|
BASEPLATE UNIVERSAL GLENOID SMALL AR-9120-01
|
Facility
|
OP
|
$9,121.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4240352
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,553.88 |
| Max. Negotiated Rate |
$36,484.00 |
| Rate for Payer: Aetna Commercial |
$8,208.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,553.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,928.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,560.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,378.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.13
|
| Rate for Payer: Cash Price |
$2,736.30
|
| Rate for Payer: Cigna Commercial |
$8,391.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,104.11
|
| Rate for Payer: Health EOS Commercial |
$8,117.69
|
| Rate for Payer: HFN Commercial |
$8,391.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,840.75
|
| Rate for Payer: Multiplan Commercial |
$7,296.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,472.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,391.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.29
|
| Rate for Payer: Quartz Commercial |
$5,928.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5,472.60
|
| Rate for Payer: The Alliance Commercial |
$36,484.00
|
| Rate for Payer: WEA Trust Commercial |
$5,016.55
|
| Rate for Payer: WPS Commercial |
$6,755.92
|
|
|
Basic Dosimetry Calculation
|
Facility
|
OP
|
$1,130.00
|
|
|
Service Code
|
CPT 77300
|
| Hospital Charge Code |
3040379
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$134.11 |
| Max. Negotiated Rate |
$1,039.60 |
| Rate for Payer: Aetna Commercial |
$1,017.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$971.80
|
| Rate for Payer: Aetna Managed Medicare |
$134.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$502.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$402.33
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$382.21
|
| Rate for Payer: Anthem Medicare Advantage |
$134.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$134.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$134.11
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Cigna Commercial |
$1,039.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$134.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$632.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$134.11
|
| Rate for Payer: Health EOS Commercial |
$1,005.70
|
| Rate for Payer: HFN Commercial |
$1,039.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$498.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$134.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$134.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$134.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$134.11
|
| Rate for Payer: Multiplan Commercial |
$904.00
|
| Rate for Payer: NAPHCARE Commercial |
$201.16
|
| Rate for Payer: Preferred Network Access Commercial |
$1,039.60
|
| Rate for Payer: Quartz Beloit One Network |
$553.70
|
| Rate for Payer: Quartz Commercial |
$734.50
|
| Rate for Payer: Quartz Medicare Advantage |
$134.11
|
| Rate for Payer: The Alliance Commercial |
$536.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$134.11
|
| Rate for Payer: United Healthcare PPO |
$847.50
|
| Rate for Payer: WEA Trust Commercial |
$621.50
|
| Rate for Payer: Wellcare Medicare |
$134.11
|
| Rate for Payer: WPS Commercial |
$836.99
|
|
|
Basic Dosimetry Calculation
|
Facility
|
IP
|
$1,130.00
|
|
|
Service Code
|
CPT 77300
|
| Hospital Charge Code |
3040379
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$553.70 |
| Max. Negotiated Rate |
$1,039.60 |
| Rate for Payer: Aetna Commercial |
$1,017.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$971.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.90
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Cigna Commercial |
$1,039.60
|
| Rate for Payer: Health EOS Commercial |
$1,005.70
|
| Rate for Payer: HFN Commercial |
$1,039.60
|
| Rate for Payer: Multiplan Commercial |
$904.00
|
| Rate for Payer: NAPHCARE Commercial |
$678.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,039.60
|
| Rate for Payer: Quartz Beloit One Network |
$553.70
|
| Rate for Payer: Quartz Commercial |
$678.00
|
