|
EPIDRM A-GRFT FACE/NCK/HF/G 15115
|
Professional
|
Both
|
$4,300.00
|
|
|
Service Code
|
CPT 15115
|
| Hospital Charge Code |
3013635
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$144.03 |
| Max. Negotiated Rate |
$4,248.40 |
| Rate for Payer: Aetna Commercial |
$4,248.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,845.92
|
| Rate for Payer: Aetna Managed Medicare |
$621.51
|
| Rate for Payer: Anthem Medicare Advantage |
$621.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$621.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$621.51
|
| Rate for Payer: Cash Price |
$1,290.00
|
| Rate for Payer: Cash Price |
$1,290.00
|
| Rate for Payer: Cash Price |
$1,290.00
|
| Rate for Payer: Cigna Commercial |
$4,248.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$144.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$621.51
|
| Rate for Payer: Health EOS Commercial |
$4,069.52
|
| Rate for Payer: HFN Commercial |
$4,248.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,386.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,386.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$621.51
|
| Rate for Payer: Multiplan Commercial |
$3,577.60
|
| Rate for Payer: NAPHCARE Commercial |
$932.27
|
| Rate for Payer: Preferred Network Access Commercial |
$4,248.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,967.68
|
| Rate for Payer: Quartz Commercial |
$2,549.04
|
| Rate for Payer: Quartz Medicare Advantage |
$621.51
|
| Rate for Payer: The Alliance Commercial |
$2,641.44
|
| Rate for Payer: United Healthcare Medicaid |
$144.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$621.51
|
| Rate for Payer: WEA Trust Commercial |
$2,459.60
|
| Rate for Payer: WPS Commercial |
$2,796.81
|
|
|
EPIDURAL ANES - SET-UP CHARGE
|
Facility
|
IP
|
$1,295.00
|
|
| Hospital Charge Code |
4519580
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$659.93 |
| Max. Negotiated Rate |
$1,239.06 |
| Rate for Payer: Aetna Commercial |
$1,212.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,158.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$713.80
|
| Rate for Payer: Cash Price |
$388.50
|
| Rate for Payer: Cigna Commercial |
$1,239.06
|
| Rate for Payer: Health EOS Commercial |
$1,198.65
|
| Rate for Payer: HFN Commercial |
$1,239.06
|
| Rate for Payer: Multiplan Commercial |
$1,077.44
|
| Rate for Payer: Preferred Network Access Commercial |
$1,239.06
|
| Rate for Payer: Quartz Beloit One Network |
$659.93
|
| Rate for Payer: Quartz Commercial |
$808.08
|
| Rate for Payer: WEA Trust Commercial |
$740.74
|
| Rate for Payer: WPS Commercial |
$997.54
|
|
|
EPIDURAL ANES - SET-UP CHARGE
|
Facility
|
OP
|
$1,295.00
|
|
| Hospital Charge Code |
4519580
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$377.10 |
| Max. Negotiated Rate |
$1,239.06 |
| Rate for Payer: Aetna Commercial |
$1,212.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,158.25
|
| Rate for Payer: Aetna Managed Medicare |
$377.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$875.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$673.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$646.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$713.80
|
| Rate for Payer: Cash Price |
$388.50
|
| Rate for Payer: Cigna Commercial |
$1,239.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$753.69
|
| Rate for Payer: Health EOS Commercial |
$1,198.65
|
| Rate for Payer: HFN Commercial |
$1,239.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,010.10
|
| Rate for Payer: Multiplan Commercial |
$1,077.44
|
| Rate for Payer: NAPHCARE Commercial |
$808.08
|
| Rate for Payer: Preferred Network Access Commercial |
$1,239.06
|
| Rate for Payer: Quartz Beloit One Network |
$659.93
|
| Rate for Payer: Quartz Commercial |
$875.42
|
| Rate for Payer: Quartz Medicare Advantage |
$808.08
|
| Rate for Payer: The Alliance Commercial |
$673.40
|
| Rate for Payer: WEA Trust Commercial |
$740.74
|
| Rate for Payer: WPS Commercial |
$997.54
|
|
|
EPIDURAL STEROID INJECTION
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2960018
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$145.24 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
EPIDURAL STEROID INJECTION
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2960018
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$82.99 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Aetna Managed Medicare |
$82.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$192.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.87
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.30
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: NAPHCARE Commercial |
$177.84
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$192.66
