|
Destroy Lumbar/Sac Facet Joint 64635
|
Professional
|
Both
|
$1,549.00
|
|
|
Service Code
|
CPT 64635
|
| Hospital Charge Code |
5232729
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$339.97 |
| Max. Negotiated Rate |
$1,471.55 |
| Rate for Payer: Aetna Commercial |
$1,471.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,332.14
|
| Rate for Payer: Cash Price |
$464.70
|
| Rate for Payer: Cash Price |
$464.70
|
| Rate for Payer: Cigna Commercial |
$1,471.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$339.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$929.40
|
| Rate for Payer: Health EOS Commercial |
$1,409.59
|
| Rate for Payer: HFN Commercial |
$1,471.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$749.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$749.07
|
| Rate for Payer: Multiplan Commercial |
$1,239.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,471.55
|
| Rate for Payer: Quartz Beloit One Network |
$681.56
|
| Rate for Payer: Quartz Commercial |
$882.93
|
| Rate for Payer: The Alliance Commercial |
$774.50
|
| Rate for Payer: United Healthcare Medicaid |
$339.97
|
| Rate for Payer: WEA Trust Commercial |
$851.95
|
| Rate for Payer: WPS Commercial |
$1,147.34
|
|
|
Destroy Lumbar/Sac Facet Joint 6463550
|
Professional
|
Both
|
$3,096.00
|
|
|
Service Code
|
CPT 64635 50
|
| Hospital Charge Code |
5232730
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$339.97 |
| Max. Negotiated Rate |
$2,941.20 |
| Rate for Payer: Aetna Commercial |
$2,941.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,662.56
|
| Rate for Payer: Cash Price |
$928.80
|
| Rate for Payer: Cash Price |
$928.80
|
| Rate for Payer: Cigna Commercial |
$2,941.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$339.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,857.60
|
| Rate for Payer: Health EOS Commercial |
$2,817.36
|
| Rate for Payer: HFN Commercial |
$2,941.20
|
| Rate for Payer: Multiplan Commercial |
$2,476.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,362.24
|
| Rate for Payer: Quartz Commercial |
$1,764.72
|
| Rate for Payer: The Alliance Commercial |
$1,548.00
|
| Rate for Payer: United Healthcare Medicaid |
$339.97
|
| Rate for Payer: WEA Trust Commercial |
$1,702.80
|
| Rate for Payer: WPS Commercial |
$2,293.21
|
|
|
DESTROY NERVE C/T FACET EACH +
|
Facility
|
IP
|
$678.00
|
|
| Hospital Charge Code |
5262693
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$332.22 |
| Max. Negotiated Rate |
$623.76 |
| Rate for Payer: Aetna Commercial |
$610.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$583.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$359.34
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$623.76
|
| Rate for Payer: Health EOS Commercial |
$603.42
|
| Rate for Payer: HFN Commercial |
$623.76
|
| Rate for Payer: Multiplan Commercial |
$542.40
|
| Rate for Payer: NAPHCARE Commercial |
$406.80
|
| Rate for Payer: Preferred Network Access Commercial |
$623.76
|
| Rate for Payer: Quartz Beloit One Network |
$332.22
|
| Rate for Payer: Quartz Commercial |
$406.80
|
| Rate for Payer: WEA Trust Commercial |
$372.90
|
| Rate for Payer: WPS Commercial |
$502.19
|
|
|
DESTROY NERVE C/T FACET EACH +
|
Facility
|
OP
|
$678.00
|
|
| Hospital Charge Code |
5262693
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$189.84 |
| Max. Negotiated Rate |
$2,712.00 |
| Rate for Payer: Aetna Commercial |
$610.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$583.08
|
| Rate for Payer: Aetna Managed Medicare |
$189.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$440.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$325.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$359.34
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$623.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$379.41
|
| Rate for Payer: Health EOS Commercial |
$603.42
|
| Rate for Payer: HFN Commercial |
$623.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$508.50
|
| Rate for Payer: Multiplan Commercial |
$542.40
|
| Rate for Payer: NAPHCARE Commercial |
$406.80
|
| Rate for Payer: Preferred Network Access Commercial |
$623.76
|
| Rate for Payer: Quartz Beloit One Network |
$332.22
|
| Rate for Payer: Quartz Commercial |
$440.70
|
| Rate for Payer: Quartz Medicare Advantage |
$406.80
|
| Rate for Payer: The Alliance Commercial |
$2,712.00
|
| Rate for Payer: WEA Trust Commercial |
$372.90
|
| Rate for Payer: WPS Commercial |
$502.19
|
|
|
DESTROY NERVE C/T FACET SINGLE