| Rate for Payer: WEA Trust Commercial |
$621.50
|
| Rate for Payer: WPS Commercial |
$836.99
|
|
|
Basic Metabolic Panel
|
Professional
|
Both
|
$259.00
|
|
|
Service Code
|
CPT 80048
|
| Hospital Charge Code |
633628
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.86 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Aetna Commercial |
$246.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$222.74
|
| Rate for Payer: Cash Price |
$77.70
|
| Rate for Payer: Cash Price |
$77.70
|
| Rate for Payer: Cigna Commercial |
$246.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$129.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.40
|
| Rate for Payer: Health EOS Commercial |
$235.69
|
| Rate for Payer: HFN Commercial |
$246.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.86
|
| Rate for Payer: Multiplan Commercial |
$207.20
|
| Rate for Payer: Preferred Network Access Commercial |
$246.05
|
| Rate for Payer: Quartz Beloit One Network |
$113.96
|
| Rate for Payer: Quartz Commercial |
$147.63
|
| Rate for Payer: The Alliance Commercial |
$129.50
|
| Rate for Payer: WEA Trust Commercial |
$142.45
|
| Rate for Payer: WPS Commercial |
$191.84
|
|
|
Basic Metabolic Panel
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT 80048
|
| Hospital Charge Code |
633628
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$238.28 |
| Rate for Payer: Aetna Commercial |
$233.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$222.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$137.27
|
| Rate for Payer: Cash Price |
$77.70
|
| Rate for Payer: Cigna Commercial |
$238.28
|
| Rate for Payer: Health EOS Commercial |
$230.51
|
| Rate for Payer: HFN Commercial |
$238.28
|
| Rate for Payer: Multiplan Commercial |
$207.20
|
| Rate for Payer: NAPHCARE Commercial |
$155.40
|
| Rate for Payer: Preferred Network Access Commercial |
$238.28
|
| Rate for Payer: Quartz Beloit One Network |
$126.91
|
| Rate for Payer: Quartz Commercial |
$155.40
|
| Rate for Payer: WEA Trust Commercial |
$142.45
|
| Rate for Payer: WPS Commercial |
$191.84
|
|
|
Basic Metabolic Panel
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT 80048
|
| Hospital Charge Code |
633628
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$238.28 |
| Rate for Payer: Aetna Commercial |
$233.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$222.74
|
| Rate for Payer: Aetna Managed Medicare |
$8.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.04
|
| Rate for Payer: Anthem Medicaid |
$8.74
|
| Rate for Payer: Anthem Medicare Advantage |
$8.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$137.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.46
|
| Rate for Payer: Cash Price |
$77.70
|
| Rate for Payer: Cash Price |
$77.70
|
| Rate for Payer: Cigna Commercial |
$238.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.94
|
| Rate for Payer: Dean Health Medicaid |
$8.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.46
|
| Rate for Payer: Health EOS Commercial |
$230.51
|
| Rate for Payer: HFN Commercial |
$238.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.46
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.46
|
| Rate for Payer: Managed Health Services Medicaid |
$9.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.46
|
| Rate for Payer: Multiplan Commercial |
$207.20
|
| Rate for Payer: NAPHCARE Commercial |
$12.69
|
| Rate for Payer: Preferred Network Access Commercial |
$238.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.74
|
| Rate for Payer: Quartz Beloit One Network |
$126.91
|
| Rate for Payer: Quartz Commercial |
$168.35
|
| Rate for Payer: Quartz Medicare Advantage |
$8.46
|
| Rate for Payer: The Alliance Commercial |
$33.84
|
| Rate for Payer: United Healthcare Medicaid |
$8.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.46
|
| Rate for Payer: United Healthcare PPO |
$194.25
|
| Rate for Payer: WEA Trust Commercial |
$142.45
|
| Rate for Payer: Wellcare Medicare |
$8.46
|
| Rate for Payer: WMAP Medicaid |
$8.74
|
| Rate for Payer: WPS Commercial |
$191.84
|
|
|
Basic Vestibular Eval
|
Facility
|
IP
|
$733.00
|
|
|
Service Code
|
CPT 92540
|
| Hospital Charge Code |
3856720
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$359.17 |