|
| Rate for Payer: Quartz Medicare Advantage |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
EPIDURAL STEROID INJECTION, CERVICAL/THORACIC
|
Facility
|
IP
|
$2,099.00
|
|
| Hospital Charge Code |
2959922
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,069.65 |
| Max. Negotiated Rate |
$2,008.32 |
| Rate for Payer: Aetna Commercial |
$1,964.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,877.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,156.97
|
| Rate for Payer: Cash Price |
$629.70
|
| Rate for Payer: Cigna Commercial |
$2,008.32
|
| Rate for Payer: Health EOS Commercial |
$1,942.83
|
| Rate for Payer: HFN Commercial |
$2,008.32
|
| Rate for Payer: Multiplan Commercial |
$1,746.37
|
| Rate for Payer: Preferred Network Access Commercial |
$2,008.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,069.65
|
| Rate for Payer: Quartz Commercial |
$1,309.78
|
| Rate for Payer: WEA Trust Commercial |
$1,200.63
|
| Rate for Payer: WPS Commercial |
$1,616.86
|
|
|
EPIDURAL STEROID INJECTION, CERVICAL/THORACIC
|
Facility
|
OP
|
$2,099.00
|
|
| Hospital Charge Code |
2959922
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$611.23 |
| Max. Negotiated Rate |
$2,008.32 |
| Rate for Payer: Aetna Commercial |
$1,964.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,877.35
|
| Rate for Payer: Aetna Managed Medicare |
$611.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,418.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,091.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,047.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,156.97
|
| Rate for Payer: Cash Price |
$629.70
|
| Rate for Payer: Cigna Commercial |
$2,008.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,221.62
|
| Rate for Payer: Health EOS Commercial |
$1,942.83
|
| Rate for Payer: HFN Commercial |
$2,008.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,637.22
|
| Rate for Payer: Multiplan Commercial |
$1,746.37
|
| Rate for Payer: NAPHCARE Commercial |
$1,309.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,008.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,069.65
|
| Rate for Payer: Quartz Commercial |
$1,418.92
|
| Rate for Payer: Quartz Medicare Advantage |
$1,309.78
|
| Rate for Payer: The Alliance Commercial |
$1,091.48
|
| Rate for Payer: WEA Trust Commercial |
$1,200.63
|
| Rate for Payer: WPS Commercial |
$1,616.86
|
|
|
EPIDURAL STEROID INJECTION C/T TRANSFORAMINAL
|
Facility
|
IP
|
$2,485.00
|
|
| Hospital Charge Code |
5262679
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,266.36 |
| Max. Negotiated Rate |
$2,377.65 |
| Rate for Payer: Aetna Commercial |
$2,325.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,222.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,369.73
|
| Rate for Payer: Cash Price |
$745.50
|
| Rate for Payer: Cigna Commercial |
$2,377.65
|
| Rate for Payer: Health EOS Commercial |
$2,300.12
|
| Rate for Payer: HFN Commercial |
$2,377.65
|
| Rate for Payer: Multiplan Commercial |
$2,067.52
|
| Rate for Payer: Preferred Network Access Commercial |
$2,377.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,266.36
|
| Rate for Payer: Quartz Commercial |
$1,550.64
|
| Rate for Payer: WEA Trust Commercial |
$1,421.42
|
| Rate for Payer: WPS Commercial |
$1,914.20
|
|
|
EPIDURAL STEROID INJECTION C/T TRANSFORAMINAL
|
Facility
|
OP
|
$2,485.00
|
|
| Hospital Charge Code |
5262679
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$723.63 |
| Max. Negotiated Rate |
$2,377.65 |
| Rate for Payer: Aetna Commercial |
$2,325.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,222.58
|
| Rate for Payer: Aetna Managed Medicare |
$723.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,679.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,292.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,240.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,369.73
|
| Rate for Payer: Cash Price |
$745.50
|
| Rate for Payer: Cigna Commercial |
$2,377.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,446.27
|
| Rate for Payer: Health EOS Commercial |
$2,300.12
|
| Rate for Payer: HFN Commercial |
$2,377.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,938.30
|
| Rate for Payer: Multiplan Commercial |
$2,067.52
|
| Rate for Payer: NAPHCARE Commercial |
$1,550.64
|
| Rate for Payer: Preferred Network Access Commercial |
$2,377.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,266.36
|
| Rate for Payer: Quartz Commercial |
$1,679.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,550.64
|
| Rate for Payer: The Alliance Commercial |
$1,292.20
|
| Rate for Payer: WEA Trust Commercial |
$1,421.42
|
| Rate for Payer: WPS Commercial |
$1,914.20
|
|
|
EPIDURAL STEROID INJECTION L/S TRANSFORAMINAL
