|
BLOCK CELIAC PLEXUS
|
Facility
|
OP
|
$2,332.00
|
|
| Hospital Charge Code |
5262688
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$652.96 |
| Max. Negotiated Rate |
$9,328.00 |
| Rate for Payer: Aetna Commercial |
$2,098.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,005.52
|
| Rate for Payer: Aetna Managed Medicare |
$652.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,515.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,166.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,119.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,235.96
|
| Rate for Payer: Cash Price |
$699.60
|
| Rate for Payer: Cigna Commercial |
$2,145.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,304.99
|
| Rate for Payer: Health EOS Commercial |
$2,075.48
|
| Rate for Payer: HFN Commercial |
$2,145.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,749.00
|
| Rate for Payer: Multiplan Commercial |
$1,865.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,399.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,145.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,142.68
|
| Rate for Payer: Quartz Commercial |
$1,515.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,399.20
|
| Rate for Payer: The Alliance Commercial |
$9,328.00
|
| Rate for Payer: WEA Trust Commercial |
$1,282.60
|
| Rate for Payer: WPS Commercial |
$1,727.31
|
|
|
BLOCK FOAM R-LITE PINK SOFT #A908-6
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
2969661
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$20.58 |
| Max. Negotiated Rate |
$38.64 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.26
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$38.64
|
| Rate for Payer: Health EOS Commercial |
$37.38
|
| Rate for Payer: HFN Commercial |
$38.64
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.20
|
| Rate for Payer: Preferred Network Access Commercial |
$38.64
|
| Rate for Payer: Quartz Beloit One Network |
$20.58
|
| Rate for Payer: Quartz Commercial |
$25.20
|
| Rate for Payer: WEA Trust Commercial |
$23.10
|
| Rate for Payer: WPS Commercial |
$31.11
|
|
|
BLOCK FOAM R-LITE PINK SOFT #A908-6
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
2969661
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$168.00 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36.12
|
| Rate for Payer: Aetna Managed Medicare |
$11.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.26
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$38.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.50
|
| Rate for Payer: Health EOS Commercial |
$37.38
|
| Rate for Payer: HFN Commercial |
$38.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.20
|
| Rate for Payer: Preferred Network Access Commercial |
$38.64
|
| Rate for Payer: Quartz Beloit One Network |
$20.58
|
| Rate for Payer: Quartz Commercial |
$27.30
|
| Rate for Payer: Quartz Medicare Advantage |
$25.20
|
| Rate for Payer: The Alliance Commercial |
$168.00
|
| Rate for Payer: WEA Trust Commercial |
$23.10
|
| Rate for Payer: WPS Commercial |
$31.11
|
|
|
BLOCK, INTERCOSTAL NERVE
|
Facility
|
IP
|
$291.00
|
|
| Hospital Charge Code |
2960157
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$142.59 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: Aetna Commercial |
$261.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.23
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$267.72
|
| Rate for Payer: Health EOS Commercial |
$258.99
|
| Rate for Payer: HFN Commercial |
$267.72
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: NAPHCARE Commercial |
$174.60
|
| Rate for Payer: Preferred Network Access Commercial |
$267.72
|
| Rate for Payer: Quartz Beloit One Network |
$142.59
|
| Rate for Payer: Quartz Commercial |
$174.60
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
|
BLOCK, INTERCOSTAL NERVE
|
Facility
|
OP
|
$291.00
|
|
| Hospital Charge Code |
2960157
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$81.48 |
| Max. Negotiated Rate |
$1,164.00 |
| Rate for Payer: Aetna Commercial |
$261.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Aetna Managed Medicare |
$81.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$189.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.23
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$267.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.84
|
| Rate for Payer: Health EOS Commercial |
$258.99
|
| Rate for Payer: HFN Commercial |
$267.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$218.25
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: NAPHCARE Commercial |
$174.60
|
| Rate for Payer: Preferred Network Access Commercial |
