|
Desipramine Level
|
Facility
|
OP
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977922
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$139.48 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Aetna Managed Medicare |
$139.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$323.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$249.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$239.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.78
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$373.62
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: NAPHCARE Commercial |
$298.90
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$323.80
|
| Rate for Payer: Quartz Medicare Advantage |
$298.90
|
| Rate for Payer: The Alliance Commercial |
$249.08
|
| Rate for Payer: United Healthcare PPO |
$373.62
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
Desipramine Level
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977922
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$244.10 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$298.90
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
Desipramine Level
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977922
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$473.25 |
| Rate for Payer: Aetna Commercial |
$473.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$473.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$249.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$298.90
|
| Rate for Payer: Health EOS Commercial |
$453.33
|
| Rate for Payer: HFN Commercial |
$473.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: Preferred Network Access Commercial |
$473.25
|
| Rate for Payer: Quartz Beloit One Network |
$219.19
|
| Rate for Payer: Quartz Commercial |
$283.95
|
| Rate for Payer: The Alliance Commercial |
$249.08
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
Destr of local les choroid, photocoag, 1 or more session 67220
|
Professional
|
Both
|
$1,302.00
|
|
|
Service Code
|
CPT 67220
|
| Hospital Charge Code |
5551405
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$424.50 |
| Max. Negotiated Rate |
$1,910.24 |
| Rate for Payer: Aetna Commercial |
$1,286.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,164.51
|
| Rate for Payer: Aetna Managed Medicare |
$424.50
|
| Rate for Payer: Anthem Medicare Advantage |
$424.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$424.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$424.50
|
| Rate for Payer: Cash Price |
$390.60
|
| Rate for Payer: Cash Price |
$390.60
|
| Rate for Payer: Cash Price |
$390.60
|
| Rate for Payer: Cigna Commercial |
$1,286.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$655.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$424.50
|
| Rate for Payer: Health EOS Commercial |
$1,232.21
|
| Rate for Payer: HFN Commercial |
$1,286.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,742.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,742.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$424.50
|
| Rate for Payer: Multiplan Commercial |
$1,083.26
|
| Rate for Payer: NAPHCARE Commercial |
$636.75
|
| Rate for Payer: Preferred Network Access Commercial |
$1,286.38
|
| Rate for Payer: Quartz Beloit One Network |
$595.80
|
| Rate for Payer: Quartz Commercial |
$771.83
|
| Rate for Payer: Quartz Medicare Advantage |
$424.50
|
| Rate for Payer: The Alliance Commercial |
$1,804.11
|
| Rate for Payer: United Healthcare Medicaid |
$655.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$424.50
|
| Rate for Payer: WEA Trust Commercial |
$744.74
|
| Rate for Payer: WPS Commercial |
$1,910.24
|
|
|
Destr of local les choroid, photocoag, 1 or more session 6722050
|
Professional
|
Both
|
$2,604.00
|
|
|
Service Code
|
CPT 67220 50
|
| Hospital Charge Code |
5551406
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$655.91 |
| Max. Negotiated Rate |
$2,572.75 |
| Rate for Payer: Aetna Commercial |
$2,572.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,329.02
|
| Rate for Payer: Cash Price |
$781.20
|
| Rate for Payer: Cash Price |
$781.20
|
| Rate for Payer: Cash Price |
$781.20
|
| Rate for Payer: Cigna Commercial |
$2,572.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$655.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,624.90
|
| Rate for Payer: Health EOS Commercial |
$2,464.43
|
| Rate for Payer: HFN Commercial |
$2,572.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,742.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,742.38
|
| Rate for Payer: Multiplan Commercial |
$2,166.53
|
| Rate for Payer: Preferred Network Access Commercial |
$2,572.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,191.59
|