|
Facility
|
OP
|
$2,980.00
|
|
| Hospital Charge Code |
5262692
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$834.40 |
| Max. Negotiated Rate |
$11,920.00 |
| Rate for Payer: Aetna Commercial |
$2,682.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,562.80
|
| Rate for Payer: Aetna Managed Medicare |
$834.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,937.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,490.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,430.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,579.40
|
| Rate for Payer: Cash Price |
$894.00
|
| Rate for Payer: Cigna Commercial |
$2,741.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,667.61
|
| Rate for Payer: Health EOS Commercial |
$2,652.20
|
| Rate for Payer: HFN Commercial |
$2,741.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,235.00
|
| Rate for Payer: Multiplan Commercial |
$2,384.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,788.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,741.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,460.20
|
| Rate for Payer: Quartz Commercial |
$1,937.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,788.00
|
| Rate for Payer: The Alliance Commercial |
$11,920.00
|
| Rate for Payer: WEA Trust Commercial |
$1,639.00
|
| Rate for Payer: WPS Commercial |
$2,207.29
|
|
|
DESTROY NERVE C/T FACET SINGLE
|
Facility
|
IP
|
$2,980.00
|
|
| Hospital Charge Code |
5262692
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,460.20 |
| Max. Negotiated Rate |
$2,741.60 |
| Rate for Payer: Aetna Commercial |
$2,682.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,562.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,579.40
|
| Rate for Payer: Cash Price |
$894.00
|
| Rate for Payer: Cigna Commercial |
$2,741.60
|
| Rate for Payer: Health EOS Commercial |
$2,652.20
|
| Rate for Payer: HFN Commercial |
$2,741.60
|
| Rate for Payer: Multiplan Commercial |
$2,384.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,788.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,741.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,460.20
|
| Rate for Payer: Quartz Commercial |
$1,788.00
|
| Rate for Payer: WEA Trust Commercial |
$1,639.00
|
| Rate for Payer: WPS Commercial |
$2,207.29
|
|
|
DESTROY NERVE, FACE MUSCLE 64612
|
Professional
|
Both
|
$643.00
|
|
|
Service Code
|
CPT 64612
|
| Hospital Charge Code |
3015196
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$181.81 |
| Max. Negotiated Rate |
$610.85 |
| Rate for Payer: Aetna Commercial |
$610.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$552.98
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cigna Commercial |
$610.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$181.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$385.80
|
| Rate for Payer: Health EOS Commercial |
$585.13
|
| Rate for Payer: HFN Commercial |
$610.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$387.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$387.74
|
| Rate for Payer: Multiplan Commercial |
$514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$610.85
|
| Rate for Payer: Quartz Beloit One Network |
$282.92
|
| Rate for Payer: Quartz Commercial |
$366.51
|
| Rate for Payer: The Alliance Commercial |
$321.50
|
| Rate for Payer: United Healthcare Medicaid |
$181.81
|
| Rate for Payer: WEA Trust Commercial |
$353.65
|
| Rate for Payer: WPS Commercial |
$476.27
|
|
|
Destroy Nerve, Face Muscle 6461250
|
Professional
|
Both
|
$1,285.00
|
|
|
Service Code
|
CPT 64612 50
|
| Hospital Charge Code |
5482703
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$565.40 |
| Max. Negotiated Rate |
$1,220.75 |
| Rate for Payer: Aetna Commercial |
$1,220.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,105.10
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cigna Commercial |
$1,220.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$642.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$771.00
|
| Rate for Payer: Health EOS Commercial |
$1,169.35
|
| Rate for Payer: HFN Commercial |
$1,220.75
|
| Rate for Payer: Multiplan Commercial |
$1,028.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,220.75
|
| Rate for Payer: Quartz Beloit One Network |
$565.40
|
| Rate for Payer: Quartz Commercial |
$732.45
|
| Rate for Payer: The Alliance Commercial |
$642.50
|
| Rate for Payer: WEA Trust Commercial |
$706.75
|
| Rate for Payer: WPS Commercial |
$951.80
|
|
|
DESTROY NERVE L/S FACET EACH +
|