$267.72
|
| Rate for Payer: Quartz Beloit One Network |
$142.59
|
| Rate for Payer: Quartz Commercial |
$189.15
|
| Rate for Payer: Quartz Medicare Advantage |
$174.60
|
| Rate for Payer: The Alliance Commercial |
$1,164.00
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
|
BLOCK, INTERSCALENE
|
Facility
|
IP
|
$270.00
|
|
| Hospital Charge Code |
2975775
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$162.00
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
BLOCK, INTERSCALENE
|
Facility
|
OP
|
$270.00
|
|
| Hospital Charge Code |
2975775
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Aetna Managed Medicare |
$75.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$175.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$129.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.09
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.50
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$175.50
|
| Rate for Payer: Quartz Medicare Advantage |
$162.00
|
| Rate for Payer: The Alliance Commercial |
$1,080.00
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
BLOCK L/T PARAVERTEBRAL
|
Facility
|
IP
|
$2,332.00
|
|
| Hospital Charge Code |
5262689
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,142.68 |
| Max. Negotiated Rate |
$2,145.44 |
| Rate for Payer: Aetna Commercial |
$2,098.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,005.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,235.96
|
| Rate for Payer: Cash Price |
$699.60
|
| Rate for Payer: Cigna Commercial |
$2,145.44
|
| Rate for Payer: Health EOS Commercial |
$2,075.48
|
| Rate for Payer: HFN Commercial |
$2,145.44
|
| Rate for Payer: Multiplan Commercial |
$1,865.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,399.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,145.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,142.68
|
| Rate for Payer: Quartz Commercial |
$1,399.20
|
| Rate for Payer: WEA Trust Commercial |
$1,282.60
|
| Rate for Payer: WPS Commercial |
$1,727.31
|
|
|
BLOCK L/T PARAVERTEBRAL
|
Facility
|
OP
|
$2,332.00
|
|
| Hospital Charge Code |
5262689
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$652.96 |
| Max. Negotiated Rate |
$9,328.00 |
| Rate for Payer: Aetna Commercial |
$2,098.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,005.52
|
| Rate for Payer: Aetna Managed Medicare |
$652.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,515.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,166.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,119.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,235.96
|
| Rate for Payer: Cash Price |
$699.60
|
| Rate for Payer: Cigna Commercial |
$2,145.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,304.99
|
| Rate for Payer: Health EOS Commercial |
$2,075.48
|
| Rate for Payer: HFN Commercial |
$2,145.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,749.00
|
| Rate for Payer: Multiplan Commercial |
$1,865.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,399.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,145.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,142.68
|
| Rate for Payer: Quartz Commercial |
$1,515.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,399.20
|
| Rate for Payer: The Alliance Commercial |
$9,328.00
|
| Rate for Payer: WEA Trust Commercial |
$1,282.60
|
| Rate for Payer: WPS Commercial |
$1,727.31
|
|
|
BLOCK, LUMBAR SYMPATHETIC
|
Facility
|
IP
|
$270.00
|
|
| Hospital Charge Code |
2960397
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$162.00
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
BLOCK, LUMBAR SYMPATHETIC
|
Facility
|
OP
|
$270.00
|
|
| Hospital Charge Code |
2960397
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Aetna Managed Medicare |
$75.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$175.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$129.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.09
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.50
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$175.50
|
| Rate for Payer: Quartz Medicare Advantage |
$162.00
|
| Rate for Payer: The Alliance Commercial |
$1,080.00
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
BLOCK, NERVE
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2960246
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$1,140.00 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Aetna Managed Medicare |
$79.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$142.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$136.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.49
