|
Euflexxa 1 Unit = 1 Unit Charge
|
Facility
|
IP
|
$2,615.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
5386676
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,332.60 |
| Max. Negotiated Rate |
$2,502.03 |
| Rate for Payer: Aetna Commercial |
$2,447.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,338.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,441.39
|
| Rate for Payer: Cash Price |
$784.50
|
| Rate for Payer: Cigna Commercial |
$2,502.03
|
| Rate for Payer: Health EOS Commercial |
$2,420.44
|
| Rate for Payer: HFN Commercial |
$2,502.03
|
| Rate for Payer: Multiplan Commercial |
$2,175.68
|
| Rate for Payer: Preferred Network Access Commercial |
$2,502.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,332.60
|
| Rate for Payer: Quartz Commercial |
$1,631.76
|
| Rate for Payer: WEA Trust Commercial |
$1,495.78
|
| Rate for Payer: WPS Commercial |
$2,014.33
|
|
|
Euflexxa 1 Unit = 1 Unit Charge
|
Facility
|
OP
|
$2,615.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
5386676
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.68 |
| Max. Negotiated Rate |
$2,502.03 |
| Rate for Payer: Aetna Commercial |
$2,447.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,338.86
|
| Rate for Payer: Aetna Managed Medicare |
$109.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,767.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,359.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,305.41
|
| Rate for Payer: Anthem Medicare Advantage |
$109.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,441.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$109.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$109.68
|
| Rate for Payer: Cash Price |
$784.50
|
| Rate for Payer: Cash Price |
$784.50
|
| Rate for Payer: Cigna Commercial |
$2,502.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$109.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$109.68
|
| Rate for Payer: Health EOS Commercial |
$2,420.44
|
| Rate for Payer: HFN Commercial |
$2,502.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$408.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$109.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$109.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$109.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$109.68
|
| Rate for Payer: Multiplan Commercial |
$2,175.68
|
| Rate for Payer: NAPHCARE Commercial |
$164.52
|
| Rate for Payer: Preferred Network Access Commercial |
$2,502.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,332.60
|
| Rate for Payer: Quartz Commercial |
$1,767.74
|
| Rate for Payer: Quartz Medicare Advantage |
$109.68
|
| Rate for Payer: The Alliance Commercial |
$438.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$109.68
|
| Rate for Payer: WEA Trust Commercial |
$1,495.78
|
| Rate for Payer: Wellcare Medicare |
$109.68
|
| Rate for Payer: WPS Commercial |
$300.49
|
|
|
Euflexxa inj per dose J7323
|
Facility
|
OP
|
$2,666.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
4422622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.68 |
| Max. Negotiated Rate |
$2,550.83 |
| Rate for Payer: Aetna Commercial |
$2,495.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,384.47
|
| Rate for Payer: Aetna Managed Medicare |
$109.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,802.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,386.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,330.87
|
| Rate for Payer: Anthem Medicare Advantage |
$109.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,469.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$109.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$109.68
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cigna Commercial |
$2,550.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$109.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$109.68
|
| Rate for Payer: Health EOS Commercial |
$2,467.65
|
| Rate for Payer: HFN Commercial |
$2,550.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$408.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$109.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$109.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$109.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$109.68
|
| Rate for Payer: Multiplan Commercial |
$2,218.11
