|
CHANGE OF URETEROSTOMY TUBE OR EXTERNALLY ACCESSIBLE URETERAL STENT VIA ILEAL CONDUIT
|
Facility
|
OP
|
$8,052.80
|
|
|
Service Code
|
CPT 50688
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,013.20 |
| Max. Negotiated Rate |
$8,052.80 |
| Rate for Payer: Aetna Managed Medicare |
$2,013.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$2,013.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,013.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,013.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,013.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,013.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,489.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,013.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,013.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,013.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,013.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,019.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,013.20
|
| Rate for Payer: The Alliance Commercial |
$8,052.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,013.20
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$2,013.20
|
|
|
Change Suprapubic Tube
|
Facility
|
IP
|
$543.00
|
|
|
Service Code
|
CPT 51705
|
| Hospital Charge Code |
5386630
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$266.07 |
| Max. Negotiated Rate |
$499.56 |
| Rate for Payer: Aetna Commercial |
$488.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$466.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$287.79
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cigna Commercial |
$499.56
|
| Rate for Payer: Health EOS Commercial |
$483.27
|
| Rate for Payer: HFN Commercial |
$499.56
|
| Rate for Payer: Multiplan Commercial |
$434.40
|
| Rate for Payer: NAPHCARE Commercial |
$325.80
|
| Rate for Payer: Preferred Network Access Commercial |
$499.56
|
| Rate for Payer: Quartz Beloit One Network |
$266.07
|
| Rate for Payer: Quartz Commercial |
$325.80
|
| Rate for Payer: WEA Trust Commercial |
$298.65
|
| Rate for Payer: WPS Commercial |
$402.20
|
|
|
Change Suprapubic Tube
|
Facility
|
OP
|
$543.00
|
|
|
Service Code
|
CPT 51705
|
| Hospital Charge Code |
5386630
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$244.28 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$488.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$466.98
|
| Rate for Payer: Aetna Managed Medicare |
$244.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$352.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$271.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$260.64
|
| Rate for Payer: Anthem Medicare Advantage |
$244.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$287.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$244.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$244.28
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cigna Commercial |
$499.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$244.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$244.28
|
| Rate for Payer: Health EOS Commercial |
$483.27
|
| Rate for Payer: HFN Commercial |
$499.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$908.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$244.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$244.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$244.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$244.28
|
| Rate for Payer: Multiplan Commercial |
$434.40
|
| Rate for Payer: NAPHCARE Commercial |
$366.42
|
| Rate for Payer: Preferred Network Access Commercial |
$499.56
|
| Rate for Payer: Quartz Beloit One Network |
$266.07
|
| Rate for Payer: Quartz Commercial |
$352.95
|
| Rate for Payer: Quartz Medicare Advantage |
$244.28
|
| Rate for Payer: The Alliance Commercial |
$977.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$244.28
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$298.65
|
| Rate for Payer: Wellcare Medicare |
$244.28
|
| Rate for Payer: WPS Commercial |
$402.20
|
|
|
CHEILECTOMY
|
Facility
|
OP
|
$1,337.00
|
|
| Hospital Charge Code |
2959924
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$374.36 |
| Max. Negotiated Rate |
$5,348.00 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Aetna Managed Medicare |
$374.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$869.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$668.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$641.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$748.19
