,966.90
|
| Rate for Payer: Cigna Commercial |
$12,165.16
|
| Rate for Payer: Health EOS Commercial |
$11,768.47
|
| Rate for Payer: HFN Commercial |
$12,165.16
|
| Rate for Payer: Multiplan Commercial |
$10,578.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,933.80
|
| Rate for Payer: Preferred Network Access Commercial |
$12,165.16
|
| Rate for Payer: Quartz Beloit One Network |
$6,479.27
|
| Rate for Payer: Quartz Commercial |
$7,933.80
|
| Rate for Payer: WEA Trust Commercial |
$7,272.65
|
| Rate for Payer: WPS Commercial |
$9,794.28
|
|
|
SPEEDBRIDGE BIO-COMP ACHILLES IMPLANT SYS AR-8928BC-CP
|
Facility
|
OP
|
$13,223.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4167706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,702.44 |
| Max. Negotiated Rate |
$52,892.00 |
| Rate for Payer: Aetna Commercial |
$11,900.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,371.78
|
| Rate for Payer: Aetna Managed Medicare |
$3,702.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,594.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,611.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,347.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,008.19
|
| Rate for Payer: Cash Price |
$3,966.90
|
| Rate for Payer: Cigna Commercial |
$12,165.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,399.59
|
| Rate for Payer: Health EOS Commercial |
$11,768.47
|
| Rate for Payer: HFN Commercial |
$12,165.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,917.25
|
| Rate for Payer: Multiplan Commercial |
$10,578.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,933.80
|
| Rate for Payer: Preferred Network Access Commercial |
$12,165.16
|
| Rate for Payer: Quartz Beloit One Network |
$6,479.27
|
| Rate for Payer: Quartz Commercial |
$8,594.95
|
| Rate for Payer: Quartz Medicare Advantage |
$7,933.80
|
| Rate for Payer: The Alliance Commercial |
$52,892.00
|
| Rate for Payer: WEA Trust Commercial |
$7,272.65
|
| Rate for Payer: WPS Commercial |
$9,794.28
|
|
|
SPEEDBRIDGE BIO-COMP ACHILLES MID-SUBSTANCE IMPLANT AR-8929BC-CP
|
Facility
|
OP
|
$7,409.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,074.52 |
| Max. Negotiated Rate |
$29,636.00 |
| Rate for Payer: Aetna Commercial |
$6,668.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,371.74
|
| Rate for Payer: Aetna Managed Medicare |
$2,074.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,815.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,704.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,556.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,926.77
|
| Rate for Payer: Cash Price |
$2,222.70
|
| Rate for Payer: Cigna Commercial |
$6,816.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,146.08
|
| Rate for Payer: Health EOS Commercial |
$6,594.01
|
| Rate for Payer: HFN Commercial |
$6,816.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,556.75
|
| Rate for Payer: Multiplan Commercial |
$5,927.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,445.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,816.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,630.41
|
| Rate for Payer: Quartz Commercial |
$4,815.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,445.40
|
| Rate for Payer: The Alliance Commercial |
$29,636.00
|
| Rate for Payer: WEA Trust Commercial |
$4,074.95
|
| Rate for Payer: WPS Commercial |
$5,487.85
|
|
|
SPEEDBRIDGE BIO-COMP ACHILLES MID-SUBSTANCE IMPLANT AR-8929BC-CP
|
Facility
|
IP
|
$7,409.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,630.41 |
| Max. Negotiated Rate |
$6,816.28 |
| Rate for Payer: Aetna Commercial |
$6,668.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,371.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,926.77
|
| Rate for Payer: Cash Price |
$2,222.70
|
| Rate for Payer: Cigna Commercial |
$6,816.28
|
| Rate for Payer: Health EOS Commercial |
$6,594.01
|
| Rate for Payer: HFN Commercial |
$6,816.28
|
| Rate for Payer: Multiplan Commercial |
$5,927.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,445.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,816.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,630.41
|
| Rate for Payer: Quartz Commercial |
$4,445.40
|
| Rate for Payer: WEA Trust Commercial |
$4,074.95
|
| Rate for Payer: WPS Commercial |
$5,487.85
|
|
|
SPEP Interpretation
|
Facility
|
OP
|
$213.00
|
|
|
Service Code
|
CPT 84165
|
| Hospital Charge Code |
2942977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.74 |
| Max. Negotiated Rate |
$195.96 |
| Rate for Payer: Aetna Commercial |
$191.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.18
|
| Rate for Payer: Aetna Managed Medicare |
$10.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.83
|
| Rate for Payer: Anthem Medicaid |
$11.10
|
| Rate for Payer: Anthem Medicare Advantage |
$10.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.74
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$195.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.19
|
| Rate for Payer: Dean Health Medicaid |
$11.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10.74
|
| Rate for Payer: Health EOS Commercial |
$189.57
|
| Rate for Payer: HFN Commercial |
$195.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.74
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.74
|
| Rate for Payer: Managed Health Services Medicaid |
$11.54
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10.74
|
| Rate for Payer: Multiplan Commercial |
$170.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.11
|
| Rate for Payer: Preferred Network Access Commercial |
$195.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.10
|
| Rate for Payer: Quartz Beloit One Network |
$104.37
|
| Rate for Payer: Quartz Commercial |
$138.45
|
| Rate for Payer: Quartz Medicare Advantage |
$10.74
|
| Rate for Payer: The Alliance Commercial |
$42.96
|
| Rate for Payer: United Healthcare Medicaid |
$11.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.74
|
| Rate for Payer: United Healthcare PPO |
$159.75
|
| Rate for Payer: WEA Trust Commercial |
$117.15
|
| Rate for Payer: Wellcare Medicare |
$10.74
|
| Rate for Payer: WMAP Medicaid |
$11.10
|
| Rate for Payer: WPS Commercial |
$157.77
|
|
|
SPEP Interpretation
|