|
Facility
|
OP
|
$2,495.00
|
|
| Hospital Charge Code |
4882606
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$726.54 |
| Max. Negotiated Rate |
$2,387.22 |
| Rate for Payer: Aetna Commercial |
$2,335.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,231.53
|
| Rate for Payer: Aetna Managed Medicare |
$726.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,686.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,297.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,245.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,375.24
|
| Rate for Payer: Cash Price |
$748.50
|
| Rate for Payer: Cigna Commercial |
$2,387.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,452.09
|
| Rate for Payer: Health EOS Commercial |
$2,309.37
|
| Rate for Payer: HFN Commercial |
$2,387.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,946.10
|
| Rate for Payer: Multiplan Commercial |
$2,075.84
|
| Rate for Payer: NAPHCARE Commercial |
$1,556.88
|
| Rate for Payer: Preferred Network Access Commercial |
$2,387.22
|
| Rate for Payer: Quartz Beloit One Network |
$1,271.45
|
| Rate for Payer: Quartz Commercial |
$1,686.62
|
| Rate for Payer: Quartz Medicare Advantage |
$1,556.88
|
| Rate for Payer: The Alliance Commercial |
$1,297.40
|
| Rate for Payer: WEA Trust Commercial |
$1,427.14
|
| Rate for Payer: WPS Commercial |
$1,921.90
|
|
|
EPIDURAL STEROID INJECTION L/S TRANSFORAMINAL
|
Facility
|
IP
|
$2,495.00
|
|
| Hospital Charge Code |
4882606
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,271.45 |
| Max. Negotiated Rate |
$2,387.22 |
| Rate for Payer: Aetna Commercial |
$2,335.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,231.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,375.24
|
| Rate for Payer: Cash Price |
$748.50
|
| Rate for Payer: Cigna Commercial |
$2,387.22
|
| Rate for Payer: Health EOS Commercial |
$2,309.37
|
| Rate for Payer: HFN Commercial |
$2,387.22
|
| Rate for Payer: Multiplan Commercial |
$2,075.84
|
| Rate for Payer: Preferred Network Access Commercial |
$2,387.22
|
| Rate for Payer: Quartz Beloit One Network |
$1,271.45
|
| Rate for Payer: Quartz Commercial |
$1,556.88
|
| Rate for Payer: WEA Trust Commercial |
$1,427.14
|
| Rate for Payer: WPS Commercial |
$1,921.90
|
|
|
EPIDURAL STEROID INJECTION L/S TRANS + LVL
|
Facility
|
IP
|
$870.00
|
|
| Hospital Charge Code |
5262680
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$443.35 |
| Max. Negotiated Rate |
$832.42 |
| Rate for Payer: Aetna Commercial |
$814.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$778.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$479.54
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cigna Commercial |
$832.42
|
| Rate for Payer: Health EOS Commercial |
$805.27
|
| Rate for Payer: HFN Commercial |
$832.42
|
| Rate for Payer: Multiplan Commercial |
$723.84
|
| Rate for Payer: Preferred Network Access Commercial |
$832.42
|
| Rate for Payer: Quartz Beloit One Network |
$443.35
|
| Rate for Payer: Quartz Commercial |
$542.88
|
| Rate for Payer: WEA Trust Commercial |
$497.64
|
| Rate for Payer: WPS Commercial |
$670.16
|
|
|
EPIDURAL STEROID INJECTION L/S TRANS + LVL
|
Facility
|
OP
|
$870.00
|
|
| Hospital Charge Code |
5262680
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$253.34 |
| Max. Negotiated Rate |
$832.42 |
| Rate for Payer: Aetna Commercial |
$814.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$778.13
|
| Rate for Payer: Aetna Managed Medicare |
$253.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$588.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$452.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$434.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$479.54
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cigna Commercial |
$832.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$506.34
|
| Rate for Payer: Health EOS Commercial |
$805.27
|
| Rate for Payer: HFN Commercial |
$832.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$678.60
|
| Rate for Payer: Multiplan Commercial |
$723.84
|
| Rate for Payer: NAPHCARE Commercial |
$542.88
|
| Rate for Payer: Preferred Network Access Commercial |
$832.42
|
| Rate for Payer: Quartz Beloit One Network |
$443.35
|
| Rate for Payer: Quartz Commercial |
$588.12
|
| Rate for Payer: Quartz Medicare Advantage |
$542.88
|
| Rate for Payer: The Alliance Commercial |
$452.40
|
| Rate for Payer: WEA Trust Commercial |
$497.64
|
| Rate for Payer: WPS Commercial |
$670.16
|
|
|
EPIDURAL STEROID INJECTION, LUMBAR/SACRAL
|
Facility
|
IP
|
$1,075.00
|
|
| Hospital Charge Code |
2960564
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$547.82 |
| Max. Negotiated Rate |
$1,028.56 |