Facility
|
OP
|
$566.00
|
|
| Hospital Charge Code |
5262695
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$158.48 |
| Max. Negotiated Rate |
$2,264.00 |
| Rate for Payer: Aetna Commercial |
$509.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$486.76
|
| Rate for Payer: Aetna Managed Medicare |
$158.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$367.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$283.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$271.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$299.98
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cigna Commercial |
$520.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$316.73
|
| Rate for Payer: Health EOS Commercial |
$503.74
|
| Rate for Payer: HFN Commercial |
$520.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$424.50
|
| Rate for Payer: Multiplan Commercial |
$452.80
|
| Rate for Payer: NAPHCARE Commercial |
$339.60
|
| Rate for Payer: Preferred Network Access Commercial |
$520.72
|
| Rate for Payer: Quartz Beloit One Network |
$277.34
|
| Rate for Payer: Quartz Commercial |
$367.90
|
| Rate for Payer: Quartz Medicare Advantage |
$339.60
|
| Rate for Payer: The Alliance Commercial |
$2,264.00
|
| Rate for Payer: WEA Trust Commercial |
$311.30
|
| Rate for Payer: WPS Commercial |
$419.24
|
|
|
DESTROY NERVE L/S FACET EACH +
|
Facility
|
IP
|
$566.00
|
|
| Hospital Charge Code |
5262695
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$277.34 |
| Max. Negotiated Rate |
$520.72 |
| Rate for Payer: Aetna Commercial |
$509.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$486.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$299.98
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cigna Commercial |
$520.72
|
| Rate for Payer: Health EOS Commercial |
$503.74
|
| Rate for Payer: HFN Commercial |
$520.72
|
| Rate for Payer: Multiplan Commercial |
$452.80
|
| Rate for Payer: NAPHCARE Commercial |
$339.60
|
| Rate for Payer: Preferred Network Access Commercial |
$520.72
|
| Rate for Payer: Quartz Beloit One Network |
$277.34
|
| Rate for Payer: Quartz Commercial |
$339.60
|
| Rate for Payer: WEA Trust Commercial |
$311.30
|
| Rate for Payer: WPS Commercial |
$419.24
|
|
|
DESTROY NERVE L/S FACET SINGLE
|
Facility
|
IP
|
$2,971.00
|
|
| Hospital Charge Code |
5262694
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,455.79 |
| Max. Negotiated Rate |
$2,733.32 |
| Rate for Payer: Aetna Commercial |
$2,673.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,555.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,574.63
|
| Rate for Payer: Cash Price |
$891.30
|
| Rate for Payer: Cigna Commercial |
$2,733.32
|
| Rate for Payer: Health EOS Commercial |
$2,644.19
|
| Rate for Payer: HFN Commercial |
$2,733.32
|
| Rate for Payer: Multiplan Commercial |
$2,376.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,782.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,733.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,455.79
|
| Rate for Payer: Quartz Commercial |
$1,782.60
|
| Rate for Payer: WEA Trust Commercial |
$1,634.05
|
| Rate for Payer: WPS Commercial |
$2,200.62
|
|
|
DESTROY NERVE L/S FACET SINGLE
|
Facility
|
OP
|
$2,971.00
|
|
| Hospital Charge Code |
5262694
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$831.88 |
| Max. Negotiated Rate |
$11,884.00 |
| Rate for Payer: Aetna Commercial |
$2,673.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,555.06
|
| Rate for Payer: Aetna Managed Medicare |
$831.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,931.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,485.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,426.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,574.63
|
| Rate for Payer: Cash Price |
$891.30
|
| Rate for Payer: Cigna Commercial |
$2,733.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,662.57
|
| Rate for Payer: Health EOS Commercial |
$2,644.19
|
| Rate for Payer: HFN Commercial |
$2,733.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,228.25
|
| Rate for Payer: Multiplan Commercial |
$2,376.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,782.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,733.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,455.79
|
| Rate for Payer: Quartz Commercial |
$1,931.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,782.60
|
| Rate for Payer: The Alliance Commercial |
$11,884.00
|
| Rate for Payer: WEA Trust Commercial |
$1,634.05
|