| Max. Negotiated Rate |
$674.36 |
| Rate for Payer: Aetna Commercial |
$659.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$630.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$388.49
|
| Rate for Payer: Cash Price |
$219.90
|
| Rate for Payer: Cigna Commercial |
$674.36
|
| Rate for Payer: Health EOS Commercial |
$652.37
|
| Rate for Payer: HFN Commercial |
$674.36
|
| Rate for Payer: Multiplan Commercial |
$586.40
|
| Rate for Payer: NAPHCARE Commercial |
$439.80
|
| Rate for Payer: Preferred Network Access Commercial |
$674.36
|
| Rate for Payer: Quartz Beloit One Network |
$359.17
|
| Rate for Payer: Quartz Commercial |
$439.80
|
| Rate for Payer: WEA Trust Commercial |
$403.15
|
| Rate for Payer: WPS Commercial |
$542.93
|
|
|
Basic Vestibular Eval
|
Facility
|
OP
|
$733.00
|
|
|
Service Code
|
CPT 92540
|
| Hospital Charge Code |
3856720
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$154.39 |
| Max. Negotiated Rate |
$674.36 |
| Rate for Payer: Aetna Commercial |
$659.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$630.38
|
| Rate for Payer: Aetna Managed Medicare |
$154.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$476.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$366.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$351.84
|
| Rate for Payer: Anthem Medicare Advantage |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$388.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$154.39
|
| Rate for Payer: Cash Price |
$219.90
|
| Rate for Payer: Cash Price |
$219.90
|
| Rate for Payer: Cigna Commercial |
$674.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$154.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$410.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$154.39
|
| Rate for Payer: Health EOS Commercial |
$652.37
|
| Rate for Payer: HFN Commercial |
$674.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$154.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$154.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$154.39
|
| Rate for Payer: Multiplan Commercial |
$586.40
|
| Rate for Payer: NAPHCARE Commercial |
$231.58
|
| Rate for Payer: Preferred Network Access Commercial |
$674.36
|
| Rate for Payer: Quartz Beloit One Network |
$359.17
|
| Rate for Payer: Quartz Commercial |
$476.45
|
| Rate for Payer: Quartz Medicare Advantage |
$154.39
|
| Rate for Payer: The Alliance Commercial |
$617.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare PPO |
$549.75
|
| Rate for Payer: WEA Trust Commercial |
$403.15
|
| Rate for Payer: Wellcare Medicare |
$154.39
|
| Rate for Payer: WPS Commercial |
$542.93
|
|
|
Basic Vestibular Eval
|
Professional
|
Both
|
$733.00
|
|
|
Service Code
|
CPT 92540
|
| Hospital Charge Code |
3856720
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$81.22 |
| Max. Negotiated Rate |
$696.35 |
| Rate for Payer: Aetna Commercial |
$696.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$630.38
|
| Rate for Payer: Cash Price |
$219.90
|
| Rate for Payer: Cash Price |
$219.90
|
| Rate for Payer: Cigna Commercial |
$696.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$439.80
|
| Rate for Payer: Health EOS Commercial |
$667.03
|
| Rate for Payer: HFN Commercial |
$696.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$379.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$379.19
|
| Rate for Payer: Multiplan Commercial |
$586.40
|
| Rate for Payer: Preferred Network Access Commercial |
$696.35
|
| Rate for Payer: Quartz Beloit One Network |
$322.52
|
| Rate for Payer: Quartz Commercial |
$417.81
|
| Rate for Payer: The Alliance Commercial |
$366.50
|
| Rate for Payer: United Healthcare Medicaid |
$81.22
|
| Rate for Payer: WEA Trust Commercial |
$403.15
|
| Rate for Payer: WPS Commercial |
$542.93
|
|
|
Basic Vestibular Eval 9254026
|
Professional
|
Both
|
$794.00
|
|
|
Service Code
|
CPT 92540 26
|
| Hospital Charge Code |
3206200
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$270.93 |
| Max. Negotiated Rate |
$754.30 |
| Rate for Payer: Aetna Commercial |
$754.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$682.84
|
| Rate for Payer: Cash Price |
$238.20
|
| Rate for Payer: Cash Price |
$238.20
|
| Rate for Payer: Cigna Commercial |