Professional
|
Both
|
$213.00
|
|
|
Service Code
|
CPT 84165
|
| Hospital Charge Code |
2942977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$202.35 |
| Rate for Payer: Aetna Commercial |
$202.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.18
|
| Rate for Payer: Anthem Commercial |
$16.61
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$202.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$106.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.80
|
| Rate for Payer: Health EOS Commercial |
$193.83
|
| Rate for Payer: HFN Commercial |
$202.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$37.91
|
| Rate for Payer: Multiplan Commercial |
$170.40
|
| Rate for Payer: Preferred Network Access Commercial |
$202.35
|
| Rate for Payer: Quartz Beloit One Network |
$93.72
|
| Rate for Payer: Quartz Commercial |
$121.41
|
| Rate for Payer: The Alliance Commercial |
$106.50
|
| Rate for Payer: WEA Trust Commercial |
$117.15
|
| Rate for Payer: WPS Commercial |
$157.77
|
|
|
SPEP Interpretation
|
Facility
|
IP
|
$213.00
|
|
|
Service Code
|
CPT 84165
|
| Hospital Charge Code |
2942977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.37 |
| Max. Negotiated Rate |
$195.96 |
| Rate for Payer: Aetna Commercial |
$191.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.89
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$195.96
|
| Rate for Payer: Health EOS Commercial |
$189.57
|
| Rate for Payer: HFN Commercial |
$195.96
|
| Rate for Payer: Multiplan Commercial |
$170.40
|
| Rate for Payer: NAPHCARE Commercial |
$127.80
|
| Rate for Payer: Preferred Network Access Commercial |
$195.96
|
| Rate for Payer: Quartz Beloit One Network |
$104.37
|
| Rate for Payer: Quartz Commercial |
$127.80
|
| Rate for Payer: WEA Trust Commercial |
$117.15
|
| Rate for Payer: WPS Commercial |
$157.77
|
|
|
SPERMATOCELE/EPIDIDYMECTOMY
|
Facility
|
IP
|
$1,129.00
|
|
| Hospital Charge Code |
2960013
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$553.21 |
| Max. Negotiated Rate |
$1,038.68 |
| Rate for Payer: Aetna Commercial |
$1,016.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.37
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,038.68
|
| Rate for Payer: Health EOS Commercial |
$1,004.81
|
| Rate for Payer: HFN Commercial |
$1,038.68
|
| Rate for Payer: Multiplan Commercial |
$903.20
|
| Rate for Payer: NAPHCARE Commercial |
$677.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,038.68
|
| Rate for Payer: Quartz Beloit One Network |
$553.21
|
| Rate for Payer: Quartz Commercial |
$677.40
|
| Rate for Payer: WEA Trust Commercial |
$620.95
|
| Rate for Payer: WPS Commercial |
$836.25
|
|
|
SPERMATOCELE/EPIDIDYMECTOMY
|
Facility
|
OP
|
$1,129.00
|
|
| Hospital Charge Code |
2960013
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$316.12 |
| Max. Negotiated Rate |
$4,516.00 |
| Rate for Payer: Aetna Commercial |
$1,016.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.94
|
| Rate for Payer: Aetna Managed Medicare |
$316.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$733.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$564.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.37
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,038.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$631.79
|
| Rate for Payer: Health EOS Commercial |
$1,004.81
|
| Rate for Payer: HFN Commercial |
$1,038.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$846.75
|
| Rate for Payer: Multiplan Commercial |
$903.20
|
| Rate for Payer: NAPHCARE Commercial |
$677.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,038.68
|
| Rate for Payer: Quartz Beloit One Network |
$553.21
|
| Rate for Payer: Quartz Commercial |
$733.85
|
| Rate for Payer: Quartz Medicare Advantage |
$677.40
|
| Rate for Payer: The Alliance Commercial |
$4,516.00
|
| Rate for Payer: WEA Trust Commercial |
$620.95
|
| Rate for Payer: WPS Commercial |
$836.25
|
|
|
SPHENOPALATIME ARTERY LIGATION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960381
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
SPHENOPALATIME ARTERY LIGATION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960381
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
SPHERE MARKER OPTICAL PM8005
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2965209
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$593.88 |
| Max. Negotiated Rate |
$1,115.04 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$727.20
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
SPHERE MARKER OPTICAL PM8005
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2965209
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$339.36 |
| Max. Negotiated Rate |
$4,848.00 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Aetna Managed Medicare |
$339.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$787.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$606.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$581.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$678.24
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$909.00
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$787.80
|
| Rate for Payer: Quartz Medicare Advantage |
$727.20
|
| Rate for Payer: The Alliance Commercial |
$4,848.00
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
SPHINCTEROTOME JAGTOME RX39 M00573080
|
Facility
|
IP
|
$3,649.00
|
|
| Hospital Charge Code |
2973416
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,788.01 |
| Max. Negotiated Rate |
$3,357.08 |
| Rate for Payer: Aetna Commercial |
$3,284.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,138.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,933.97
|
| Rate for Payer: Cash Price |
$1,094.70
|
| Rate for Payer: Cigna Commercial |
$3,357.08
|
| Rate for Payer: Health EOS Commercial |
$3,247.61
|
| Rate for Payer: HFN Commercial |
$3,357.08
|
| Rate for Payer: Multiplan Commercial |
$2,919.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,189.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,357.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,788.01
|
| Rate for Payer: Quartz Commercial |
$2,189.40
|
| Rate for Payer: WEA Trust Commercial |
$2,006.95
|
| Rate for Payer: WPS Commercial |
$2,702.81
|
|