|
| Rate for Payer: NAPHCARE Commercial |
$164.52
|
| Rate for Payer: Preferred Network Access Commercial |
$2,550.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,358.59
|
| Rate for Payer: Quartz Commercial |
$1,802.22
|
| Rate for Payer: Quartz Medicare Advantage |
$109.68
|
| Rate for Payer: The Alliance Commercial |
$438.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$109.68
|
| Rate for Payer: WEA Trust Commercial |
$1,524.95
|
| Rate for Payer: Wellcare Medicare |
$109.68
|
| Rate for Payer: WPS Commercial |
$300.49
|
|
|
Euflexxa inj per dose J7323
|
Facility
|
IP
|
$2,666.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
4422622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,358.59 |
| Max. Negotiated Rate |
$2,550.83 |
| Rate for Payer: Aetna Commercial |
$2,495.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,384.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,469.50
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cigna Commercial |
$2,550.83
|
| Rate for Payer: Health EOS Commercial |
$2,467.65
|
| Rate for Payer: HFN Commercial |
$2,550.83
|
| Rate for Payer: Multiplan Commercial |
$2,218.11
|
| Rate for Payer: Preferred Network Access Commercial |
$2,550.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,358.59
|
| Rate for Payer: Quartz Commercial |
$1,663.58
|
| Rate for Payer: WEA Trust Commercial |
$1,524.95
|
| Rate for Payer: WPS Commercial |
$2,053.62
|
|
|
Euflexxa inj per dose J7323
|
Professional
|
Both
|
$2,666.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
4422622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.68 |
| Max. Negotiated Rate |
$2,634.01 |
| Rate for Payer: Aetna Commercial |
$2,634.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,384.47
|
| Rate for Payer: Aetna Managed Medicare |
$109.68
|
| Rate for Payer: Anthem Medicare Advantage |
$109.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$109.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$109.68
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cigna Commercial |
$2,634.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$109.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$120.20
|
| Rate for Payer: Health EOS Commercial |
$2,523.10
|
| Rate for Payer: HFN Commercial |
$2,634.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$210.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$109.68
|
| Rate for Payer: Multiplan Commercial |
$2,218.11
|
| Rate for Payer: NAPHCARE Commercial |
$164.52
|
| Rate for Payer: Preferred Network Access Commercial |
$2,634.01
|
| Rate for Payer: Quartz Beloit One Network |
$1,219.96
|
| Rate for Payer: Quartz Commercial |
$1,580.40
|
| Rate for Payer: Quartz Medicare Advantage |
$109.68
|
| Rate for Payer: The Alliance Commercial |
$301.62
|
| Rate for Payer: United Healthcare Medicaid |
$109.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$109.68
|
| Rate for Payer: WEA Trust Commercial |
$1,524.95
|
| Rate for Payer: WPS Commercial |
$300.49
|
|
|
EUSTACHIAN TUBE BALLOON SYSTEM ACCLARENT AERA EU061655
|
Facility
|
OP
|
$11,334.00
|
|
|
Service Code
|
HCPCS C9745
|
| Hospital Charge Code |
5306666
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,300.46 |
| Max. Negotiated Rate |
$10,844.37 |
| Rate for Payer: Aetna Commercial |
$10,608.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,137.13
|
| Rate for Payer: Aetna Managed Medicare |
$3,300.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,661.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,893.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,657.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,247.30
|
| Rate for Payer: Cash Price |
$3,400.20
|
| Rate for Payer: Cigna Commercial |
$10,844.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,596.39
|
| Rate for Payer: Health EOS Commercial |
$10,490.75
|
| Rate for Payer: HFN Commercial |
$10,844.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,840.52
|
| Rate for Payer: Multiplan Commercial |
$9,429.89
|
| Rate for Payer: NAPHCARE Commercial |
$7,072.42
|
| Rate for Payer: Preferred Network Access Commercial |
$10,844.37
|
| Rate for Payer: Quartz Beloit One Network |
$5,775.81
|
| Rate for Payer: Quartz Commercial |
$7,661.78
|
| Rate for Payer: Quartz Medicare Advantage |
$7,072.42
|
