|
Speech Audiometry Threshold
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
CPT 92555
|
| Hospital Charge Code |
1152818
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.09 |
| Max. Negotiated Rate |
$248.35 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Aetna Managed Medicare |
$62.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$86.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$66.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$63.90
|
| Rate for Payer: Anthem Medicare Advantage |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.09
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$62.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$62.09
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$62.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$62.09
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: NAPHCARE Commercial |
$93.13
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$86.53
|
| Rate for Payer: Quartz Medicare Advantage |
$62.09
|
| Rate for Payer: The Alliance Commercial |
$248.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.09
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: Wellcare Medicare |
$62.09
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
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 |
$46.03 |
| Max. Negotiated Rate |
$184.12 |
| Rate for Payer: Aetna Commercial |
$136.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$46.03
|
| Rate for Payer: Anthem Medicare Advantage |
$46.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.03
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$136.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$71.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.03
|
| Rate for Payer: Health EOS Commercial |
$130.60
|
| Rate for Payer: HFN Commercial |
$136.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$136.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.03
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$69.05
|
| Rate for Payer: Preferred Network Access Commercial |
$136.34
|
| Rate for Payer: Quartz Beloit One Network |
$63.15
|
| Rate for Payer: Quartz Commercial |
$81.81
|
| Rate for Payer: Quartz Medicare Advantage |
$46.03
|
| Rate for Payer: The Alliance Commercial |
$115.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.03
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$184.12
|
|
|
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 |
$62.09 |
| Max. Negotiated Rate |
$248.35 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$62.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.89
|
| Rate for Payer: Anthem Medicare Advantage |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.09
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$62.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$62.09
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$62.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$62.09
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$93.13
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$93.29
|
| Rate for Payer: Quartz Medicare Advantage |
$62.09
|
| Rate for Payer: The Alliance Commercial |
$248.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.09
|
| Rate for Payer: United Healthcare PPO |
$107.64
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: Wellcare Medicare |
$62.09
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
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 |
$70.32 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$86.11
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
Speech Language Therapy
|
Facility
|
OP
|
$574.00
|
|
|
Service Code
|
CPT 92507 GN
|
| Hospital Charge Code |
5313692
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$167.15 |
| Max. Negotiated Rate |
$549.20 |
| Rate for Payer: Aetna Commercial |
$537.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$513.39
|
| Rate for Payer: Aetna Managed Medicare |
$167.15
|
| 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 |
$316.39
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cigna Commercial |
$549.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$334.07
|
| Rate for Payer: Health EOS Commercial |
$531.29
|
| Rate for Payer: HFN Commercial |
$549.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$477.57
|
| Rate for Payer: NAPHCARE Commercial |
$358.18
|
| Rate for Payer: Preferred Network Access Commercial |
$549.20
|
| Rate for Payer: Quartz Beloit One Network |
$292.51
|
| Rate for Payer: Quartz Commercial |
$388.02
|
| Rate for Payer: Quartz Medicare Advantage |
$358.18
|
| Rate for Payer: The Alliance Commercial |
$298.48
|
| Rate for Payer: United Healthcare PPO |
$447.72
|
| Rate for Payer: WEA Trust Commercial |
$328.33
|
| Rate for Payer: WPS Commercial |
$442.15
|
|
|
Speech Language Therapy
|
Facility
|
IP
|
$574.00
|
|
|
Service Code
|
CPT 92507 GN
|
| Hospital Charge Code |
5313692
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$292.51 |
| Max. Negotiated Rate |
$549.20 |
| Rate for Payer: Aetna Commercial |
$537.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$513.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$316.39
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cigna Commercial |
$549.20
|