| Rate for Payer: Quartz Commercial |
$1,543.65
|
| Rate for Payer: The Alliance Commercial |
$1,354.08
|
| Rate for Payer: United Healthcare Medicaid |
$655.91
|
| Rate for Payer: WEA Trust Commercial |
$1,489.49
|
| Rate for Payer: WPS Commercial |
$2,005.86
|
|
|
Destroy Cervical/Thor Facet JT 64633
|
Professional
|
Both
|
$1,292.00
|
|
|
Service Code
|
CPT 64633
|
| Hospital Charge Code |
5232714
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$170.00 |
| Max. Negotiated Rate |
$1,276.50 |
| Rate for Payer: Aetna Commercial |
$1,276.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,155.56
|
| Rate for Payer: Aetna Managed Medicare |
$170.00
|
| Rate for Payer: Anthem Medicare Advantage |
$170.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$170.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$170.00
|
| Rate for Payer: Cash Price |
$387.60
|
| Rate for Payer: Cash Price |
$387.60
|
| Rate for Payer: Cash Price |
$387.60
|
| Rate for Payer: Cigna Commercial |
$1,276.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$359.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$170.00
|
| Rate for Payer: Health EOS Commercial |
$1,222.75
|
| Rate for Payer: HFN Commercial |
$1,276.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$789.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$789.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$170.00
|
| Rate for Payer: Multiplan Commercial |
$1,074.94
|
| Rate for Payer: NAPHCARE Commercial |
$255.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,276.50
|
| Rate for Payer: Quartz Beloit One Network |
$591.22
|
| Rate for Payer: Quartz Commercial |
$765.90
|
| Rate for Payer: Quartz Medicare Advantage |
$170.00
|
| Rate for Payer: The Alliance Commercial |
$722.49
|
| Rate for Payer: United Healthcare Medicaid |
$359.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$170.00
|
| Rate for Payer: WEA Trust Commercial |
$739.02
|
| Rate for Payer: WPS Commercial |
$764.99
|
|
|
Destroy C/TH Facet Joint Addl 64634
|
Professional
|
Both
|
$401.00
|
|
|
Service Code
|
CPT 64634
|
| Hospital Charge Code |
5232727
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$56.74 |
| Max. Negotiated Rate |
$396.19 |
| Rate for Payer: Aetna Commercial |
$396.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Aetna Managed Medicare |
$56.74
|
| Rate for Payer: Anthem Medicare Advantage |
$56.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$56.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$56.74
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$396.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$165.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.74
|
| Rate for Payer: Health EOS Commercial |
$379.51
|
| Rate for Payer: HFN Commercial |
$396.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$237.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$56.74
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: NAPHCARE Commercial |
$85.11
|
| Rate for Payer: Preferred Network Access Commercial |
$396.19
|
| Rate for Payer: Quartz Beloit One Network |
$183.50
|
| Rate for Payer: Quartz Commercial |
$237.71
|
| Rate for Payer: Quartz Medicare Advantage |
$56.74
|
| Rate for Payer: The Alliance Commercial |
$241.16
|
| Rate for Payer: United Healthcare Medicaid |
$165.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.74
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$255.34
|
|
|
Destroy L/S Facet Joint Add Level 64636
|
Professional
|
Both
|
$494.00
|
|
|
Service Code
|
CPT 64636
|
| Hospital Charge Code |
5232731
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.74 |
| Max. Negotiated Rate |
$488.07 |
| Rate for Payer: Aetna Commercial |
$488.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$441.83
|
| Rate for Payer: Aetna Managed Medicare |
$49.74
|
| Rate for Payer: Anthem Medicare Advantage |
$49.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.74
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cigna Commercial |
$488.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.74
|
| Rate for Payer: Health EOS Commercial |
$467.52
|
| Rate for Payer: HFN Commercial |
$488.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$209.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$209.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.74
|
| Rate for Payer: Multiplan Commercial |
$411.01
|
| Rate for Payer: NAPHCARE Commercial |
$74.61
|
| Rate for Payer: Preferred Network Access Commercial |
$488.07
|
| Rate for Payer: Quartz Beloit One Network |
$226.05
|
| Rate for Payer: Quartz Commercial |
$292.84
|
| Rate for Payer: Quartz Medicare Advantage |
$49.74
|
| Rate for Payer: The Alliance Commercial |
$211.41
|
| Rate for Payer: United Healthcare Medicaid |