| Rate for Payer: The Alliance Commercial |
$5,893.68
|
| Rate for Payer: WEA Trust Commercial |
$6,483.05
|
| Rate for Payer: WPS Commercial |
$8,730.58
|
|
|
EUSTACHIAN TUBE BALLOON SYSTEM ACCLARENT AERA EU061655
|
Facility
|
IP
|
$11,334.00
|
|
|
Service Code
|
HCPCS C9745
|
| Hospital Charge Code |
5306666
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,775.81 |
| Max. Negotiated Rate |
$10,844.37 |
| Rate for Payer: Aetna Commercial |
$10,608.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,137.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,247.30
|
| Rate for Payer: Cash Price |
$3,400.20
|
| Rate for Payer: Cigna Commercial |
$10,844.37
|
| Rate for Payer: Health EOS Commercial |
$10,490.75
|
| Rate for Payer: HFN Commercial |
$10,844.37
|
| Rate for Payer: Multiplan Commercial |
$9,429.89
|
| Rate for Payer: Preferred Network Access Commercial |
$10,844.37
|
| Rate for Payer: Quartz Beloit One Network |
$5,775.81
|
| Rate for Payer: Quartz Commercial |
$7,072.42
|
| Rate for Payer: WEA Trust Commercial |
$6,483.05
|
| Rate for Payer: WPS Commercial |
$8,730.58
|
|
|
Evacuation of a subungual Hematoma
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
1190876
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.13 |
| Max. Negotiated Rate |
$148.20 |
| Rate for Payer: Aetna Commercial |
$148.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Aetna Managed Medicare |
$31.13
|
| Rate for Payer: Anthem Medicare Advantage |
$31.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$31.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$31.13
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$148.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.13
|
| Rate for Payer: Health EOS Commercial |
$141.96
|
| Rate for Payer: HFN Commercial |
$148.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$109.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$31.13
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$46.69
|
| Rate for Payer: Preferred Network Access Commercial |
$148.20
|
| Rate for Payer: Quartz Beloit One Network |
$68.64
|
| Rate for Payer: Quartz Commercial |
$88.92
|
| Rate for Payer: Quartz Medicare Advantage |
$31.13
|
| Rate for Payer: The Alliance Commercial |
$132.29
|
| Rate for Payer: United Healthcare Medicaid |
$37.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31.13
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$140.07
|
|
|
EVACUATOR UROVAC BLADDER 730125 M0067301250
|
Facility
|
OP
|
$510.00
|
|
| Hospital Charge Code |
5306820
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$148.51 |
| Max. Negotiated Rate |
$487.97 |
| Rate for Payer: Aetna Commercial |
$477.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$456.14
|
| Rate for Payer: Aetna Managed Medicare |
$148.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$344.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$265.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$254.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.11
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cigna Commercial |
$487.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$296.82
|
| Rate for Payer: Health EOS Commercial |
$472.06
|
| Rate for Payer: HFN Commercial |
$487.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$397.80
|
| Rate for Payer: Multiplan Commercial |
$424.32
|
| Rate for Payer: NAPHCARE Commercial |
$318.24
|
| Rate for Payer: Preferred Network Access Commercial |
$487.97
|
| Rate for Payer: Quartz Beloit One Network |
$259.90
|
| Rate for Payer: Quartz Commercial |
$344.76
|
| Rate for Payer: Quartz Medicare Advantage |
$318.24
|
| Rate for Payer: The Alliance Commercial |
$265.20
|
| Rate for Payer: WEA Trust Commercial |
$291.72
|
| Rate for Payer: WPS Commercial |
$392.85
|
|
|
EVACUATOR UROVAC BLADDER 730125 M0067301250
|
Facility
|
IP
|
$510.00
|
|
| Hospital Charge Code |
5306820
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$259.90 |
| Max. Negotiated Rate |
$487.97 |
| Rate for Payer: Aetna Commercial |
$477.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$456.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.11
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cigna Commercial |
$487.97
|
| Rate for Payer: Health EOS Commercial |
$472.06
|
| Rate for Payer: HFN Commercial |
$487.97
|