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,002.75
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$869.05
|
| Rate for Payer: Quartz Medicare Advantage |
$802.20
|
| Rate for Payer: The Alliance Commercial |
$5,348.00
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
CHEILECTOMY
|
Facility
|
IP
|
$1,337.00
|
|
| Hospital Charge Code |
2959924
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$655.13 |
| Max. Negotiated Rate |
$1,230.04 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$802.20
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
Chemical Cauterizaion of Granulation Tissue 17250
|
Professional
|
Both
|
$253.00
|
|
|
Service Code
|
CPT 17250
|
| Hospital Charge Code |
2568799
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.26 |
| Max. Negotiated Rate |
$240.35 |
| Rate for Payer: Aetna Commercial |
$240.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.58
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$240.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.80
|
| Rate for Payer: Health EOS Commercial |
$230.23
|
| Rate for Payer: HFN Commercial |
$240.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$121.79
|
| Rate for Payer: Multiplan Commercial |
$202.40
|
| Rate for Payer: Preferred Network Access Commercial |
$240.35
|
| Rate for Payer: Quartz Beloit One Network |
$111.32
|
| Rate for Payer: Quartz Commercial |
$144.21
|
| Rate for Payer: The Alliance Commercial |
$126.50
|
| Rate for Payer: United Healthcare Medicaid |
$24.26
|
| Rate for Payer: WEA Trust Commercial |
$139.15
|
| Rate for Payer: WPS Commercial |
$187.40
|
|
|
CHEMICAL PEEL/DERMABRASION
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2959995
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
CHEMICAL PEEL/DERMABRASION
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2959995
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
Chemodenervation Internal Anal Sphincter 46505
|
Professional
|
Both
|
$1,217.00
|
|
|
Service Code
|
CPT 46505
|
| Hospital Charge Code |
4622629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$189.67 |
| Max. Negotiated Rate |
$1,156.15 |
| Rate for Payer: Aetna Commercial |
$1,156.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,046.62
|
| Rate for Payer: Cash Price |
$365.10
|
| Rate for Payer: Cash Price |
$365.10
|
| Rate for Payer: Cigna Commercial |
$1,156.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$189.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$730.20
|
| Rate for Payer: Health EOS Commercial |
$1,107.47
|
| Rate for Payer: HFN Commercial |
$1,156.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$838.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$838.80
|
| Rate for Payer: Multiplan Commercial |
$973.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,156.15
|
| Rate for Payer: Quartz Beloit One Network |
$535.48
|
| Rate for Payer: Quartz Commercial |
$693.69
|
| Rate for Payer: The Alliance Commercial |
$608.50
|
| Rate for Payer: United Healthcare Medicaid |
$189.67
|
| Rate for Payer: WEA Trust Commercial |
$669.35
|
| Rate for Payer: WPS Commercial |
$901.43
|
|
|
Chemodenervation muscle neck unilat for dystonia 6461650
|
Professional
|
Both
|
$2,722.00
|
|
|
Service Code
|
CPT 64616 50
|
| Hospital Charge Code |
5432926
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$76.56 |
| Max. Negotiated Rate |
$2,585.90 |
| Rate for Payer: Aetna Commercial |
$2,585.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,340.92
|
| Rate for Payer: Cash Price |
$816.60
|
| Rate for Payer: Cash Price |
$816.60
|
| Rate for Payer: Cigna Commercial |
$2,585.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,633.20
|
| Rate for Payer: Health EOS Commercial |
$2,477.02
|
| Rate for Payer: HFN Commercial |
$2,585.90
|
| Rate for Payer: Multiplan Commercial |
$2,177.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,585.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,197.68
|
| Rate for Payer: Quartz Commercial |
$1,551.54
|
| Rate for Payer: The Alliance Commercial |
$1,361.00
|
| Rate for Payer: United Healthcare Medicaid |
$76.56
|
| Rate for Payer: WEA Trust Commercial |
$1,497.10
|
| Rate for Payer: WPS Commercial |
$2,016.19
|
|
|
Chemodenervation of 1 extremity; 1-4 muscle(s) 64642
|
Professional
|
Both
|
$737.00
|
|
|
Service Code