| Rate for Payer: Aetna Commercial |
$1,006.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$961.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$592.54
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cigna Commercial |
$1,028.56
|
| Rate for Payer: Health EOS Commercial |
$995.02
|
| Rate for Payer: HFN Commercial |
$1,028.56
|
| Rate for Payer: Multiplan Commercial |
$894.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,028.56
|
| Rate for Payer: Quartz Beloit One Network |
$547.82
|
| Rate for Payer: Quartz Commercial |
$670.80
|
| Rate for Payer: WEA Trust Commercial |
$614.90
|
| Rate for Payer: WPS Commercial |
$828.07
|
|
|
EPIDURAL STEROID INJECTION, LUMBAR/SACRAL
|
Facility
|
OP
|
$1,075.00
|
|
| Hospital Charge Code |
2960564
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$1,028.56 |
| Rate for Payer: Aetna Commercial |
$1,006.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$961.48
|
| Rate for Payer: Aetna Managed Medicare |
$313.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$726.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$559.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$536.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$592.54
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cigna Commercial |
$1,028.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$625.65
|
| Rate for Payer: Health EOS Commercial |
$995.02
|
| Rate for Payer: HFN Commercial |
$1,028.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$838.50
|
| Rate for Payer: Multiplan Commercial |
$894.40
|
| Rate for Payer: NAPHCARE Commercial |
$670.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,028.56
|
| Rate for Payer: Quartz Beloit One Network |
$547.82
|
| Rate for Payer: Quartz Commercial |
$726.70
|
| Rate for Payer: Quartz Medicare Advantage |
$670.80
|
| Rate for Payer: The Alliance Commercial |
$559.00
|
| Rate for Payer: WEA Trust Commercial |
$614.90
|
| Rate for Payer: WPS Commercial |
$828.07
|
|
|
EPIDURAL STEROID INJECTION WITH C-ARM
|
Facility
|
OP
|
$291.00
|
|
| Hospital Charge Code |
2960524
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$84.74 |
| Max. Negotiated Rate |
$278.43 |
| Rate for Payer: Aetna Commercial |
$272.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$260.27
|
| Rate for Payer: Aetna Managed Medicare |
$84.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$196.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$151.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$145.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.40
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$278.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$169.36
|
| Rate for Payer: Health EOS Commercial |
$269.35
|
| Rate for Payer: HFN Commercial |
$278.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$226.98
|
| Rate for Payer: Multiplan Commercial |
$242.11
|
| Rate for Payer: NAPHCARE Commercial |
$181.58
|
| Rate for Payer: Preferred Network Access Commercial |
$278.43
|
| Rate for Payer: Quartz Beloit One Network |
$148.29
|
| Rate for Payer: Quartz Commercial |
$196.72
|
| Rate for Payer: Quartz Medicare Advantage |
$181.58
|
| Rate for Payer: The Alliance Commercial |
$151.32
|
| Rate for Payer: WEA Trust Commercial |
$166.45
|
| Rate for Payer: WPS Commercial |
$224.16
|
|
|
EPIDURAL STEROID INJECTION WITH C-ARM
|
Facility
|
IP
|
$291.00
|
|
| Hospital Charge Code |
2960524
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$148.29 |
| Max. Negotiated Rate |
$278.43 |
| Rate for Payer: Aetna Commercial |
$272.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$260.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.40
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$278.43
|
| Rate for Payer: Health EOS Commercial |
$269.35
|
| Rate for Payer: HFN Commercial |
$278.43
|
| Rate for Payer: Multiplan Commercial |
$242.11
|
| Rate for Payer: Preferred Network Access Commercial |
$278.43
|
| Rate for Payer: Quartz Beloit One Network |
$148.29
|
| Rate for Payer: Quartz Commercial |
$181.58
|
| Rate for Payer: WEA Trust Commercial |
$166.45
|
| Rate for Payer: WPS Commercial |
$224.16
|
|
|
EPIDURAL WITH GENERAL ANES - SET-UP CHARGE
|
Facility
|
IP
|
$1,668.00
|
|
| Hospital Charge Code |
4519584
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$850.01 |
| Max. Negotiated Rate |
$1,595.94 |
| Rate for Payer: Aetna Commercial |
$1,561.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,491.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$919.40
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cigna Commercial |
$1,595.94
|
| Rate for Payer: Health EOS Commercial |
$1,543.90
|
| Rate for Payer: HFN Commercial |
$1,595.94
|
| Rate for Payer: Multiplan Commercial |