$754.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$397.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$476.40
|
| Rate for Payer: Health EOS Commercial |
$722.54
|
| Rate for Payer: HFN Commercial |
$754.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$270.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$270.93
|
| Rate for Payer: Multiplan Commercial |
$635.20
|
| Rate for Payer: Preferred Network Access Commercial |
$754.30
|
| Rate for Payer: Quartz Beloit One Network |
$349.36
|
| Rate for Payer: Quartz Commercial |
$452.58
|
| Rate for Payer: The Alliance Commercial |
$397.00
|
| Rate for Payer: WEA Trust Commercial |
$436.70
|
| Rate for Payer: WPS Commercial |
$588.12
|
|
|
Basic Vestibular Eval 92540TC
|
Professional
|
Both
|
$162.00
|
|
|
Service Code
|
CPT 92540 TC
|
| Hospital Charge Code |
3206194
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.28 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$153.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.20
|
| Rate for Payer: Health EOS Commercial |
$147.42
|
| Rate for Payer: HFN Commercial |
$153.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.27
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: Preferred Network Access Commercial |
$153.90
|
| Rate for Payer: Quartz Beloit One Network |
$71.28
|
| Rate for Payer: Quartz Commercial |
$92.34
|
| Rate for Payer: The Alliance Commercial |
$81.00
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
BASIC VESTIBULAR EVAL, INCL SPONT. NYSTAGMUS TEST 92540
|
Professional
|
Both
|
$733.00
|
|
|
Service Code
|
CPT 92540
|
| Hospital Charge Code |
3015329
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$81.22 |
| Max. Negotiated Rate |
$696.35 |
| Rate for Payer: Aetna Commercial |
$696.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$630.38
|
| Rate for Payer: Cash Price |
$219.90
|
| Rate for Payer: Cash Price |
$219.90
|
| Rate for Payer: Cigna Commercial |
$696.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$439.80
|
| Rate for Payer: Health EOS Commercial |
$667.03
|
| Rate for Payer: HFN Commercial |
$696.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$379.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$379.19
|
| Rate for Payer: Multiplan Commercial |
$586.40
|
| Rate for Payer: Preferred Network Access Commercial |
$696.35
|
| Rate for Payer: Quartz Beloit One Network |
$322.52
|
| Rate for Payer: Quartz Commercial |
$417.81
|
| Rate for Payer: The Alliance Commercial |
$366.50
|
| Rate for Payer: United Healthcare Medicaid |
$81.22
|
| Rate for Payer: WEA Trust Commercial |
$403.15
|
| Rate for Payer: WPS Commercial |
$542.93
|
|
|
Basic Vestibular Evaluation 26
|
Facility
|
IP
|
$794.00
|
|
|
Service Code
|
CPT 92540 26
|
| Hospital Charge Code |
3203486
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$389.06 |
| Max. Negotiated Rate |
$730.48 |
| Rate for Payer: Aetna Commercial |
$714.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$682.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$420.82
|
| Rate for Payer: Cash Price |
$238.20
|
| Rate for Payer: Cigna Commercial |
$730.48
|
| Rate for Payer: Health EOS Commercial |
$706.66
|
| Rate for Payer: HFN Commercial |
$730.48
|
| Rate for Payer: Multiplan Commercial |
$635.20
|
| Rate for Payer: NAPHCARE Commercial |
$476.40
|
| Rate for Payer: Preferred Network Access Commercial |
$730.48
|
| Rate for Payer: Quartz Beloit One Network |
$389.06
|
| Rate for Payer: Quartz Commercial |
$476.40
|
| Rate for Payer: WEA Trust Commercial |
$436.70
|
| Rate for Payer: WPS Commercial |
$588.12
|
|
|
Basic Vestibular Evaluation 26
|
Facility
|
OP
|
$794.00
|
|
|
Service Code
|
CPT 92540 26
|
| Hospital Charge Code |
3203486
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$222.32 |
| Max. Negotiated Rate |
$3,176.00 |
| Rate for Payer: Aetna Commercial |
$714.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$682.84
|
| Rate for Payer: Aetna Managed Medicare |
$222.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$516.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$397.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$381.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$420.82