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$185.25
|
| Rate for Payer: Quartz Medicare Advantage |
$171.00
|
| Rate for Payer: The Alliance Commercial |
$1,140.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
BLOCK, NERVE
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2960246
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$139.65 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
BLOCK SPHENOPALATINE GANGLION
|
Facility
|
IP
|
$1,218.00
|
|
| Hospital Charge Code |
5262687
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$596.82 |
| Max. Negotiated Rate |
$1,120.56 |
| Rate for Payer: Aetna Commercial |
$1,096.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,047.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$645.54
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cigna Commercial |
$1,120.56
|
| Rate for Payer: Health EOS Commercial |
$1,084.02
|
| Rate for Payer: HFN Commercial |
$1,120.56
|
| Rate for Payer: Multiplan Commercial |
$974.40
|
| Rate for Payer: NAPHCARE Commercial |
$730.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,120.56
|
| Rate for Payer: Quartz Beloit One Network |
$596.82
|
| Rate for Payer: Quartz Commercial |
$730.80
|
| Rate for Payer: WEA Trust Commercial |
$669.90
|
| Rate for Payer: WPS Commercial |
$902.17
|
|
|
BLOCK SPHENOPALATINE GANGLION
|
Facility
|
OP
|
$1,218.00
|
|
| Hospital Charge Code |
5262687
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$341.04 |
| Max. Negotiated Rate |
$4,872.00 |
| Rate for Payer: Aetna Commercial |
$1,096.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,047.48
|
| Rate for Payer: Aetna Managed Medicare |
$341.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$791.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$609.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$584.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$645.54
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cigna Commercial |
$1,120.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$681.59
|
| Rate for Payer: Health EOS Commercial |
$1,084.02
|
| Rate for Payer: HFN Commercial |
$1,120.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$913.50
|
| Rate for Payer: Multiplan Commercial |
$974.40
|
| Rate for Payer: NAPHCARE Commercial |
$730.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,120.56
|
| Rate for Payer: Quartz Beloit One Network |
$596.82
|
| Rate for Payer: Quartz Commercial |
$791.70
|
| Rate for Payer: Quartz Medicare Advantage |
$730.80
|
| Rate for Payer: The Alliance Commercial |
$4,872.00
|
| Rate for Payer: WEA Trust Commercial |
$669.90
|
| Rate for Payer: WPS Commercial |
$902.17
|
|
|
BLOCK, STELLATE GANGLION
|
Facility
|
OP
|
$913.00
|
|
|
Service Code
|
CPT 64510
|
| Hospital Charge Code |
2960388
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$447.37 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$821.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$785.18
|
| Rate for Payer: Aetna Managed Medicare |
$900.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$900.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$483.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$900.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$900.91
|
| Rate for Payer: Cash Price |
$273.90
|
| Rate for Payer: Cash Price |
$273.90
|
| Rate for Payer: Cash Price |
$273.90
|
| Rate for Payer: Cigna Commercial |
$839.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$900.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$900.91
|
| Rate for Payer: Health EOS Commercial |
$812.57
|
| Rate for Payer: HFN Commercial |
$839.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,351.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$900.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$900.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$900.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$900.91
|
| Rate for Payer: Multiplan Commercial |
$730.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,351.36
|
| Rate for Payer: Preferred Network Access Commercial |
$839.96
|
| Rate for Payer: Quartz Beloit One Network |
$447.37
|
| Rate for Payer: Quartz Commercial |
$593.45
|
| Rate for Payer: Quartz Medicare Advantage |
$900.91
|
| Rate for Payer: The Alliance Commercial |
$3,603.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$900.91
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: WEA Trust Commercial |
$502.15
|
| Rate for Payer: Wellcare Medicare |
$900.91
|
| Rate for Payer: WPS Commercial |
$676.26
|
|
|
BLOCK, STELLATE GANGLION
|
Facility
|
IP
|
$913.00
|
|
|
Service Code