$1,387.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,595.94
|
| Rate for Payer: Quartz Beloit One Network |
$850.01
|
| Rate for Payer: Quartz Commercial |
$1,040.83
|
| Rate for Payer: WEA Trust Commercial |
$954.10
|
| Rate for Payer: WPS Commercial |
$1,284.86
|
|
|
EPIDURAL WITH GENERAL ANES - SET-UP CHARGE
|
Facility
|
OP
|
$1,668.00
|
|
| Hospital Charge Code |
4519584
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$485.72 |
| Max. Negotiated Rate |
$1,595.94 |
| Rate for Payer: Aetna Commercial |
$1,561.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,491.86
|
| Rate for Payer: Aetna Managed Medicare |
$485.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,127.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$867.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$832.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$919.40
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cigna Commercial |
$1,595.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$970.78
|
| Rate for Payer: Health EOS Commercial |
$1,543.90
|
| Rate for Payer: HFN Commercial |
$1,595.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,301.04
|
| Rate for Payer: Multiplan Commercial |
$1,387.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,040.83
|
| Rate for Payer: Preferred Network Access Commercial |
$1,595.94
|
| Rate for Payer: Quartz Beloit One Network |
$850.01
|
| Rate for Payer: Quartz Commercial |
$1,127.57
|
| Rate for Payer: Quartz Medicare Advantage |
$1,040.83
|
| Rate for Payer: The Alliance Commercial |
$867.36
|
| Rate for Payer: WEA Trust Commercial |
$954.10
|
| Rate for Payer: WPS Commercial |
$1,284.86
|
|
|
Epidural (with IV Pump) - Individual Charges
|
Facility
|
IP
|
$1,054.00
|
|
| Hospital Charge Code |
3003916
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$537.12 |
| Max. Negotiated Rate |
$1,008.47 |
| Rate for Payer: Aetna Commercial |
$986.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$942.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$580.96
|
| Rate for Payer: Cash Price |
$316.20
|
| Rate for Payer: Cigna Commercial |
$1,008.47
|
| Rate for Payer: Health EOS Commercial |
$975.58
|
| Rate for Payer: HFN Commercial |
$1,008.47
|
| Rate for Payer: Multiplan Commercial |
$876.93
|
| Rate for Payer: Preferred Network Access Commercial |
$1,008.47
|
| Rate for Payer: Quartz Beloit One Network |
$537.12
|
| Rate for Payer: Quartz Commercial |
$657.70
|
| Rate for Payer: WEA Trust Commercial |
$602.89
|
| Rate for Payer: WPS Commercial |
$811.90
|
|
|
Epidural (with IV Pump) - Individual Charges
|
Facility
|
OP
|
$1,054.00
|
|
| Hospital Charge Code |
3003916
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$306.92 |
| Max. Negotiated Rate |
$1,008.47 |
| Rate for Payer: Aetna Commercial |
$986.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$942.70
|
| Rate for Payer: Aetna Managed Medicare |
$306.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$712.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$548.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$526.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$580.96
|
| Rate for Payer: Cash Price |
$316.20
|
| Rate for Payer: Cigna Commercial |
$1,008.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$613.43
|
| Rate for Payer: Health EOS Commercial |
$975.58
|
| Rate for Payer: HFN Commercial |
$1,008.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$822.12
|
| Rate for Payer: Multiplan Commercial |
$876.93
|
| Rate for Payer: NAPHCARE Commercial |
$657.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,008.47
|
| Rate for Payer: Quartz Beloit One Network |
$537.12
|
| Rate for Payer: Quartz Commercial |
$712.50
|
| Rate for Payer: Quartz Medicare Advantage |
$657.70
|
| Rate for Payer: The Alliance Commercial |
$548.08
|
| Rate for Payer: WEA Trust Commercial |
$602.89
|
| Rate for Payer: WPS Commercial |
$811.90
|
|
|
EPIFIX, PER SQ CM Q4186
|
Facility
|
OP
|
$868.00
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
5571280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$830.50 |
| Rate for Payer: Aetna Commercial |
$812.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$776.34
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$586.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$451.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$433.31
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$478.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cigna Commercial |
$830.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$211.13
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$803.42
|
| Rate for Payer: HFN Commercial |
$830.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$722.18