|
| Rate for Payer: Cash Price |
$238.20
|
| Rate for Payer: Cigna Commercial |
$730.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$444.32
|
| Rate for Payer: Health EOS Commercial |
$706.66
|
| Rate for Payer: HFN Commercial |
$730.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$595.50
|
| Rate for Payer: Multiplan Commercial |
$635.20
|
| Rate for Payer: NAPHCARE Commercial |
$476.40
|
| Rate for Payer: Preferred Network Access Commercial |
$730.48
|
| Rate for Payer: Quartz Beloit One Network |
$389.06
|
| Rate for Payer: Quartz Commercial |
$516.10
|
| Rate for Payer: Quartz Medicare Advantage |
$476.40
|
| Rate for Payer: The Alliance Commercial |
$3,176.00
|
| Rate for Payer: United Healthcare PPO |
$595.50
|
| Rate for Payer: WEA Trust Commercial |
$436.70
|
| Rate for Payer: WPS Commercial |
$588.12
|
|
|
Basic Vestibular Evaluation 26
|
Professional
|
Both
|
$794.00
|
|
|
Service Code
|
CPT 92540 26
|
| Hospital Charge Code |
3203486
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$270.93 |
| Max. Negotiated Rate |
$754.30 |
| Rate for Payer: Aetna Commercial |
$754.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$682.84
|
| Rate for Payer: Cash Price |
$238.20
|
| Rate for Payer: Cash Price |
$238.20
|
| Rate for Payer: Cigna Commercial |
$754.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$397.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$476.40
|
| Rate for Payer: Health EOS Commercial |
$722.54
|
| Rate for Payer: HFN Commercial |
$754.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$270.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$270.93
|
| Rate for Payer: Multiplan Commercial |
$635.20
|
| Rate for Payer: Preferred Network Access Commercial |
$754.30
|
| Rate for Payer: Quartz Beloit One Network |
$349.36
|
| Rate for Payer: Quartz Commercial |
$452.58
|
| Rate for Payer: The Alliance Commercial |
$397.00
|
| Rate for Payer: WEA Trust Commercial |
$436.70
|
| Rate for Payer: WPS Commercial |
$588.12
|
|
|
Basic Vestibular Evaluation TC
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
CPT 92540 TC
|
| Hospital Charge Code |
1230809
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$45.36 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Aetna Commercial |
$145.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Aetna Managed Medicare |
$45.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$105.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.86
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$149.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.66
|
| Rate for Payer: Health EOS Commercial |
$144.18
|
| Rate for Payer: HFN Commercial |
$149.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.50
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: NAPHCARE Commercial |
$97.20
|
| Rate for Payer: Preferred Network Access Commercial |
$149.04
|
| Rate for Payer: Quartz Beloit One Network |
$79.38
|
| Rate for Payer: Quartz Commercial |
$105.30
|
| Rate for Payer: Quartz Medicare Advantage |
$97.20
|
| Rate for Payer: The Alliance Commercial |
$648.00
|
| Rate for Payer: United Healthcare PPO |
$121.50
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
Basic Vestibular Evaluation TC
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
CPT 92540 TC
|
| Hospital Charge Code |
1230809
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$79.38 |
| Max. Negotiated Rate |
$149.04 |
| Rate for Payer: Aetna Commercial |
$145.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.86
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$149.04
|
| Rate for Payer: Health EOS Commercial |
$144.18
|
| Rate for Payer: HFN Commercial |
$149.04
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: NAPHCARE Commercial |
$97.20
|
| Rate for Payer: Preferred Network Access Commercial |
$149.04
|
| Rate for Payer: Quartz Beloit One Network |
$79.38
|
| Rate for Payer: Quartz Commercial |
$97.20
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
Basic Vestibular Evaluation TC
|
Professional
|
Both
|
$162.00
|
|
|
Service Code
|
CPT 92540 TC
|
| Hospital Charge Code |
1230809