|
CPT 64510
|
| Hospital Charge Code |
2960388
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$447.37 |
| Max. Negotiated Rate |
$839.96 |
| Rate for Payer: Aetna Commercial |
$821.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$785.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$483.89
|
| Rate for Payer: Cash Price |
$273.90
|
| Rate for Payer: Cigna Commercial |
$839.96
|
| Rate for Payer: Health EOS Commercial |
$812.57
|
| Rate for Payer: HFN Commercial |
$839.96
|
| Rate for Payer: Multiplan Commercial |
$730.40
|
| Rate for Payer: NAPHCARE Commercial |
$547.80
|
| Rate for Payer: Preferred Network Access Commercial |
$839.96
|
| Rate for Payer: Quartz Beloit One Network |
$447.37
|
| Rate for Payer: Quartz Commercial |
$547.80
|
| Rate for Payer: WEA Trust Commercial |
$502.15
|
| Rate for Payer: WPS Commercial |
$676.26
|
|
|
BLOCK SZ 7 TIB AUGMENT LCCK 5988-07-26
|
Facility
|
IP
|
$8,160.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2969413
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,998.40 |
| Max. Negotiated Rate |
$7,507.20 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$4,896.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
BLOCK SZ 7 TIB AUGMENT LCCK 5988-07-26
|
Facility
|
OP
|
$8,160.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2969413
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.80 |
| Max. Negotiated Rate |
$32,640.00 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,284.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,566.34
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,120.00
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$5,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,896.00
|
| Rate for Payer: The Alliance Commercial |
$32,640.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
BLOCK WITH GENERAL ANES - SET-UP CHARGE
|
Facility
|
IP
|
$1,668.00
|
|
| Hospital Charge Code |
4519582
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$817.32 |
| Max. Negotiated Rate |
$1,534.56 |
| Rate for Payer: Aetna Commercial |
$1,501.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,434.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$884.04
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cigna Commercial |
$1,534.56
|
| Rate for Payer: Health EOS Commercial |
$1,484.52
|
| Rate for Payer: HFN Commercial |
$1,534.56
|
| Rate for Payer: Multiplan Commercial |
$1,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,000.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,534.56
|
| Rate for Payer: Quartz Beloit One Network |
$817.32
|
| Rate for Payer: Quartz Commercial |
$1,000.80
|
| Rate for Payer: WEA Trust Commercial |
$917.40
|
| Rate for Payer: WPS Commercial |
$1,235.49
|
|
|
BLOCK WITH GENERAL ANES - SET-UP CHARGE
|
Facility
|
OP
|
$1,668.00
|
|
| Hospital Charge Code |
4519582
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$467.04 |
| Max. Negotiated Rate |
$6,672.00 |
| Rate for Payer: Aetna Commercial |
$1,501.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,434.48
|
| Rate for Payer: Aetna Managed Medicare |
$467.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,084.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$834.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$800.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$884.04
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cigna Commercial |
$1,534.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$933.41
|
| Rate for Payer: Health EOS Commercial |
$1,484.52
|
| Rate for Payer: HFN Commercial |
$1,534.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,251.00
|
| Rate for Payer: Multiplan Commercial |
$1,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,000.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,534.56
|
| Rate for Payer: Quartz Beloit One Network |
$817.32
|
| Rate for Payer: Quartz Commercial |
$1,084.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,000.80
|
| Rate for Payer: The Alliance Commercial |
$6,672.00
|
| Rate for Payer: WEA Trust Commercial |
$917.40
|
| Rate for Payer: WPS Commercial |
$1,235.49
|
|
|
BLOCK WITH MAC ANES - SET-UP CHARGE
|
Facility
|
IP
|
$1,303.00
|
|
| Hospital Charge Code |
4519581
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$638.47 |
| Max. Negotiated Rate |
$1,198.76 |
| Rate for Payer: Aetna Commercial |
$1,172.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,120.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.59
|
| Rate for Payer: Cash Price |
$390.90
|
| Rate for Payer: Cigna Commercial |
$1,198.76
|
| Rate for Payer: Health EOS Commercial |
$1,159.67