$148.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.74
|
| Rate for Payer: WEA Trust Commercial |
$282.57
|
| Rate for Payer: WPS Commercial |
$223.84
|
|
|
Destroy L/S Facet Joint Add Level 6463650
|
Professional
|
Both
|
$3,685.00
|
|
|
Service Code
|
CPT 64636 50
|
| Hospital Charge Code |
5232732
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$148.55 |
| Max. Negotiated Rate |
$3,640.78 |
| Rate for Payer: Aetna Commercial |
$3,640.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,295.86
|
| Rate for Payer: Cash Price |
$1,105.50
|
| Rate for Payer: Cash Price |
$1,105.50
|
| Rate for Payer: Cash Price |
$1,105.50
|
| Rate for Payer: Cigna Commercial |
$3,640.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,299.44
|
| Rate for Payer: Health EOS Commercial |
$3,487.48
|
| Rate for Payer: HFN Commercial |
$3,640.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$209.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$209.48
|
| Rate for Payer: Multiplan Commercial |
$3,065.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,640.78
|
| Rate for Payer: Quartz Beloit One Network |
$1,686.26
|
| Rate for Payer: Quartz Commercial |
$2,184.47
|
| Rate for Payer: The Alliance Commercial |
$1,916.20
|
| Rate for Payer: United Healthcare Medicaid |
$148.55
|
| Rate for Payer: WEA Trust Commercial |
$2,107.82
|
| Rate for Payer: WPS Commercial |
$2,838.56
|
|
|
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 |
$170.56 |
| Max. Negotiated Rate |
$1,530.41 |
| Rate for Payer: Aetna Commercial |
$1,530.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,385.43
|
| Rate for Payer: Aetna Managed Medicare |
$170.56
|
| Rate for Payer: Anthem Medicare Advantage |
$170.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$170.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$170.56
|
| Rate for Payer: Cash Price |
$464.70
|
| Rate for Payer: Cash Price |
$464.70
|
| Rate for Payer: Cash Price |
$464.70
|
| Rate for Payer: Cigna Commercial |
$1,530.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$353.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$170.56
|
| Rate for Payer: Health EOS Commercial |
$1,465.97
|
| Rate for Payer: HFN Commercial |
$1,530.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$779.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$779.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$170.56
|
| Rate for Payer: Multiplan Commercial |
$1,288.77
|
| Rate for Payer: NAPHCARE Commercial |
$255.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,530.41
|
| Rate for Payer: Quartz Beloit One Network |
$708.82
|
| Rate for Payer: Quartz Commercial |
$918.25
|
| Rate for Payer: Quartz Medicare Advantage |
$170.56
|
| Rate for Payer: The Alliance Commercial |
$724.88
|
| Rate for Payer: United Healthcare Medicaid |
$353.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$170.56
|
| Rate for Payer: WEA Trust Commercial |
$886.03
|
| Rate for Payer: WPS Commercial |
$767.52
|
|
|
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 |
$353.57 |
| Max. Negotiated Rate |
$3,058.85 |
| Rate for Payer: Aetna Commercial |
$3,058.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,769.06
|
| Rate for Payer: Cash Price |
$928.80
|
| Rate for Payer: Cash Price |
$928.80
|
| Rate for Payer: Cash Price |
$928.80
|
| Rate for Payer: Cigna Commercial |
$3,058.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$353.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,931.90
|
| Rate for Payer: Health EOS Commercial |
$2,930.05
|
| Rate for Payer: HFN Commercial |
$3,058.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$779.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$779.03
|
| Rate for Payer: Multiplan Commercial |
$2,575.87
|
| Rate for Payer: Preferred Network Access Commercial |
$3,058.85
|
| Rate for Payer: Quartz Beloit One Network |
$1,416.73
|
| Rate for Payer: Quartz Commercial |
$1,835.31
|
| Rate for Payer: The Alliance Commercial |
$1,609.92
|
| Rate for Payer: United Healthcare Medicaid |
$353.57
|
| Rate for Payer: WEA Trust Commercial |
$1,770.91
|
| Rate for Payer: WPS Commercial |
$2,384.85
|
|
|
DESTROY NERVE C/T FACET EACH +
|
Facility
|
OP
|
$678.00
|
|
| Hospital Charge Code |
5262693
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$197.43 |
| Max. Negotiated Rate |
$648.71 |
| Rate for Payer: Aetna Commercial |
$634.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.40
|
| Rate for Payer: Aetna Managed Medicare |
$197.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$458.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$352.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$338.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.71