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$71.28 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$153.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.20
|
| Rate for Payer: Health EOS Commercial |
$147.42
|
| Rate for Payer: HFN Commercial |
$153.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.27
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: Preferred Network Access Commercial |
$153.90
|
| Rate for Payer: Quartz Beloit One Network |
$71.28
|
| Rate for Payer: Quartz Commercial |
$92.34
|
| Rate for Payer: The Alliance Commercial |
$81.00
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
BASKET 3.2FR NFORCE STONE
|
Facility
|
OP
|
$2,747.00
|
|
| Hospital Charge Code |
2964975
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$769.16 |
| Max. Negotiated Rate |
$10,988.00 |
| Rate for Payer: Aetna Commercial |
$2,472.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,362.42
|
| Rate for Payer: Aetna Managed Medicare |
$769.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,785.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,373.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,318.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,455.91
|
| Rate for Payer: Cash Price |
$824.10
|
| Rate for Payer: Cigna Commercial |
$2,527.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,537.22
|
| Rate for Payer: Health EOS Commercial |
$2,444.83
|
| Rate for Payer: HFN Commercial |
$2,527.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,060.25
|
| Rate for Payer: Multiplan Commercial |
$2,197.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,648.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,527.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,346.03
|
| Rate for Payer: Quartz Commercial |
$1,785.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,648.20
|
| Rate for Payer: The Alliance Commercial |
$10,988.00
|
| Rate for Payer: WEA Trust Commercial |
$1,510.85
|
| Rate for Payer: WPS Commercial |
$2,034.70
|
|
|
BASKET 3.2FR NFORCE STONE
|
Facility
|
IP
|
$2,747.00
|
|
| Hospital Charge Code |
2964975
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,346.03 |
| Max. Negotiated Rate |
$2,527.24 |
| Rate for Payer: Aetna Commercial |
$2,472.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,362.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,455.91
|
| Rate for Payer: Cash Price |
$824.10
|
| Rate for Payer: Cigna Commercial |
$2,527.24
|
| Rate for Payer: Health EOS Commercial |
$2,444.83
|
| Rate for Payer: HFN Commercial |
$2,527.24
|
| Rate for Payer: Multiplan Commercial |
$2,197.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,648.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,527.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,346.03
|
| Rate for Payer: Quartz Commercial |
$1,648.20
|
| Rate for Payer: WEA Trust Commercial |
$1,510.85
|
| Rate for Payer: WPS Commercial |
$2,034.70
|
|
|
BASKET 5-WIRE GEMINI HELICAL 330-115
|
Facility
|
OP
|
$2,412.00
|
|
| Hospital Charge Code |
2964804
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$675.36 |
| Max. Negotiated Rate |
$9,648.00 |
| Rate for Payer: Aetna Commercial |
$2,170.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,074.32
|
| Rate for Payer: Aetna Managed Medicare |
$675.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,567.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,206.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,157.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,278.36
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,219.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,349.76
|
| Rate for Payer: Health EOS Commercial |
$2,146.68
|
| Rate for Payer: HFN Commercial |
$2,219.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,809.00
|
| Rate for Payer: Multiplan Commercial |
$1,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,447.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,219.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,181.88
|
| Rate for Payer: Quartz Commercial |
$1,567.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,447.20
|
| Rate for Payer: The Alliance Commercial |
$9,648.00
|
| Rate for Payer: WEA Trust Commercial |
$1,326.60
|
| Rate for Payer: WPS Commercial |
$1,786.57
|
|
|