| Rate for Payer: WPS Commercial |
$2,200.62
|
|
|
DESTROY NERVE, NECK MUSCLE 64613
|
Professional
|
Both
|
$796.00
|
|
| Hospital Charge Code |
3015197
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$350.24 |
| Max. Negotiated Rate |
$756.20 |
| Rate for Payer: Aetna Commercial |
$756.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$684.56
|
| Rate for Payer: Cash Price |
$238.80
|
| Rate for Payer: Cigna Commercial |
$756.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$398.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$477.60
|
| Rate for Payer: Health EOS Commercial |
$724.36
|
| Rate for Payer: HFN Commercial |
$756.20
|
| Rate for Payer: Multiplan Commercial |
$636.80
|
| Rate for Payer: Preferred Network Access Commercial |
$756.20
|
| Rate for Payer: Quartz Beloit One Network |
$350.24
|
| Rate for Payer: Quartz Commercial |
$453.72
|
| Rate for Payer: The Alliance Commercial |
$398.00
|
| Rate for Payer: WEA Trust Commercial |
$437.80
|
| Rate for Payer: WPS Commercial |
$589.60
|
|
|
DESTROY NERVE OTHER PERIPHERAL
|
Facility
|
IP
|
$210.00
|
|
| Hospital Charge Code |
5262696
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$193.20 |
| Rate for Payer: Aetna Commercial |
$189.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$111.30
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$193.20
|
| Rate for Payer: Health EOS Commercial |
$186.90
|
| Rate for Payer: HFN Commercial |
$193.20
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: NAPHCARE Commercial |
$126.00
|
| Rate for Payer: Preferred Network Access Commercial |
$193.20
|
| Rate for Payer: Quartz Beloit One Network |
$102.90
|
| Rate for Payer: Quartz Commercial |
$126.00
|
| Rate for Payer: WEA Trust Commercial |
$115.50
|
| Rate for Payer: WPS Commercial |
$155.55
|
|
|
DESTROY NERVE OTHER PERIPHERAL
|
Facility
|
OP
|
$210.00
|
|
| Hospital Charge Code |
5262696
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$840.00 |
| Rate for Payer: Aetna Commercial |
$189.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.60
|
| Rate for Payer: Aetna Managed Medicare |
$58.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$136.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$105.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$100.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$111.30
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$193.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$117.52
|
| Rate for Payer: Health EOS Commercial |
$186.90
|
| Rate for Payer: HFN Commercial |
$193.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$157.50
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: NAPHCARE Commercial |
$126.00
|
| Rate for Payer: Preferred Network Access Commercial |
$193.20
|
| Rate for Payer: Quartz Beloit One Network |
$102.90
|
| Rate for Payer: Quartz Commercial |
$136.50
|
| Rate for Payer: Quartz Medicare Advantage |
$126.00
|
| Rate for Payer: The Alliance Commercial |
$840.00
|
| Rate for Payer: WEA Trust Commercial |
$115.50
|
| Rate for Payer: WPS Commercial |
$155.55
|
|
|
DESTROY NERVE TRIGEMINAL
|
Facility
|
IP
|
$379.00
|
|
| Hospital Charge Code |
5262690
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$185.71 |
| Max. Negotiated Rate |
$348.68 |
| Rate for Payer: Aetna Commercial |
$341.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$200.87
|
| Rate for Payer: Cash Price |
$113.70
|
| Rate for Payer: Cigna Commercial |
$348.68
|
| Rate for Payer: Health EOS Commercial |
$337.31
|
| Rate for Payer: HFN Commercial |
$348.68
|
| Rate for Payer: Multiplan Commercial |
$303.20
|
| Rate for Payer: NAPHCARE Commercial |
$227.40
|
| Rate for Payer: Preferred Network Access Commercial |
$348.68
|
| Rate for Payer: Quartz Beloit One Network |
$185.71
|
| Rate for Payer: Quartz Commercial |
$227.40
|
| Rate for Payer: WEA Trust Commercial |
$208.45
|
| Rate for Payer: WPS Commercial |
$280.73
|
|
|
DESTROY NERVE TRIGEMINAL
|
Facility
|
OP
|
$379.00
|
|
| Hospital Charge Code |
5262690
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$106.12 |
| Max. Negotiated Rate |
$1,516.00 |
| Rate for Payer: Aetna Commercial |
$341.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.94
|
| Rate for Payer: Aetna Managed Medicare |
$106.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$246.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$189.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$181.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$200.87
|