| Rate for Payer: Multiplan Commercial |
$424.32
|
| Rate for Payer: Preferred Network Access Commercial |
$487.97
|
| Rate for Payer: Quartz Beloit One Network |
$259.90
|
| Rate for Payer: Quartz Commercial |
$318.24
|
| Rate for Payer: WEA Trust Commercial |
$291.72
|
| Rate for Payer: WPS Commercial |
$392.85
|
|
|
Evaluation of Speech Fluency - SLP TH Evaluation Chg
|
Facility
|
IP
|
$1,007.00
|
|
|
Service Code
|
CPT 95251 GN,95
|
| Hospital Charge Code |
5585356
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$513.17 |
| Max. Negotiated Rate |
$963.50 |
| Rate for Payer: Aetna Commercial |
$942.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$555.06
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$963.50
|
| Rate for Payer: Health EOS Commercial |
$932.08
|
| Rate for Payer: HFN Commercial |
$963.50
|
| Rate for Payer: Multiplan Commercial |
$837.82
|
| Rate for Payer: Preferred Network Access Commercial |
$963.50
|
| Rate for Payer: Quartz Beloit One Network |
$513.17
|
| Rate for Payer: Quartz Commercial |
$628.37
|
| Rate for Payer: WEA Trust Commercial |
$576.00
|
| Rate for Payer: WPS Commercial |
$775.69
|
|
|
Evaluation of Speech Fluency - SLP TH Evaluation Chg
|
Facility
|
OP
|
$1,007.00
|
|
|
Service Code
|
CPT 95251 GN,95
|
| Hospital Charge Code |
5585356
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$210.08 |
| Max. Negotiated Rate |
$963.50 |
| Rate for Payer: Aetna Commercial |
$942.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.66
|
| Rate for Payer: Aetna Managed Medicare |
$293.24
|
| 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 |
$555.06
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$963.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$586.07
|
| Rate for Payer: Health EOS Commercial |
$932.08
|
| Rate for Payer: HFN Commercial |
$963.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$837.82
|
| Rate for Payer: NAPHCARE Commercial |
$628.37
|
| Rate for Payer: Preferred Network Access Commercial |
$963.50
|
| Rate for Payer: Quartz Beloit One Network |
$513.17
|
| Rate for Payer: Quartz Commercial |
$680.73
|
| Rate for Payer: Quartz Medicare Advantage |
$628.37
|
| Rate for Payer: The Alliance Commercial |
$523.64
|
| Rate for Payer: United Healthcare PPO |
$785.46
|
| Rate for Payer: WEA Trust Commercial |
$576.00
|
| Rate for Payer: WPS Commercial |
$775.69
|
|
|
Evaluation of Speech Fluency - Speech Language Evaluation
|
Facility
|
IP
|
$1,007.00
|
|
|
Service Code
|
CPT 92521 GN
|
| Hospital Charge Code |
3978011
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$513.17 |
| Max. Negotiated Rate |
$963.50 |
| Rate for Payer: Aetna Commercial |
$942.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$555.06
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$963.50
|
| Rate for Payer: Health EOS Commercial |
$932.08
|
| Rate for Payer: HFN Commercial |
$963.50
|
| Rate for Payer: Multiplan Commercial |
$837.82
|
| Rate for Payer: Preferred Network Access Commercial |
$963.50
|
| Rate for Payer: Quartz Beloit One Network |
$513.17
|
| Rate for Payer: Quartz Commercial |
$628.37
|
| Rate for Payer: WEA Trust Commercial |
$576.00
|
| Rate for Payer: WPS Commercial |
$775.69
|
|
|
Evaluation of Speech Fluency - Speech Language Evaluation
|
Facility
|
OP
|
$1,007.00
|
|
|
Service Code
|
CPT 92521 GN
|
| Hospital Charge Code |
3978011
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$210.08 |
| Max. Negotiated Rate |
$963.50 |
| Rate for Payer: Aetna Commercial |
$942.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.66
|
| Rate for Payer: Aetna Managed Medicare |
$293.24
|
| 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 |
$555.06
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$963.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$586.07
|
| Rate for Payer: Health EOS Commercial |
$932.08
|
| Rate for Payer: HFN Commercial |
$963.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$837.82
|
| Rate for Payer: NAPHCARE Commercial |
$628.37
|
| Rate for Payer: Preferred Network Access Commercial |
$963.50
|
| Rate for Payer: Quartz Beloit One Network |
$513.17
|
| Rate for Payer: Quartz Commercial |
$680.73
|
| Rate for Payer: Quartz Medicare Advantage |
$628.37
|
| Rate for Payer: The Alliance Commercial |
$523.64
|
| Rate for Payer: United Healthcare PPO |