|
| Rate for Payer: HFN Commercial |
$1,198.76
|
| Rate for Payer: Multiplan Commercial |
$1,042.40
|
| Rate for Payer: NAPHCARE Commercial |
$781.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,198.76
|
| Rate for Payer: Quartz Beloit One Network |
$638.47
|
| Rate for Payer: Quartz Commercial |
$781.80
|
| Rate for Payer: WEA Trust Commercial |
$716.65
|
| Rate for Payer: WPS Commercial |
$965.13
|
|
|
BLOCK WITH MAC ANES - SET-UP CHARGE
|
Facility
|
OP
|
$1,303.00
|
|
| Hospital Charge Code |
4519581
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$364.84 |
| Max. Negotiated Rate |
$5,212.00 |
| Rate for Payer: Aetna Commercial |
$1,172.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,120.58
|
| Rate for Payer: Aetna Managed Medicare |
$364.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$846.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$651.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$625.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.59
|
| Rate for Payer: Cash Price |
$390.90
|
| Rate for Payer: Cigna Commercial |
$1,198.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$729.16
|
| Rate for Payer: Health EOS Commercial |
$1,159.67
|
| Rate for Payer: HFN Commercial |
$1,198.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$977.25
|
| Rate for Payer: Multiplan Commercial |
$1,042.40
|
| Rate for Payer: NAPHCARE Commercial |
$781.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,198.76
|
| Rate for Payer: Quartz Beloit One Network |
$638.47
|
| Rate for Payer: Quartz Commercial |
$846.95
|
| Rate for Payer: Quartz Medicare Advantage |
$781.80
|
| Rate for Payer: The Alliance Commercial |
$5,212.00
|
| Rate for Payer: WEA Trust Commercial |
$716.65
|
| Rate for Payer: WPS Commercial |
$965.13
|
|
|
Blood Culture
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
CPT 87040
|
| Hospital Charge Code |
633882
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$277.84 |
| Rate for Payer: Aetna Commercial |
$271.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.72
|
| Rate for Payer: Aetna Managed Medicare |
$10.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.06
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.13
|
| Rate for Payer: Anthem Medicaid |
$10.66
|
| Rate for Payer: Anthem Medicare Advantage |
$10.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.32
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cigna Commercial |
$277.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$169.00
|
| Rate for Payer: Dean Health Medicaid |
$10.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10.32
|
| Rate for Payer: Health EOS Commercial |
$268.78
|
| Rate for Payer: HFN Commercial |
$277.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.32
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$10.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.32
|
| Rate for Payer: Managed Health Services Medicaid |
$11.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10.32
|
| Rate for Payer: Multiplan Commercial |
$241.60
|
| Rate for Payer: NAPHCARE Commercial |
$15.48
|
| Rate for Payer: Preferred Network Access Commercial |
$277.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$10.66
|
| Rate for Payer: Quartz Beloit One Network |
$147.98
|
| Rate for Payer: Quartz Commercial |
$196.30
|
| Rate for Payer: Quartz Medicare Advantage |
$10.32
|
| Rate for Payer: The Alliance Commercial |
$41.28
|
| Rate for Payer: United Healthcare Medicaid |
$10.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.32
|
| Rate for Payer: United Healthcare PPO |
$226.50
|
| Rate for Payer: WEA Trust Commercial |
$166.10
|
| Rate for Payer: Wellcare Medicare |
$10.32
|
| Rate for Payer: WMAP Medicaid |
$10.66
|
| Rate for Payer: WPS Commercial |
$223.69
|
|
|
Blood Culture
|
Facility
|
IP
|
$302.00
|
|
|
Service Code
|
CPT 87040
|
| Hospital Charge Code |
633882
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$147.98 |
| Max. Negotiated Rate |
$277.84 |
| Rate for Payer: Aetna Commercial |
$271.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.06
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cigna Commercial |
$277.84
|
| Rate for Payer: Health EOS Commercial |
$268.78
|
| Rate for Payer: HFN Commercial |
$277.84
|
| Rate for Payer: Multiplan Commercial |
$241.60
|
| Rate for Payer: NAPHCARE Commercial |
$181.20
|
| Rate for Payer: Preferred Network Access Commercial |
$277.84
|
| Rate for Payer: Quartz Beloit One Network |
$147.98
|
| Rate for Payer: Quartz Commercial |
$181.20
|
| Rate for Payer: WEA Trust Commercial |
$166.10
|
| Rate for Payer: WPS Commercial |
$223.69
|
|