|
CPT 64642
|
| Hospital Charge Code |
5072639
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$700.15 |
| Rate for Payer: Aetna Commercial |
$700.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$633.82
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$700.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$77.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$442.20
|
| Rate for Payer: Health EOS Commercial |
$670.67
|
| Rate for Payer: HFN Commercial |
$700.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$347.46
|
| Rate for Payer: Multiplan Commercial |
$589.60
|
| Rate for Payer: Preferred Network Access Commercial |
$700.15
|
| Rate for Payer: Quartz Beloit One Network |
$324.28
|
| Rate for Payer: Quartz Commercial |
$420.09
|
| Rate for Payer: The Alliance Commercial |
$368.50
|
| Rate for Payer: United Healthcare Medicaid |
$77.70
|
| Rate for Payer: WEA Trust Commercial |
$405.35
|
| Rate for Payer: WPS Commercial |
$545.90
|
|
|
Chemodenervation of 1 extremity; => 5 muscles 64644
|
Professional
|
Both
|
$836.00
|
|
|
Service Code
|
CPT 64644
|
| Hospital Charge Code |
5072637
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$84.91 |
| Max. Negotiated Rate |
$794.20 |
| Rate for Payer: Aetna Commercial |
$794.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$718.96
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cigna Commercial |
$794.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$84.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$501.60
|
| Rate for Payer: Health EOS Commercial |
$760.76
|
| Rate for Payer: HFN Commercial |
$794.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$381.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$381.10
|
| Rate for Payer: Multiplan Commercial |
$668.80
|
| Rate for Payer: Preferred Network Access Commercial |
$794.20
|
| Rate for Payer: Quartz Beloit One Network |
$367.84
|
| Rate for Payer: Quartz Commercial |
$476.52
|
| Rate for Payer: The Alliance Commercial |
$418.00
|
| Rate for Payer: United Healthcare Medicaid |
$84.91
|
| Rate for Payer: WEA Trust Commercial |
$459.80
|
| Rate for Payer: WPS Commercial |
$619.23
|
|
|
Chemodenervation of 1 extremity; ea addi'l extremity, 1-4 muscle(s) 64643
|
Professional
|
Both
|
$288.00
|
|
|
Service Code
|
CPT 64643
|
| Hospital Charge Code |
5072638
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.01 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna Commercial |
$273.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.68
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$273.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$172.80
|
| Rate for Payer: Health EOS Commercial |
$262.08
|
| Rate for Payer: HFN Commercial |
$273.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$231.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$231.74
|
| Rate for Payer: Multiplan Commercial |
$230.40
|
| Rate for Payer: Preferred Network Access Commercial |
$273.60
|
| Rate for Payer: Quartz Beloit One Network |
$126.72
|
| Rate for Payer: Quartz Commercial |
$164.16
|
| Rate for Payer: The Alliance Commercial |
$144.00
|
| Rate for Payer: United Healthcare Medicaid |
$52.01
|
| Rate for Payer: WEA Trust Commercial |
$158.40
|
| Rate for Payer: WPS Commercial |
$213.32
|
|
|
Chemodenervation of 1 extremity; ea add'l extremity, =>5 muscles 64645
|
Professional
|
Both
|
$528.00
|
|
|
Service Code
|
CPT 64645
|
| Hospital Charge Code |
5072636
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$501.60 |
| Rate for Payer: Aetna Commercial |
$501.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.08
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna Commercial |
$501.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$316.80
|
| Rate for Payer: Health EOS Commercial |
$480.48
|
| Rate for Payer: HFN Commercial |
$501.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$264.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$264.89
|
| Rate for Payer: Multiplan Commercial |
$422.40
|
| Rate for Payer: Preferred Network Access Commercial |
$501.60
|
| Rate for Payer: Quartz Beloit One Network |
$232.32
|
| Rate for Payer: Quartz Commercial |
$300.96
|
| Rate for Payer: The Alliance Commercial |
$264.00
|
| Rate for Payer: United Healthcare Medicaid |
$59.52
|
| Rate for Payer: WEA Trust Commercial |
$290.40
|
| Rate for Payer: WPS Commercial |
$391.09
|
|
|