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$648.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$394.60
|
| Rate for Payer: Health EOS Commercial |
$627.56
|
| Rate for Payer: HFN Commercial |
$648.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$528.84
|
| Rate for Payer: Multiplan Commercial |
$564.10
|
| Rate for Payer: NAPHCARE Commercial |
$423.07
|
| Rate for Payer: Preferred Network Access Commercial |
$648.71
|
| Rate for Payer: Quartz Beloit One Network |
$345.51
|
| Rate for Payer: Quartz Commercial |
$458.33
|
| Rate for Payer: Quartz Medicare Advantage |
$423.07
|
| Rate for Payer: The Alliance Commercial |
$352.56
|
| Rate for Payer: WEA Trust Commercial |
$387.82
|
| Rate for Payer: WPS Commercial |
$522.26
|
|
|
DESTROY NERVE C/T FACET EACH +
|
Facility
|
IP
|
$678.00
|
|
| Hospital Charge Code |
5262693
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$345.51 |
| Max. Negotiated Rate |
$648.71 |
| Rate for Payer: Aetna Commercial |
$634.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.71
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$648.71
|
| Rate for Payer: Health EOS Commercial |
$627.56
|
| Rate for Payer: HFN Commercial |
$648.71
|
| Rate for Payer: Multiplan Commercial |
$564.10
|
| Rate for Payer: Preferred Network Access Commercial |
$648.71
|
| Rate for Payer: Quartz Beloit One Network |
$345.51
|
| Rate for Payer: Quartz Commercial |
$423.07
|
| Rate for Payer: WEA Trust Commercial |
$387.82
|
| Rate for Payer: WPS Commercial |
$522.26
|
|
|
DESTROY NERVE C/T FACET SINGLE
|
Facility
|
IP
|
$2,980.00
|
|
| Hospital Charge Code |
5262692
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,518.61 |
| Max. Negotiated Rate |
$2,851.26 |
| Rate for Payer: Aetna Commercial |
$2,789.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,665.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,642.58
|
| Rate for Payer: Cash Price |
$894.00
|
| Rate for Payer: Cigna Commercial |
$2,851.26
|
| Rate for Payer: Health EOS Commercial |
$2,758.29
|
| Rate for Payer: HFN Commercial |
$2,851.26
|
| Rate for Payer: Multiplan Commercial |
$2,479.36
|
| Rate for Payer: Preferred Network Access Commercial |
$2,851.26
|
| Rate for Payer: Quartz Beloit One Network |
$1,518.61
|
| Rate for Payer: Quartz Commercial |
$1,859.52
|
| Rate for Payer: WEA Trust Commercial |
$1,704.56
|
| Rate for Payer: WPS Commercial |
$2,295.49
|
|
|
DESTROY NERVE C/T FACET SINGLE
|
Facility
|
OP
|
$2,980.00
|
|
| Hospital Charge Code |
5262692
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$867.78 |
| Max. Negotiated Rate |
$2,851.26 |
| Rate for Payer: Aetna Commercial |
$2,789.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,665.31
|
| Rate for Payer: Aetna Managed Medicare |
$867.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,014.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,549.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,487.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,642.58
|
| Rate for Payer: Cash Price |
$894.00
|
| Rate for Payer: Cigna Commercial |
$2,851.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,734.36
|
| Rate for Payer: Health EOS Commercial |
$2,758.29
|
| Rate for Payer: HFN Commercial |
$2,851.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,324.40
|
| Rate for Payer: Multiplan Commercial |
$2,479.36
|
| Rate for Payer: NAPHCARE Commercial |
$1,859.52
|
| Rate for Payer: Preferred Network Access Commercial |
$2,851.26
|
| Rate for Payer: Quartz Beloit One Network |
$1,518.61
|
| Rate for Payer: Quartz Commercial |
$2,014.48
|
| Rate for Payer: Quartz Medicare Advantage |
$1,859.52
|
| Rate for Payer: The Alliance Commercial |
$1,549.60
|
| Rate for Payer: WEA Trust Commercial |
$1,704.56
|
| Rate for Payer: WPS Commercial |
$2,295.49
|
|
|
DESTROY NERVE, FACE MUSCLE 64612
|
Professional
|
Both
|
$643.00
|
|
|
Service Code
|
CPT 64612
|
| Hospital Charge Code |
3015196
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$103.27 |
| Max. Negotiated Rate |
$635.28 |
| Rate for Payer: Aetna Commercial |
$635.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.10
|
| Rate for Payer: Aetna Managed Medicare |
$103.27
|
| Rate for Payer: Anthem Medicare Advantage |
$103.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$103.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$103.27
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cigna Commercial |
$635.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$189.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.27
|
| Rate for Payer: Health EOS Commercial |
$608.54
|
| Rate for Payer: HFN Commercial |
$635.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$403.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$403.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$103.27