| Rate for Payer: Cash Price |
$113.70
|
| Rate for Payer: Cigna Commercial |
$348.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$212.09
|
| Rate for Payer: Health EOS Commercial |
$337.31
|
| Rate for Payer: HFN Commercial |
$348.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$284.25
|
| Rate for Payer: Multiplan Commercial |
$303.20
|
| Rate for Payer: NAPHCARE Commercial |
$227.40
|
| Rate for Payer: Preferred Network Access Commercial |
$348.68
|
| Rate for Payer: Quartz Beloit One Network |
$185.71
|
| Rate for Payer: Quartz Commercial |
$246.35
|
| Rate for Payer: Quartz Medicare Advantage |
$227.40
|
| Rate for Payer: The Alliance Commercial |
$1,516.00
|
| Rate for Payer: WEA Trust Commercial |
$208.45
|
| Rate for Payer: WPS Commercial |
$280.73
|
|
|
DESTROY VAG LESIONS, COMPLEX 57065
|
Professional
|
Both
|
$2,953.00
|
|
|
Service Code
|
CPT 57065
|
| Hospital Charge Code |
3015068
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$300.23 |
| Max. Negotiated Rate |
$2,805.35 |
| Rate for Payer: Aetna Commercial |
$2,805.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,539.58
|
| Rate for Payer: Cash Price |
$885.90
|
| Rate for Payer: Cash Price |
$885.90
|
| Rate for Payer: Cigna Commercial |
$2,805.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$300.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,771.80
|
| Rate for Payer: Health EOS Commercial |
$2,687.23
|
| Rate for Payer: HFN Commercial |
$2,805.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$615.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$615.99
|
| Rate for Payer: Multiplan Commercial |
$2,362.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,805.35
|
| Rate for Payer: Quartz Beloit One Network |
$1,299.32
|
| Rate for Payer: Quartz Commercial |
$1,683.21
|
| Rate for Payer: The Alliance Commercial |
$1,476.50
|
| Rate for Payer: United Healthcare Medicaid |
$300.23
|
| Rate for Payer: WEA Trust Commercial |
$1,624.15
|
| Rate for Payer: WPS Commercial |
$2,187.29
|
|
|
DESTROY VAG LESIONS, SIMPLE 57061
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
CPT 57061
|
| Hospital Charge Code |
3015067
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.08 |
| Max. Negotiated Rate |
$376.62 |
| Rate for Payer: Aetna Commercial |
$356.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$322.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$356.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$225.00
|
| Rate for Payer: Health EOS Commercial |
$341.25
|
| Rate for Payer: HFN Commercial |
$356.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$376.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$376.62
|
| Rate for Payer: Multiplan Commercial |
$300.00
|
| Rate for Payer: Preferred Network Access Commercial |
$356.25
|
| Rate for Payer: Quartz Beloit One Network |
$165.00
|
| Rate for Payer: Quartz Commercial |
$213.75
|
| Rate for Payer: The Alliance Commercial |
$187.50
|
| Rate for Payer: United Healthcare Medicaid |
$43.08
|
| Rate for Payer: WEA Trust Commercial |
$206.25
|
| Rate for Payer: WPS Commercial |
$277.76
|
|
|
DESTRUCTION, ANAL LESION(S) 46900
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
CPT 46900
|
| Hospital Charge Code |
3014846
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.97 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Aetna Commercial |
$470.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$470.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$297.00
|
| Rate for Payer: Health EOS Commercial |
$450.45
|
| Rate for Payer: HFN Commercial |
$470.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$454.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$454.38
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: Preferred Network Access Commercial |
$470.25
|
| Rate for Payer: Quartz Beloit One Network |
$217.80
|
| Rate for Payer: Quartz Commercial |
$282.15
|
| Rate for Payer: The Alliance Commercial |
$247.50
|
| Rate for Payer: United Healthcare Medicaid |
$26.97
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
DESTRUCTION, ANAL LESION(S) 46924
|
Professional
|
Both
|
$2,273.00
|
|
|
Service Code
|
CPT 46924
|
| Hospital Charge Code |
3014849
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$301.31 |
| Max. Negotiated Rate |
$2,159.35 |
| Rate for Payer: Aetna Commercial |
$2,159.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,954.78
|
| Rate for Payer: Cash Price |
$681.90
|
| Rate for Payer: Cash Price |
$681.90
|