Chemodenervation of parotid and submandibular salivary glands, bilateral 64611
|
Professional
|
Both
|
$416.00
|
|
|
Service Code
|
CPT 64611
|
| Hospital Charge Code |
5244779
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.78 |
| Max. Negotiated Rate |
$395.20 |
| Rate for Payer: Aetna Commercial |
$395.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$357.76
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cigna Commercial |
$395.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$249.60
|
| Rate for Payer: Health EOS Commercial |
$378.56
|
| Rate for Payer: HFN Commercial |
$395.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$348.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$348.83
|
| Rate for Payer: Multiplan Commercial |
$332.80
|
| Rate for Payer: Preferred Network Access Commercial |
$395.20
|
| Rate for Payer: Quartz Beloit One Network |
$183.04
|
| Rate for Payer: Quartz Commercial |
$237.12
|
| Rate for Payer: The Alliance Commercial |
$208.00
|
| Rate for Payer: United Healthcare Medicaid |
$62.78
|
| Rate for Payer: WEA Trust Commercial |
$228.80
|
| Rate for Payer: WPS Commercial |
$308.13
|
|
|
CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES 64647
|
Professional
|
Both
|
$513.00
|
|
|
Service Code
|
CPT 64647
|
| Hospital Charge Code |
5749666
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$97.11 |
| Max. Negotiated Rate |
$487.35 |
| Rate for Payer: Aetna Commercial |
$487.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$441.18
|
| Rate for Payer: Cash Price |
$153.90
|
| Rate for Payer: Cash Price |
$153.90
|
| Rate for Payer: Cigna Commercial |
$487.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$97.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$307.80
|
| Rate for Payer: Health EOS Commercial |
$466.83
|
| Rate for Payer: HFN Commercial |
$487.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$426.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$426.95
|
| Rate for Payer: Multiplan Commercial |
$410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$487.35
|
| Rate for Payer: Quartz Beloit One Network |
$225.72
|
| Rate for Payer: Quartz Commercial |
$292.41
|
| Rate for Payer: The Alliance Commercial |
$256.50
|
| Rate for Payer: United Healthcare Medicaid |
$97.11
|
| Rate for Payer: WEA Trust Commercial |
$282.15
|
| Rate for Payer: WPS Commercial |
$379.98
|
|
|
Chemodenervation of trunk muscle(s); 1-5 muscle(s) 64616
|
Professional
|
Both
|
$953.00
|
|
|
Service Code
|
CPT 64616
|
| Hospital Charge Code |
5308637
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$76.56 |
| Max. Negotiated Rate |
$905.35 |
| Rate for Payer: Aetna Commercial |
$905.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$819.58
|
| Rate for Payer: Cash Price |
$285.90
|
| Rate for Payer: Cash Price |
$285.90
|
| Rate for Payer: Cigna Commercial |
$905.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$571.80
|
| Rate for Payer: Health EOS Commercial |
$867.23
|
| Rate for Payer: HFN Commercial |
$905.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$343.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$343.68
|
| Rate for Payer: Multiplan Commercial |
$762.40
|
| Rate for Payer: Preferred Network Access Commercial |
$905.35
|
| Rate for Payer: Quartz Beloit One Network |
$419.32
|
| Rate for Payer: Quartz Commercial |
$543.21
|
| Rate for Payer: The Alliance Commercial |
$476.50
|
| Rate for Payer: United Healthcare Medicaid |
$76.56
|
| Rate for Payer: WEA Trust Commercial |
$524.15
|
| Rate for Payer: WPS Commercial |
$705.89
|
|
|
Chemodenervation trunk muscles, 1-5 muscles 64646
|
Professional
|
Both
|
$806.00
|
|
|
Service Code
|
CPT 64646
|
| Hospital Charge Code |
5551848
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$84.12 |
| Max. Negotiated Rate |
$765.70 |
| Rate for Payer: Aetna Commercial |
$765.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$693.16
|
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cigna Commercial |
$765.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$84.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$483.60
|
| Rate for Payer: Health EOS Commercial |
$733.46
|
| Rate for Payer: HFN Commercial |
$765.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$371.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$371.99
|
| Rate for Payer: Multiplan Commercial |
$644.80
|
| Rate for Payer: Preferred Network Access Commercial |