$785.46
|
| Rate for Payer: WEA Trust Commercial |
$576.00
|
| Rate for Payer: WPS Commercial |
$775.69
|
|
|
Evaluation of Speech Sound Production - SLP TH Evaluation Chg
|
Facility
|
OP
|
$1,007.00
|
|
|
Service Code
|
CPT 92522 GN,95
|
| Hospital Charge Code |
5585357
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$210.08 |
| Max. Negotiated Rate |
$963.50 |
| Rate for Payer: Aetna Commercial |
$942.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.66
|
| Rate for Payer: Aetna Managed Medicare |
$293.24
|
| 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 |
$555.06
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$963.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$586.07
|
| Rate for Payer: Health EOS Commercial |
$932.08
|
| Rate for Payer: HFN Commercial |
$963.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$837.82
|
| Rate for Payer: NAPHCARE Commercial |
$628.37
|
| Rate for Payer: Preferred Network Access Commercial |
$963.50
|
| Rate for Payer: Quartz Beloit One Network |
$513.17
|
| Rate for Payer: Quartz Commercial |
$680.73
|
| Rate for Payer: Quartz Medicare Advantage |
$628.37
|
| Rate for Payer: The Alliance Commercial |
$523.64
|
| Rate for Payer: United Healthcare PPO |
$785.46
|
| Rate for Payer: WEA Trust Commercial |
$576.00
|
| Rate for Payer: WPS Commercial |
$775.69
|
|
|
Evaluation of Speech Sound Production - SLP TH Evaluation Chg
|
Facility
|
IP
|
$1,007.00
|
|
|
Service Code
|
CPT 92522 GN,95
|
| Hospital Charge Code |
5585357
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$513.17 |
| Max. Negotiated Rate |
$963.50 |
| Rate for Payer: Aetna Commercial |
$942.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$555.06
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$963.50
|
| Rate for Payer: Health EOS Commercial |
$932.08
|
| Rate for Payer: HFN Commercial |
$963.50
|
| Rate for Payer: Multiplan Commercial |
$837.82
|
| Rate for Payer: Preferred Network Access Commercial |
$963.50
|
| Rate for Payer: Quartz Beloit One Network |
$513.17
|
| Rate for Payer: Quartz Commercial |
$628.37
|
| Rate for Payer: WEA Trust Commercial |
$576.00
|
| Rate for Payer: WPS Commercial |
$775.69
|
|
|
Evaluation of Speech Sound Production - Speech Language Evaluation
|
Facility
|
OP
|
$678.00
|
|
|
Service Code
|
CPT 92522 GN
|
| Hospital Charge Code |
3978010
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$197.43 |
| Max. Negotiated Rate |
$648.71 |
| Rate for Payer: Aetna Commercial |
$634.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.40
|
| Rate for Payer: Aetna Managed Medicare |
$197.43
|
| 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 |
$373.71
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$648.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$394.60
|
| Rate for Payer: Health EOS Commercial |
$627.56
|
| Rate for Payer: HFN Commercial |
$648.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$564.10
|
| Rate for Payer: NAPHCARE Commercial |
$423.07
|
| Rate for Payer: Preferred Network Access Commercial |
$648.71
|
| Rate for Payer: Quartz Beloit One Network |
$345.51
|
| Rate for Payer: Quartz Commercial |
$458.33
|
| Rate for Payer: Quartz Medicare Advantage |
$423.07
|
| Rate for Payer: The Alliance Commercial |
$352.56
|
| Rate for Payer: United Healthcare PPO |
$528.84
|
| Rate for Payer: WEA Trust Commercial |
$387.82
|
| Rate for Payer: WPS Commercial |
$522.26
|
|
|
Evaluation of Speech Sound Production - Speech Language Evaluation
|
Facility
|
IP
|
$678.00
|
|
|
Service Code
|
CPT 92522 GN
|
| Hospital Charge Code |
3978010
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$345.51 |
| Max. Negotiated Rate |
$648.71 |
| Rate for Payer: Aetna Commercial |
$634.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.71
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$648.71
|
| Rate for Payer: Health EOS Commercial |
$627.56
|
| Rate for Payer: HFN Commercial |
$648.71
|
| Rate for Payer: Multiplan Commercial |
$564.10
|
| Rate for Payer: Preferred Network Access Commercial |
$648.71
|
| Rate for Payer: Quartz Beloit One Network |
$345.51
|
| Rate for Payer: Quartz Commercial |
$423.07
|
| Rate for Payer: WEA Trust Commercial |
$387.82
|
| Rate for Payer: WPS Commercial |
$522.26
|
|
|
Evaluation of Speech Sound Production w/Language Comprehensi - SLP TH Evaluation Chg