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$830.50
|
| Rate for Payer: Quartz Beloit One Network |
$442.33
|
| Rate for Payer: Quartz Commercial |
$586.77
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$496.50
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$398.98
|
|
|
EPIFIX, PER SQ CM Q4186
|
Facility
|
IP
|
$868.00
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
5571280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$442.33 |
| Max. Negotiated Rate |
$830.50 |
| Rate for Payer: Aetna Commercial |
$812.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$776.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$478.44
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cigna Commercial |
$830.50
|
| Rate for Payer: Health EOS Commercial |
$803.42
|
| Rate for Payer: HFN Commercial |
$830.50
|
| Rate for Payer: Multiplan Commercial |
$722.18
|
| Rate for Payer: Preferred Network Access Commercial |
$830.50
|
| Rate for Payer: Quartz Beloit One Network |
$442.33
|
| Rate for Payer: Quartz Commercial |
$541.63
|
| Rate for Payer: WEA Trust Commercial |
$496.50
|
| Rate for Payer: WPS Commercial |
$668.62
|
|
|
EPIFIX, PER SQ CM Q4186
|
Professional
|
Both
|
$868.00
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
5571280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.79 |
| Max. Negotiated Rate |
$857.58 |
| Rate for Payer: Aetna Commercial |
$857.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$776.34
|
| Rate for Payer: Aetna Managed Medicare |
$126.79
|
| Rate for Payer: Anthem Medicare Advantage |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.79
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cigna Commercial |
$857.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.59
|
| Rate for Payer: Health EOS Commercial |
$821.48
|
| Rate for Payer: HFN Commercial |
$857.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$565.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$565.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$722.18
|
| Rate for Payer: NAPHCARE Commercial |
$190.18
|
| Rate for Payer: Preferred Network Access Commercial |
$857.58
|
| Rate for Payer: Quartz Beloit One Network |
$397.20
|
| Rate for Payer: Quartz Commercial |
$514.55
|
| Rate for Payer: Quartz Medicare Advantage |
$126.79
|
| Rate for Payer: The Alliance Commercial |
$348.66
|
| Rate for Payer: United Healthcare Medicaid |
$166.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.79
|
| Rate for Payer: WEA Trust Commercial |
$496.50
|
| Rate for Payer: WPS Commercial |
$398.98
|
|
|
EP Induction Of Arrhythmia
|
Facility
|
OP
|
$18,016.00
|
|
|
Service Code
|
CPT 93618
|
| Hospital Charge Code |
3052506
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,281.32 |
| Max. Negotiated Rate |
$30,304.56 |
| Rate for Payer: Aetna Commercial |
$16,862.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,113.51
|
| Rate for Payer: Aetna Managed Medicare |
$1,281.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30,304.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27,476.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26,104.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,281.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,930.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,281.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,281.32
|
| Rate for Payer: Cash Price |
$5,404.80
|
| Rate for Payer: Cash Price |
$5,404.80
|
| Rate for Payer: Cash Price |
$5,404.80
|
| Rate for Payer: Cigna Commercial |
$17,237.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,281.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,485.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,281.32
|
| Rate for Payer: Health EOS Commercial |
$16,675.61
|
| Rate for Payer: HFN Commercial |
$17,237.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,766.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,281.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,281.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,281.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,281.32
|
| Rate for Payer: Multiplan Commercial |
$14,989.31
|
| Rate for Payer: NAPHCARE Commercial |
$1,921.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17,237.71
|
| Rate for Payer: Quartz Beloit One Network |
$9,180.95
|
| Rate for Payer: Quartz Commercial |
$12,178.82
|
| Rate for Payer: Quartz Medicare Advantage |
$1,281.32
|
| Rate for Payer: The Alliance Commercial |
$5,125.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,281.32
|
| Rate for Payer: WEA Trust Commercial |
$10,305.15
|
| Rate for Payer: Wellcare Medicare |
$1,281.32
|
| Rate for Payer: WPS Commercial |
$13,877.72
|
|