$765.70
|
| Rate for Payer: Quartz Beloit One Network |
$354.64
|
| Rate for Payer: Quartz Commercial |
$459.42
|
| Rate for Payer: The Alliance Commercial |
$403.00
|
| Rate for Payer: United Healthcare Medicaid |
$84.12
|
| Rate for Payer: WEA Trust Commercial |
$443.30
|
| Rate for Payer: WPS Commercial |
$597.00
|
|
|
CHEMODENERV ECCRINE GLANDS 64650
|
Professional
|
Both
|
$268.00
|
|
|
Service Code
|
CPT 64650
|
| Hospital Charge Code |
3015200
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.84 |
| Max. Negotiated Rate |
$254.60 |
| Rate for Payer: Aetna Commercial |
$254.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.48
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$254.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.80
|
| Rate for Payer: Health EOS Commercial |
$243.88
|
| Rate for Payer: HFN Commercial |
$254.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$134.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$254.60
|
| Rate for Payer: Quartz Beloit One Network |
$117.92
|
| Rate for Payer: Quartz Commercial |
$152.76
|
| Rate for Payer: The Alliance Commercial |
$134.00
|
| Rate for Payer: United Healthcare Medicaid |
$50.84
|
| Rate for Payer: WEA Trust Commercial |
$147.40
|
| Rate for Payer: WPS Commercial |
$198.51
|
|
|
Chemodenerv Musc Migraine 64615
|
Professional
|
Both
|
$876.00
|
|
|
Service Code
|
CPT 64615
|
| Hospital Charge Code |
3587518
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$94.21 |
| Max. Negotiated Rate |
$832.20 |
| Rate for Payer: Aetna Commercial |
$832.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$753.36
|
| Rate for Payer: Cash Price |
$262.80
|
| Rate for Payer: Cash Price |
$262.80
|
| Rate for Payer: Cigna Commercial |
$832.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$94.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$525.60
|
| Rate for Payer: Health EOS Commercial |
$797.16
|
| Rate for Payer: HFN Commercial |
$832.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$386.29
|
| Rate for Payer: Multiplan Commercial |
$700.80
|
| Rate for Payer: Preferred Network Access Commercial |
$832.20
|
| Rate for Payer: Quartz Beloit One Network |
$385.44
|
| Rate for Payer: Quartz Commercial |
$499.32
|
| Rate for Payer: The Alliance Commercial |
$438.00
|
| Rate for Payer: United Healthcare Medicaid |
$94.21
|
| Rate for Payer: WEA Trust Commercial |
$481.80
|
| Rate for Payer: WPS Commercial |
$648.85
|
|
|
CHEMO INTRALESIONAL, UP TO 7 96405
|
Professional
|
Both
|
$384.00
|
|
|
Service Code
|
CPT 96405
|
| Hospital Charge Code |
3015503
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$168.96 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$364.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.24
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$364.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.40
|
| Rate for Payer: Health EOS Commercial |
$349.44
|
| Rate for Payer: HFN Commercial |
$364.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$291.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$291.75
|
| Rate for Payer: Multiplan Commercial |
$307.20
|
| Rate for Payer: Preferred Network Access Commercial |
$364.80
|
| Rate for Payer: Quartz Beloit One Network |
$168.96
|
| Rate for Payer: Quartz Commercial |
$218.88
|
| Rate for Payer: The Alliance Commercial |
$192.00
|
| Rate for Payer: WEA Trust Commercial |
$211.20
|
| Rate for Payer: WPS Commercial |
$284.43
|
|
|
Chemo IV Infusion 1 Hour
|
Facility
|
OP
|
$1,216.00
|
|
|
Service Code
|
CPT 96413
|
| Hospital Charge Code |
4618619
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$334.74 |
| Max. Negotiated Rate |
$1,338.96 |
| Rate for Payer: Aetna Commercial |
$1,094.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,045.76
|
| Rate for Payer: Aetna Managed Medicare |
$334.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$790.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$608.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$583.68
|
| Rate for Payer: Anthem Medicare Advantage |
$334.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$644.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$334.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$334.74
|
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Cigna Commercial |
$1,118.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$334.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$680.47