| Rate for Payer: Health EOS Commercial |
$531.29
|
| Rate for Payer: HFN Commercial |
$549.20
|
| Rate for Payer: Multiplan Commercial |
$477.57
|
| Rate for Payer: Preferred Network Access Commercial |
$549.20
|
| Rate for Payer: Quartz Beloit One Network |
$292.51
|
| Rate for Payer: Quartz Commercial |
$358.18
|
| Rate for Payer: WEA Trust Commercial |
$328.33
|
| Rate for Payer: WPS Commercial |
$442.15
|
|
|
SPEECH THERAPY AND EVALUATION
|
Facility
|
OP
|
$60.42
|
|
|
Service Code
|
EAPG 00272
|
| Min. Negotiated Rate |
$58.09 |
| Max. Negotiated Rate |
$60.42 |
| Rate for Payer: Anthem Medicaid |
$58.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$58.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$58.09
|
| Rate for Payer: Dean Health Medicaid |
$58.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$58.09
|
| Rate for Payer: Managed Health Services Medicaid |
$60.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$58.09
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$58.09
|
| Rate for Payer: United Healthcare Medicaid |
$58.09
|
|
|
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 |
$4,414.30 |
| Max. Negotiated Rate |
$14,504.13 |
| Rate for Payer: Aetna Commercial |
$14,188.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,558.21
|
| Rate for Payer: Aetna Managed Medicare |
$4,414.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,247.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,882.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,567.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,355.64
|
| Rate for Payer: Cash Price |
$4,547.70
|
| Rate for Payer: Cigna Commercial |
$14,504.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,822.54
|
| Rate for Payer: Health EOS Commercial |
$14,031.17
|
| Rate for Payer: HFN Commercial |
$14,504.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,824.02
|
| Rate for Payer: Multiplan Commercial |
$12,612.29
|
| Rate for Payer: NAPHCARE Commercial |
$9,459.22
|
| Rate for Payer: Preferred Network Access Commercial |
$14,504.13
|
| Rate for Payer: Quartz Beloit One Network |
$7,725.03
|
| Rate for Payer: Quartz Commercial |
$10,247.48
|
| Rate for Payer: Quartz Medicare Advantage |
$9,459.22
|
| Rate for Payer: The Alliance Commercial |
$7,882.68
|
| Rate for Payer: WEA Trust Commercial |
$8,670.95
|
| Rate for Payer: WPS Commercial |
$11,676.98
|
|
|
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 |
$7,725.03 |
| Max. Negotiated Rate |
$14,504.13 |
| Rate for Payer: Aetna Commercial |
$14,188.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,558.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,355.64
|
| Rate for Payer: Cash Price |
$4,547.70
|
| Rate for Payer: Cigna Commercial |
$14,504.13
|
| Rate for Payer: Health EOS Commercial |
$14,031.17
|
| Rate for Payer: HFN Commercial |
$14,504.13
|
| Rate for Payer: Multiplan Commercial |
$12,612.29
|
| Rate for Payer: Preferred Network Access Commercial |
$14,504.13
|
| Rate for Payer: Quartz Beloit One Network |
$7,725.03
|
| Rate for Payer: Quartz Commercial |
$9,459.22
|
| Rate for Payer: WEA Trust Commercial |
$8,670.95
|
| Rate for Payer: WPS Commercial |
$11,676.98
|
|
|
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 |
$7,725.03 |
| Max. Negotiated Rate |
$14,504.13 |
| Rate for Payer: Aetna Commercial |
$14,188.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,558.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,355.64
|
| Rate for Payer: Cash Price |
$4,547.70
|
| Rate for Payer: Cigna Commercial |
$14,504.13
|
| Rate for Payer: Health EOS Commercial |
$14,031.17
|
| Rate for Payer: HFN Commercial |
$14,504.13
|
| Rate for Payer: Multiplan Commercial |
$12,612.29
|
| Rate for Payer: Preferred Network Access Commercial |
$14,504.13
|
| Rate for Payer: Quartz Beloit One Network |
$7,725.03
|
| Rate for Payer: Quartz Commercial |
$9,459.22
|
| Rate for Payer: WEA Trust Commercial |
$8,670.95
|
| Rate for Payer: WPS Commercial |
$11,676.98
|
|
|
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 |
$4,414.30 |
| Max. Negotiated Rate |
$14,504.13 |
| Rate for Payer: Aetna Commercial |
$14,188.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,558.21
|
| Rate for Payer: Aetna Managed Medicare |
$4,414.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,247.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,882.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,567.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,355.64
|
| Rate for Payer: Cash Price |
$4,547.70
|
| Rate for Payer: Cigna Commercial |
$14,504.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,822.54
|
| Rate for Payer: Health EOS Commercial |
$14,031.17
|
| Rate for Payer: HFN Commercial |
$14,504.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,824.02
|
| Rate for Payer: Multiplan Commercial |
$12,612.29
|
| Rate for Payer: NAPHCARE Commercial |
$9,459.22
|
| Rate for Payer: Preferred Network Access Commercial |
$14,504.13
|
| Rate for Payer: Quartz Beloit One Network |
$7,725.03
|
| Rate for Payer: Quartz Commercial |
$10,247.48
|
| Rate for Payer: Quartz Medicare Advantage |
$9,459.22
|
| Rate for Payer: The Alliance Commercial |
$7,882.68
|
| Rate for Payer: WEA Trust Commercial |
$8,670.95
|