|
Facility
|
OP
|
$1,007.00
|
|
|
Service Code
|
CPT 92523 GN,95
|
| Hospital Charge Code |
5585358
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$210.08 |
| Max. Negotiated Rate |
$963.50 |
| Rate for Payer: Aetna Commercial |
$942.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.66
|
| Rate for Payer: Aetna Managed Medicare |
$293.24
|
| 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 |
$555.06
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$963.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$586.07
|
| Rate for Payer: Health EOS Commercial |
$932.08
|
| Rate for Payer: HFN Commercial |
$963.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$837.82
|
| Rate for Payer: NAPHCARE Commercial |
$628.37
|
| Rate for Payer: Preferred Network Access Commercial |
$963.50
|
| Rate for Payer: Quartz Beloit One Network |
$513.17
|
| Rate for Payer: Quartz Commercial |
$680.73
|
| Rate for Payer: Quartz Medicare Advantage |
$628.37
|
| Rate for Payer: The Alliance Commercial |
$523.64
|
| Rate for Payer: United Healthcare PPO |
$785.46
|
| Rate for Payer: WEA Trust Commercial |
$576.00
|
| Rate for Payer: WPS Commercial |
$775.69
|
|
|
Evaluation of Speech Sound Production w/Language Comprehensi - SLP TH Evaluation Chg
|
Facility
|
IP
|
$1,007.00
|
|
|
Service Code
|
CPT 92523 GN,95
|
| Hospital Charge Code |
5585358
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$513.17 |
| Max. Negotiated Rate |
$963.50 |
| Rate for Payer: Aetna Commercial |
$942.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$555.06
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$963.50
|
| Rate for Payer: Health EOS Commercial |
$932.08
|
| Rate for Payer: HFN Commercial |
$963.50
|
| Rate for Payer: Multiplan Commercial |
$837.82
|
| Rate for Payer: Preferred Network Access Commercial |
$963.50
|
| Rate for Payer: Quartz Beloit One Network |
$513.17
|
| Rate for Payer: Quartz Commercial |
$628.37
|
| Rate for Payer: WEA Trust Commercial |
$576.00
|
| Rate for Payer: WPS Commercial |
$775.69
|
|
|
Evaluation of Speech Sound Production w/Language Comprehensi - Speech Language Evaluation
|
Facility
|
OP
|
$865.00
|
|
|
Service Code
|
CPT 92523 GN
|
| Hospital Charge Code |
3978009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$210.08 |
| Max. Negotiated Rate |
$827.63 |
| Rate for Payer: Aetna Commercial |
$809.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$773.66
|
| Rate for Payer: Aetna Managed Medicare |
$251.89
|
| 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 |
$476.79
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cigna Commercial |
$827.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$503.43
|
| Rate for Payer: Health EOS Commercial |
$800.64
|
| Rate for Payer: HFN Commercial |
$827.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$719.68
|
| Rate for Payer: NAPHCARE Commercial |
$539.76
|
| Rate for Payer: Preferred Network Access Commercial |
$827.63
|
| Rate for Payer: Quartz Beloit One Network |
$440.80
|
| Rate for Payer: Quartz Commercial |
$584.74
|
| Rate for Payer: Quartz Medicare Advantage |
$539.76
|
| Rate for Payer: The Alliance Commercial |
$449.80
|
| Rate for Payer: United Healthcare PPO |
$674.70
|
| Rate for Payer: WEA Trust Commercial |
$494.78
|
| Rate for Payer: WPS Commercial |
$666.31
|
|
|
Evaluation of Speech Sound Production w/Language Comprehensi - Speech Language Evaluation
|
Facility
|
IP
|
$865.00
|
|
|
Service Code
|
CPT 92523 GN
|
| Hospital Charge Code |
3978009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$440.80 |
| Max. Negotiated Rate |
$827.63 |
| Rate for Payer: Aetna Commercial |
$809.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$773.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$476.79
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cigna Commercial |
$827.63
|
| Rate for Payer: Health EOS Commercial |
$800.64
|
| Rate for Payer: HFN Commercial |
$827.63
|
| Rate for Payer: Multiplan Commercial |
$719.68
|
| Rate for Payer: Preferred Network Access Commercial |
$827.63
|
| Rate for Payer: Quartz Beloit One Network |
$440.80
|
| Rate for Payer: Quartz Commercial |
$539.76
|
| Rate for Payer: WEA Trust Commercial |
$494.78
|
| Rate for Payer: WPS Commercial |
$666.31
|
|
|
Evaluation of Wheezing 9406026
|