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$334.74
|
| Rate for Payer: Health EOS Commercial |
$1,082.24
|
| Rate for Payer: HFN Commercial |
$1,118.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,245.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$334.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$334.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$334.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$334.74
|
| Rate for Payer: Multiplan Commercial |
$972.80
|
| Rate for Payer: NAPHCARE Commercial |
$502.11
|
| Rate for Payer: Preferred Network Access Commercial |
$1,118.72
|
| Rate for Payer: Quartz Beloit One Network |
$595.84
|
| Rate for Payer: Quartz Commercial |
$790.40
|
| Rate for Payer: Quartz Medicare Advantage |
$334.74
|
| Rate for Payer: The Alliance Commercial |
$1,338.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$334.74
|
| Rate for Payer: United Healthcare PPO |
$912.00
|
| Rate for Payer: WEA Trust Commercial |
$668.80
|
| Rate for Payer: Wellcare Medicare |
$334.74
|
| Rate for Payer: WPS Commercial |
$900.69
|
|
|
Chemo IV Infusion 1 Hour
|
Facility
|
IP
|
$1,216.00
|
|
|
Service Code
|
CPT 96413
|
| Hospital Charge Code |
4618619
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$595.84 |
| Max. Negotiated Rate |
$1,118.72 |
| Rate for Payer: Aetna Commercial |
$1,094.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,045.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$644.48
|
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Cigna Commercial |
$1,118.72
|
| Rate for Payer: Health EOS Commercial |
$1,082.24
|
| Rate for Payer: HFN Commercial |
$1,118.72
|
| Rate for Payer: Multiplan Commercial |
$972.80
|
| Rate for Payer: NAPHCARE Commercial |
$729.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,118.72
|
| Rate for Payer: Quartz Beloit One Network |
$595.84
|
| Rate for Payer: Quartz Commercial |
$729.60
|
| Rate for Payer: WEA Trust Commercial |
$668.80
|
| Rate for Payer: WPS Commercial |
$900.69
|
|
|
Chemo IV Infusion Additional 1-8 Hours
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
CPT 96415
|
| Hospital Charge Code |
4618620
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$195.02 |
| Max. Negotiated Rate |
$366.16 |
| Rate for Payer: Aetna Commercial |
$358.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.94
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$366.16
|
| Rate for Payer: Health EOS Commercial |
$354.22
|
| Rate for Payer: HFN Commercial |
$366.16
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: NAPHCARE Commercial |
$238.80
|
| Rate for Payer: Preferred Network Access Commercial |
$366.16
|
| Rate for Payer: Quartz Beloit One Network |
$195.02
|
| Rate for Payer: Quartz Commercial |
$238.80
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
Chemo IV Infusion Additional 1-8 Hours
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 96415
|
| Hospital Charge Code |
4618620
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$69.63 |
| Max. Negotiated Rate |
$366.16 |
| Rate for Payer: Aetna Commercial |
$358.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Aetna Managed Medicare |
$69.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$258.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$199.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$191.04
|
| Rate for Payer: Anthem Medicare Advantage |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.63
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$366.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$69.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$69.63
|
| Rate for Payer: Health EOS Commercial |
$354.22
|
| Rate for Payer: HFN Commercial |
$366.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$69.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$69.63
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: NAPHCARE Commercial |
$104.44
|
| Rate for Payer: Preferred Network Access Commercial |
$366.16
|
| Rate for Payer: Quartz Beloit One Network |
$195.02
|
| Rate for Payer: Quartz Commercial |
$258.70
|
| Rate for Payer: Quartz Medicare Advantage |
$69.63
|
| Rate for Payer: The Alliance Commercial |
$278.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare PPO |
$298.50
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: Wellcare Medicare |
$69.63
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