| Rate for Payer: WPS Commercial |
$11,676.98
|
|
|
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 |
$6,738.44 |
| Max. Negotiated Rate |
$12,651.77 |
| Rate for Payer: Aetna Commercial |
$12,376.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,826.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,288.52
|
| Rate for Payer: Cash Price |
$3,966.90
|
| Rate for Payer: Cigna Commercial |
$12,651.77
|
| Rate for Payer: Health EOS Commercial |
$12,239.21
|
| Rate for Payer: HFN Commercial |
$12,651.77
|
| Rate for Payer: Multiplan Commercial |
$11,001.54
|
| Rate for Payer: Preferred Network Access Commercial |
$12,651.77
|
| Rate for Payer: Quartz Beloit One Network |
$6,738.44
|
| Rate for Payer: Quartz Commercial |
$8,251.15
|
| Rate for Payer: WEA Trust Commercial |
$7,563.56
|
| Rate for Payer: WPS Commercial |
$10,185.68
|
|
|
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 |
$3,850.54 |
| Max. Negotiated Rate |
$12,651.77 |
| Rate for Payer: Aetna Commercial |
$12,376.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,826.65
|
| Rate for Payer: Aetna Managed Medicare |
$3,850.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,938.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,875.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,600.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,288.52
|
| Rate for Payer: Cash Price |
$3,966.90
|
| Rate for Payer: Cigna Commercial |
$12,651.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,695.79
|
| Rate for Payer: Health EOS Commercial |
$12,239.21
|
| Rate for Payer: HFN Commercial |
$12,651.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,313.94
|
| Rate for Payer: Multiplan Commercial |
$11,001.54
|
| Rate for Payer: NAPHCARE Commercial |
$8,251.15
|
| Rate for Payer: Preferred Network Access Commercial |
$12,651.77
|
| Rate for Payer: Quartz Beloit One Network |
$6,738.44
|
| Rate for Payer: Quartz Commercial |
$8,938.75
|
| Rate for Payer: Quartz Medicare Advantage |
$8,251.15
|
| Rate for Payer: The Alliance Commercial |
$6,875.96
|
| Rate for Payer: WEA Trust Commercial |
$7,563.56
|
| Rate for Payer: WPS Commercial |
$10,185.68
|
|
|
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 |
$2,157.50 |
| Max. Negotiated Rate |
$7,088.93 |
| Rate for Payer: Aetna Commercial |
$6,934.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,626.61
|
| Rate for Payer: Aetna Managed Medicare |
$2,157.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,008.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,852.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,698.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,083.84
|
| Rate for Payer: Cash Price |
$2,222.70
|
| Rate for Payer: Cigna Commercial |
$7,088.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,312.04
|
| Rate for Payer: Health EOS Commercial |
$6,857.77
|
| Rate for Payer: HFN Commercial |
$7,088.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,779.02
|
| Rate for Payer: Multiplan Commercial |
$6,164.29
|
| Rate for Payer: NAPHCARE Commercial |
$4,623.22
|
| Rate for Payer: Preferred Network Access Commercial |
$7,088.93
|
| Rate for Payer: Quartz Beloit One Network |
$3,775.63
|
| Rate for Payer: Quartz Commercial |
$5,008.48
|
| Rate for Payer: Quartz Medicare Advantage |
$4,623.22
|
| Rate for Payer: The Alliance Commercial |
$3,852.68
|
| Rate for Payer: WEA Trust Commercial |
$4,237.95
|
| Rate for Payer: WPS Commercial |
$5,707.15
|
|
|
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 |
$3,775.63 |
| Max. Negotiated Rate |
$7,088.93 |
| Rate for Payer: Aetna Commercial |
$6,934.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,626.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,083.84
|
| Rate for Payer: Cash Price |
$2,222.70
|
| Rate for Payer: Cigna Commercial |
$7,088.93
|
| Rate for Payer: Health EOS Commercial |
$6,857.77
|
| Rate for Payer: HFN Commercial |
$7,088.93
|
| Rate for Payer: Multiplan Commercial |
$6,164.29
|
| Rate for Payer: Preferred Network Access Commercial |
$7,088.93
|
| Rate for Payer: Quartz Beloit One Network |
$3,775.63
|
| Rate for Payer: Quartz Commercial |
$4,623.22
|
| Rate for Payer: WEA Trust Commercial |
$4,237.95
|
| Rate for Payer: WPS Commercial |
$5,707.15
|
|
|
SPEP Interpretation
|
Facility
|
OP
|
$213.00
|
|
|
Service Code
|
CPT 84165
|
| Hospital Charge Code |
2942977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.17 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Aetna Managed Medicare |
$11.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.55
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.54
|
| Rate for Payer: Anthem Medicare Advantage |
$11.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.17
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.17
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.17
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: NAPHCARE Commercial |
$16.75
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$143.99
|
| Rate for Payer: Quartz Medicare Advantage |
$11.17
|
| Rate for Payer: The Alliance Commercial |
$44.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.17
|
| Rate for Payer: United Healthcare PPO |
$166.14
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: Wellcare Medicare |
$11.17