Professional
|
Both
|
$215.00
|
|
|
Service Code
|
CPT 94060 26
|
| Hospital Charge Code |
3157503
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$212.42 |
| Rate for Payer: Aetna Commercial |
$212.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$192.30
|
| Rate for Payer: Aetna Managed Medicare |
$10.40
|
| Rate for Payer: Anthem Medicare Advantage |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.40
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cigna Commercial |
$212.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.40
|
| Rate for Payer: Health EOS Commercial |
$203.48
|
| Rate for Payer: HFN Commercial |
$212.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$37.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.40
|
| Rate for Payer: Multiplan Commercial |
$178.88
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$212.42
|
| Rate for Payer: Quartz Beloit One Network |
$98.38
|
| Rate for Payer: Quartz Commercial |
$127.45
|
| Rate for Payer: Quartz Medicare Advantage |
$10.40
|
| Rate for Payer: The Alliance Commercial |
$26.00
|
| Rate for Payer: United Healthcare Medicaid |
$14.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.40
|
| Rate for Payer: WEA Trust Commercial |
$122.98
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
EVALUATION OF WHEEZING 9407026
|
Professional
|
Both
|
$106.00
|
|
|
Service Code
|
CPT 94070 26
|
| Hospital Charge Code |
3015453
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.50 |
| Max. Negotiated Rate |
$115.19 |
| Rate for Payer: Aetna Commercial |
$104.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Aetna Managed Medicare |
$28.80
|
| Rate for Payer: Anthem Medicare Advantage |
$28.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$104.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.80
|
| Rate for Payer: Health EOS Commercial |
$100.32
|
| Rate for Payer: HFN Commercial |
$104.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$101.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$101.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.80
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$104.73
|
| Rate for Payer: Quartz Beloit One Network |
$48.51
|
| Rate for Payer: Quartz Commercial |
$62.84
|
| Rate for Payer: Quartz Medicare Advantage |
$28.80
|
| Rate for Payer: The Alliance Commercial |
$71.99
|
| Rate for Payer: United Healthcare Medicaid |
$28.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.80
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: WPS Commercial |
$115.19
|
|
|
EVASC RPR DPLMNT AORTO-UN-ILIAC NDGFT RPT 34704
|
Professional
|
Both
|
$14,653.00
|
|
|
Service Code
|
CPT 34704
|
| Hospital Charge Code |
6179665
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,776.50 |
| Max. Negotiated Rate |
$14,477.16 |
| Rate for Payer: Aetna Commercial |
$14,477.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,105.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,822.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,822.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,822.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,822.00
|
| Rate for Payer: Cash Price |
$4,395.90
|
| Rate for Payer: Cash Price |
$4,395.90
|
| Rate for Payer: Cash Price |
$4,395.90
|
| Rate for Payer: Cigna Commercial |
$14,477.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,776.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,822.00
|
| Rate for Payer: Health EOS Commercial |
$13,867.60
|
| Rate for Payer: HFN Commercial |
$14,477.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,516.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,516.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,822.00
|
| Rate for Payer: Multiplan Commercial |
$12,191.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,733.00
|
| Rate for Payer: Preferred Network Access Commercial |
$14,477.16
|
| Rate for Payer: Quartz Beloit One Network |
$6,705.21
|
| Rate for Payer: Quartz Commercial |
$8,686.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,822.00
|
| Rate for Payer: The Alliance Commercial |
$7,743.49
|
| Rate for Payer: United Healthcare Medicaid |
$1,776.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,822.00
|
| Rate for Payer: WEA Trust Commercial |
$8,381.52
|
| Rate for Payer: WPS Commercial |
$8,198.99
|
|
