|
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
|
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 - 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 - 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 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 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
|
|
|
Evercross 10mm x 20mm 80cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547080
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 10mm x 20mm 80cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547080
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 10mm x 20mm 80cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547080
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 10mm x 40mm 80cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547082
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 10mm x 40mm 80cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547082
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 10mm x 40mm 80cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547082
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 12mm x 20mm 80cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 12mm x 20mm 80cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 12mm x 20mm 80cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 12mm x 40mm 80cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 12mm x 40mm 80cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 12mm x 40mm 80cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 12mm x 60mm 80cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 12mm x 60mm 80cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 12mm x 60mm 80cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 3mm x 100mm 135cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547098
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Evercross 3mm x 100mm 135cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547098
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