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
SPEP Interpretation
|
Facility
|
IP
|
$213.00
|
|
|
Service Code
|
CPT 84165
|
| Hospital Charge Code |
2942977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$108.54 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$132.91
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
SPEP Interpretation
|
Professional
|
Both
|
$213.00
|
|
|
Service Code
|
CPT 84165
|
| Hospital Charge Code |
2942977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.17 |
| Max. Negotiated Rate |
$210.44 |
| Rate for Payer: Aetna Commercial |
$210.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Aetna Managed Medicare |
$11.17
|
| Rate for Payer: Anthem Commercial |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$11.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.17
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$210.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$110.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.17
|
| Rate for Payer: Health EOS Commercial |
$201.58
|
| Rate for Payer: HFN Commercial |
$210.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.17
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: NAPHCARE Commercial |
$16.75
|
| Rate for Payer: Preferred Network Access Commercial |
$210.44
|
| Rate for Payer: Quartz Beloit One Network |
$97.47
|
| Rate for Payer: Quartz Commercial |
$126.27
|
| Rate for Payer: Quartz Medicare Advantage |
$11.17
|
| Rate for Payer: The Alliance Commercial |
$44.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.17
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$49.15
|
|
|
SPERMATOCELE/EPIDIDYMECTOMY
|
Facility
|
OP
|
$1,129.00
|
|
| Hospital Charge Code |
2960013
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$328.76 |
| Max. Negotiated Rate |
$1,080.23 |
| Rate for Payer: Aetna Commercial |
$1,056.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,009.78
|
| Rate for Payer: Aetna Managed Medicare |
$328.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$763.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$587.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$563.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$622.30
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,080.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$657.08
|
| Rate for Payer: Health EOS Commercial |
$1,045.00
|
| Rate for Payer: HFN Commercial |
$1,080.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$880.62
|
| Rate for Payer: Multiplan Commercial |
$939.33
|
| Rate for Payer: NAPHCARE Commercial |
$704.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,080.23
|
| Rate for Payer: Quartz Beloit One Network |
$575.34
|
| Rate for Payer: Quartz Commercial |
$763.20
|
| Rate for Payer: Quartz Medicare Advantage |
$704.50
|
| Rate for Payer: The Alliance Commercial |
$587.08
|
| Rate for Payer: WEA Trust Commercial |
$645.79
|
| Rate for Payer: WPS Commercial |
$869.67
|
|
|
SPERMATOCELE/EPIDIDYMECTOMY
|
Facility
|
IP
|
$1,129.00
|
|
| Hospital Charge Code |
2960013
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$575.34 |
| Max. Negotiated Rate |
$1,080.23 |
| Rate for Payer: Aetna Commercial |
$1,056.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,009.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$622.30
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,080.23
|
| Rate for Payer: Health EOS Commercial |
$1,045.00
|
| Rate for Payer: HFN Commercial |
$1,080.23
|
| Rate for Payer: Multiplan Commercial |
$939.33
|
| Rate for Payer: Preferred Network Access Commercial |
$1,080.23
|
| Rate for Payer: Quartz Beloit One Network |
$575.34
|
| Rate for Payer: Quartz Commercial |
$704.50
|
| Rate for Payer: WEA Trust Commercial |
$645.79
|
| Rate for Payer: WPS Commercial |
$869.67
|
|
|
SPHENOPALATIME ARTERY LIGATION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960381
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
SPHENOPALATIME ARTERY LIGATION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960381
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
SPHERE MARKER OPTICAL PM8005
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2965209
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
SPHERE MARKER OPTICAL PM8005
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2965209
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
SPHINCTEROTOME JAGTOME RX39 M00573080
|
Facility
|
IP
|
$3,649.00
|
|
| Hospital Charge Code |
2973416
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,859.53 |
| Max. Negotiated Rate |
$3,491.36 |
| Rate for Payer: Aetna Commercial |
$3,415.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,263.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,011.33
|
| Rate for Payer: Cash Price |
$1,094.70
|
| Rate for Payer: Cigna Commercial |
$3,491.36
|
| Rate for Payer: Health EOS Commercial |
$3,377.51
|
| Rate for Payer: HFN Commercial |
$3,491.36
|
| Rate for Payer: Multiplan Commercial |
$3,035.97
|
| Rate for Payer: Preferred Network Access Commercial |
$3,491.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,859.53
|
| Rate for Payer: Quartz Commercial |
$2,276.98
|
| Rate for Payer: WEA Trust Commercial |
$2,087.23
|
| Rate for Payer: WPS Commercial |
$2,810.82
|
|