|
| Rate for Payer: Multiplan Commercial |
$534.98
|
| Rate for Payer: NAPHCARE Commercial |
$154.91
|
| Rate for Payer: Preferred Network Access Commercial |
$635.28
|
| Rate for Payer: Quartz Beloit One Network |
$294.24
|
| Rate for Payer: Quartz Commercial |
$381.17
|
| Rate for Payer: Quartz Medicare Advantage |
$103.27
|
| Rate for Payer: The Alliance Commercial |
$438.91
|
| Rate for Payer: United Healthcare Medicaid |
$189.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$103.27
|
| Rate for Payer: WEA Trust Commercial |
$367.80
|
| Rate for Payer: WPS Commercial |
$464.72
|
|
|
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 |
$189.08 |
| Max. Negotiated Rate |
$1,269.58 |
| Rate for Payer: Aetna Commercial |
$1,269.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.30
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cigna Commercial |
$1,269.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$189.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$801.84
|
| Rate for Payer: Health EOS Commercial |
$1,216.12
|
| Rate for Payer: HFN Commercial |
$1,269.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$403.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$403.25
|
| Rate for Payer: Multiplan Commercial |
$1,069.12
|
| Rate for Payer: Preferred Network Access Commercial |
$1,269.58
|
| Rate for Payer: Quartz Beloit One Network |
$588.02
|
| Rate for Payer: Quartz Commercial |
$761.75
|
| Rate for Payer: The Alliance Commercial |
$668.20
|
| Rate for Payer: United Healthcare Medicaid |
$189.08
|
| Rate for Payer: WEA Trust Commercial |
$735.02
|
| Rate for Payer: WPS Commercial |
$989.84
|
|
|
DESTROY NERVE L/S FACET EACH +
|
Facility
|
IP
|
$566.00
|
|
| Hospital Charge Code |
5262695
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$288.43 |
| Max. Negotiated Rate |
$541.55 |
| Rate for Payer: Aetna Commercial |
$529.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$506.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.98
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cigna Commercial |
$541.55
|
| Rate for Payer: Health EOS Commercial |
$523.89
|
| Rate for Payer: HFN Commercial |
$541.55
|
| Rate for Payer: Multiplan Commercial |
$470.91
|
| Rate for Payer: Preferred Network Access Commercial |
$541.55
|
| Rate for Payer: Quartz Beloit One Network |
$288.43
|
| Rate for Payer: Quartz Commercial |
$353.18
|
| Rate for Payer: WEA Trust Commercial |
$323.75
|
| Rate for Payer: WPS Commercial |
$435.99
|
|
|
DESTROY NERVE L/S FACET EACH +
|
Facility
|
OP
|
$566.00
|
|
| Hospital Charge Code |
5262695
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$164.82 |
| Max. Negotiated Rate |
$541.55 |
| Rate for Payer: Aetna Commercial |
$529.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$506.23
|
| Rate for Payer: Aetna Managed Medicare |
$164.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$382.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$294.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.98
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cigna Commercial |
$541.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$329.41
|
| Rate for Payer: Health EOS Commercial |
$523.89
|
| Rate for Payer: HFN Commercial |
$541.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$441.48
|
| Rate for Payer: Multiplan Commercial |
$470.91
|
| Rate for Payer: NAPHCARE Commercial |
$353.18
|
| Rate for Payer: Preferred Network Access Commercial |
$541.55
|
| Rate for Payer: Quartz Beloit One Network |
$288.43
|
| Rate for Payer: Quartz Commercial |
$382.62
|
| Rate for Payer: Quartz Medicare Advantage |
$353.18
|
| Rate for Payer: The Alliance Commercial |
$294.32
|
| Rate for Payer: WEA Trust Commercial |
$323.75
|
| Rate for Payer: WPS Commercial |
$435.99
|
|
|
DESTROY NERVE L/S FACET SINGLE
|
Facility
|
IP
|
$2,971.00
|
|
| Hospital Charge Code |
5262694
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,514.02 |
| Max. Negotiated Rate |
$2,842.65 |
| Rate for Payer: Aetna Commercial |
$2,780.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,657.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,637.62
|
| Rate for Payer: Cash Price |
$891.30
|
| Rate for Payer: Cigna Commercial |
$2,842.65
|
| Rate for Payer: Health EOS Commercial |
$2,749.96
|
| Rate for Payer: HFN Commercial |
$2,842.65
|
| Rate for Payer: Multiplan Commercial |
$2,471.87
|
| Rate for Payer: Preferred Network Access Commercial |
$2,842.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,514.02
|
| Rate for Payer: Quartz Commercial |
$1,853.90
|
| Rate for Payer: WEA Trust Commercial |
$1,699.41
|
| Rate for Payer: WPS Commercial |
$2,288.56
|
|
|