| Rate for Payer: Cigna Commercial |
$2,159.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$301.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,363.80
|
| Rate for Payer: Health EOS Commercial |
$2,068.43
|
| Rate for Payer: HFN Commercial |
$2,159.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$598.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$598.48
|
| Rate for Payer: Multiplan Commercial |
$1,818.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,159.35
|
| Rate for Payer: Quartz Beloit One Network |
$1,000.12
|
| Rate for Payer: Quartz Commercial |
$1,295.61
|
| Rate for Payer: The Alliance Commercial |
$1,136.50
|
| Rate for Payer: United Healthcare Medicaid |
$301.31
|
| Rate for Payer: WEA Trust Commercial |
$1,250.15
|
| Rate for Payer: WPS Commercial |
$1,683.61
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 64636
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,218.22 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT
|
Facility
|
OP
|
$7,633.60
|
|
|
Service Code
|
CPT 64635
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,908.40 |
| Max. Negotiated Rate |
$7,633.60 |
| Rate for Payer: Aetna Managed Medicare |
$1,908.40
|
| 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 |
$1,908.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,908.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,908.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,908.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,908.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,099.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,908.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,908.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,908.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,908.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,862.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,908.40
|
| Rate for Payer: The Alliance Commercial |
$7,633.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,908.40
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,908.40
|
|
|
Destruction By Neurolytic Agent, Peripheral Nerve Branch 64640
|
Professional
|
Both
|
$1,172.00
|
|
|
Service Code
|
CPT 64640
|
| Hospital Charge Code |
2572823
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$156.99 |
| Max. Negotiated Rate |
$1,113.40 |
| Rate for Payer: Aetna Commercial |
$1,113.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,007.92
|
| Rate for Payer: Cash Price |
$351.60
|
| Rate for Payer: Cash Price |
$351.60
|
| Rate for Payer: Cigna Commercial |
$1,113.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$156.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$703.20
|
| Rate for Payer: Health EOS Commercial |
$1,066.52
|
| Rate for Payer: HFN Commercial |
$1,113.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$400.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$400.48
|
| Rate for Payer: Multiplan Commercial |
$937.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,113.40
|
| Rate for Payer: Quartz Beloit One Network |
$515.68
|
| Rate for Payer: Quartz Commercial |
$668.04
|
| Rate for Payer: The Alliance Commercial |
$586.00
|
| Rate for Payer: United Healthcare Medicaid |
$156.99
|
| Rate for Payer: WEA Trust Commercial |
$644.60
|
| Rate for Payer: WPS Commercial |
$868.10
|
|
|
Destruction, malignant lesion (face, ears, eyelids, nose, lips, mucous membranes) <=0.5cm 17280
|
Professional
|
Both
|
$578.00
|
|
|
Service Code
|
CPT 17280
|
| Hospital Charge Code |
3013668
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.51 |
| Max. Negotiated Rate |
$549.10 |
| Rate for Payer: Aetna Commercial |
$549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.08
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cigna Commercial |
$549.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$346.80
|
| Rate for Payer: Health EOS Commercial |
$525.98
|
| Rate for Payer: HFN Commercial |
$549.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$289.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$289.60
|
| Rate for Payer: Multiplan Commercial |
$462.40
|
| Rate for Payer: Preferred Network Access Commercial |
$549.10
|
| Rate for Payer: Quartz Beloit One Network |
$254.32
|
| Rate for Payer: Quartz Commercial |
$329.46
|
| Rate for Payer: The Alliance Commercial |
$289.00
|
| Rate for Payer: United Healthcare Medicaid |
$87.51
|
| Rate for Payer: WEA Trust Commercial |
$317.90
|
| Rate for Payer: WPS Commercial |
$428.12
|
|