BASKET 5-WIRE GEMINI HELICAL 330-115
|
Facility
|
IP
|
$2,412.00
|
|
| Hospital Charge Code |
2964804
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,181.88 |
| Max. Negotiated Rate |
$2,219.04 |
| Rate for Payer: Aetna Commercial |
$2,170.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,074.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,278.36
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,219.04
|
| Rate for Payer: Health EOS Commercial |
$2,146.68
|
| Rate for Payer: HFN Commercial |
$2,219.04
|
| Rate for Payer: Multiplan Commercial |
$1,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,447.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,219.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,181.88
|
| Rate for Payer: Quartz Commercial |
$1,447.20
|
| Rate for Payer: WEA Trust Commercial |
$1,326.60
|
| Rate for Payer: WPS Commercial |
$1,786.57
|
|
|
BASKET DAKOTA 1.9FR X 120CM X 8MM M0063905000
|
Facility
|
IP
|
$4,297.00
|
|
| Hospital Charge Code |
5286794
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,105.53 |
| Max. Negotiated Rate |
$3,953.24 |
| Rate for Payer: Aetna Commercial |
$3,867.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,695.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,277.41
|
| Rate for Payer: Cash Price |
$1,289.10
|
| Rate for Payer: Cigna Commercial |
$3,953.24
|
| Rate for Payer: Health EOS Commercial |
$3,824.33
|
| Rate for Payer: HFN Commercial |
$3,953.24
|
| Rate for Payer: Multiplan Commercial |
$3,437.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,578.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,953.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,105.53
|
| Rate for Payer: Quartz Commercial |
$2,578.20
|
| Rate for Payer: WEA Trust Commercial |
$2,363.35
|
| Rate for Payer: WPS Commercial |
$3,182.79
|
|
|
BASKET DAKOTA 1.9FR X 120CM X 8MM M0063905000
|
Facility
|
OP
|
$4,297.00
|
|
| Hospital Charge Code |
5286794
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,203.16 |
| Max. Negotiated Rate |
$17,188.00 |
| Rate for Payer: Aetna Commercial |
$3,867.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,695.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,203.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,793.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,148.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,062.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,277.41
|
| Rate for Payer: Cash Price |
$1,289.10
|
| Rate for Payer: Cigna Commercial |
$3,953.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,404.60
|
| Rate for Payer: Health EOS Commercial |
$3,824.33
|
| Rate for Payer: HFN Commercial |
$3,953.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,222.75
|
| Rate for Payer: Multiplan Commercial |
$3,437.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,578.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,953.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,105.53
|
| Rate for Payer: Quartz Commercial |
$2,793.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,578.20
|
| Rate for Payer: The Alliance Commercial |
$17,188.00
|
| Rate for Payer: WEA Trust Commercial |
$2,363.35
|
| Rate for Payer: WPS Commercial |
$3,182.79
|
|
|
BASKET ESCAPE NITINOL STONE RETRIEVAL 1.9FR X 120CM M0063902010
|
Facility
|
IP
|
$2,935.00
|
|
| Hospital Charge Code |
4595502
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,438.15 |
| Max. Negotiated Rate |
$2,700.20 |
| Rate for Payer: Aetna Commercial |
$2,641.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,524.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,555.55
|
| Rate for Payer: Cash Price |
$880.50
|
| Rate for Payer: Cigna Commercial |
$2,700.20
|
| Rate for Payer: Health EOS Commercial |
$2,612.15
|
| Rate for Payer: HFN Commercial |
$2,700.20
|
| Rate for Payer: Multiplan Commercial |
$2,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,761.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,700.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,438.15
|
| Rate for Payer: Quartz Commercial |
$1,761.00
|
| Rate for Payer: WEA Trust Commercial |
$1,614.25
|
| Rate for Payer: WPS Commercial |
$2,173.95
|
|