DESTROY NERVE L/S FACET SINGLE
|
Facility
|
OP
|
$2,971.00
|
|
| Hospital Charge Code |
5262694
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$865.16 |
| Max. Negotiated Rate |
$2,842.65 |
| Rate for Payer: Aetna Commercial |
$2,780.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,657.26
|
| Rate for Payer: Aetna Managed Medicare |
$865.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,008.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,544.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,483.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,637.62
|
| Rate for Payer: Cash Price |
$891.30
|
| Rate for Payer: Cigna Commercial |
$2,842.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,729.12
|
| Rate for Payer: Health EOS Commercial |
$2,749.96
|
| Rate for Payer: HFN Commercial |
$2,842.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,317.38
|
| Rate for Payer: Multiplan Commercial |
$2,471.87
|
| Rate for Payer: NAPHCARE Commercial |
$1,853.90
|
| Rate for Payer: Preferred Network Access Commercial |
$2,842.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,514.02
|
| Rate for Payer: Quartz Commercial |
$2,008.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,853.90
|
| Rate for Payer: The Alliance Commercial |
$1,544.92
|
| Rate for Payer: WEA Trust Commercial |
$1,699.41
|
| Rate for Payer: WPS Commercial |
$2,288.56
|
|
|
DESTROY NERVE, NECK MUSCLE 64613
|
Professional
|
Both
|
$796.00
|
|
| Hospital Charge Code |
3015197
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$364.25 |
| Max. Negotiated Rate |
$786.45 |
| Rate for Payer: Aetna Commercial |
$786.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$711.94
|
| Rate for Payer: Cash Price |
$238.80
|
| Rate for Payer: Cigna Commercial |
$786.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$413.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$496.70
|
| Rate for Payer: Health EOS Commercial |
$753.33
|
| Rate for Payer: HFN Commercial |
$786.45
|
| Rate for Payer: Multiplan Commercial |
$662.27
|
| Rate for Payer: Preferred Network Access Commercial |
$786.45
|
| Rate for Payer: Quartz Beloit One Network |
$364.25
|
| Rate for Payer: Quartz Commercial |
$471.87
|
| Rate for Payer: The Alliance Commercial |
$413.92
|
| Rate for Payer: WEA Trust Commercial |
$455.31
|
| Rate for Payer: WPS Commercial |
$613.16
|
|
|
DESTROY NERVE OTHER PERIPHERAL
|
Facility
|
IP
|
$210.00
|
|
| Hospital Charge Code |
5262696
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$107.02 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$131.04
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
|
DESTROY NERVE OTHER PERIPHERAL
|
Facility
|
OP
|
$210.00
|
|
| Hospital Charge Code |
5262696
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$61.15 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Aetna Managed Medicare |
$61.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$141.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$109.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.22
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$163.80
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: NAPHCARE Commercial |
$131.04
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$141.96
|
| Rate for Payer: Quartz Medicare Advantage |
$131.04
|
| Rate for Payer: The Alliance Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
|
DESTROY NERVE TRIGEMINAL
|
Facility
|
OP
|
$379.00
|
|
| Hospital Charge Code |
5262690
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$110.36 |
| Max. Negotiated Rate |
$362.63 |
| Rate for Payer: Aetna Commercial |
$354.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.98
|
| Rate for Payer: Aetna Managed Medicare |
$110.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$256.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$197.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$189.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.90
|
| Rate for Payer: Cash Price |
$113.70
|
| Rate for Payer: Cigna Commercial |
$362.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$220.58
|
| Rate for Payer: Health EOS Commercial |
$350.80
|
| Rate for Payer: HFN Commercial |
$362.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$295.62
|
| Rate for Payer: Multiplan Commercial |
$315.33
|
| Rate for Payer: NAPHCARE Commercial |
$236.50
|
| Rate for Payer: Preferred Network Access Commercial |
$362.63
|
| Rate for Payer: Quartz Beloit One Network |
$193.14
|
| Rate for Payer: Quartz Commercial |
$256.20
|
| Rate for Payer: Quartz Medicare Advantage |
$236.50
|
| Rate for Payer: The Alliance Commercial |
$197.08
|
| Rate for Payer: WEA Trust Commercial |
$216.79
|
| Rate for Payer: WPS Commercial |
$291.94
|
|
