|
INJECTABLE KIT AUGMENT SYNTHETIC K30003010
|
Facility
|
IP
|
$19,044.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
6177956
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,331.56 |
| Max. Negotiated Rate |
$17,520.48 |
| Rate for Payer: Aetna Commercial |
$17,139.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,377.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,093.32
|
| Rate for Payer: Cash Price |
$5,713.20
|
| Rate for Payer: Cigna Commercial |
$17,520.48
|
| Rate for Payer: Health EOS Commercial |
$16,949.16
|
| Rate for Payer: HFN Commercial |
$17,520.48
|
| Rate for Payer: Multiplan Commercial |
$15,235.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,426.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,520.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,331.56
|
| Rate for Payer: Quartz Commercial |
$11,426.40
|
| Rate for Payer: WEA Trust Commercial |
$10,474.20
|
| Rate for Payer: WPS Commercial |
$14,105.89
|
|
|
INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG 64454
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
CPT 64454
|
| Hospital Charge Code |
5707693
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$164.88 |
| Max. Negotiated Rate |
$855.00 |
| Rate for Payer: Aetna Commercial |
$855.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$774.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$855.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$164.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$540.00
|
| Rate for Payer: Health EOS Commercial |
$819.00
|
| Rate for Payer: HFN Commercial |
$855.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$275.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$275.06
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: Preferred Network Access Commercial |
$855.00
|
| Rate for Payer: Quartz Beloit One Network |
$396.00
|
| Rate for Payer: Quartz Commercial |
$513.00
|
| Rate for Payer: The Alliance Commercial |
$450.00
|
| Rate for Payer: United Healthcare Medicaid |
$164.88
|
| Rate for Payer: WEA Trust Commercial |
$495.00
|
| Rate for Payer: WPS Commercial |
$666.63
|
|
|
Injection, Bupivicaine Hydro S0020
|
Professional
|
Both
|
$7.00
|
|
| Hospital Charge Code |
4392900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.20
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Injection, Bupivicaine Hydro S0020
|
Facility
|
IP
|
$7.00
|
|
| Hospital Charge Code |
4392900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Injection, Bupivicaine Hydro S0020
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
4392900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.92
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
INJECTION CANNULA TFNA -S TRAUMACEM V+ 03.702.121S
|
Facility
|
OP
|
$4,388.68
|
|
| Hospital Charge Code |
6246252
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,228.83 |
| Max. Negotiated Rate |
$17,554.72 |
| Rate for Payer: Aetna Commercial |
$3,949.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,774.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,228.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,852.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,194.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,106.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,326.00
|
| Rate for Payer: Cash Price |
$1,316.60
|
| Rate for Payer: Cigna Commercial |
$4,037.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,455.91
|
| Rate for Payer: Health EOS Commercial |
$3,905.93
|
| Rate for Payer: HFN Commercial |
$4,037.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,291.51
|
| Rate for Payer: Multiplan Commercial |
$3,510.94
|
| Rate for Payer: NAPHCARE Commercial |
$2,633.21
|
| Rate for Payer: Preferred Network Access Commercial |
$4,037.59
|
| Rate for Payer: Quartz Beloit One Network |
$2,150.45
|
| Rate for Payer: Quartz Commercial |
$2,852.64
|
| Rate for Payer: Quartz Medicare Advantage |
$2,633.21
|
| Rate for Payer: The Alliance Commercial |
$17,554.72
|
| Rate for Payer: WEA Trust Commercial |
$2,413.77
|
| Rate for Payer: WPS Commercial |
$3,250.70
|
|
|
INJECTION CANNULA TFNA -S TRAUMACEM V+ 03.702.121S
|
Facility
|
IP
|
$4,388.68
|
|
| Hospital Charge Code |
6246252
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,150.45 |
| Max. Negotiated Rate |
$4,037.59 |
| Rate for Payer: Aetna Commercial |
$3,949.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,774.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,326.00
|
| Rate for Payer: Cash Price |
$1,316.60
|
| Rate for Payer: Cigna Commercial |
$4,037.59
|
| Rate for Payer: Health EOS Commercial |
$3,905.93
|
| Rate for Payer: HFN Commercial |
$4,037.59
|
| Rate for Payer: Multiplan Commercial |
$3,510.94
|
| Rate for Payer: NAPHCARE Commercial |
$2,633.21
|
| Rate for Payer: Preferred Network Access Commercial |
$4,037.59
|
| Rate for Payer: Quartz Beloit One Network |
$2,150.45
|
| Rate for Payer: Quartz Commercial |
$2,633.21
|
| Rate for Payer: WEA Trust Commercial |
$2,413.77
|
| Rate for Payer: WPS Commercial |
$3,250.70
|
|
|
Injection, Certolizumab Pegol, 1MG J0717
|
Facility
|
OP
|
$3,753.00
|
|
|
Service Code
|
HCPCS J0717
|
| Hospital Charge Code |
4036657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.82 |
| Max. Negotiated Rate |
$3,452.76 |
| Rate for Payer: Aetna Commercial |
$3,377.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,227.58
|
| Rate for Payer: Aetna Managed Medicare |
$4.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,439.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,876.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,801.44
|
| Rate for Payer: Anthem Medicare Advantage |
$4.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,989.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.82
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cigna Commercial |
$3,452.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.82
|
| Rate for Payer: Health EOS Commercial |
$3,340.17
|
| Rate for Payer: HFN Commercial |
$3,452.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.82
|
| Rate for Payer: Multiplan Commercial |
$3,002.40
|
| Rate for Payer: NAPHCARE Commercial |
$7.22
|
| Rate for Payer: Preferred Network Access Commercial |
$3,452.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,838.97
|
| Rate for Payer: Quartz Commercial |
$2,439.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4.82
|
| Rate for Payer: The Alliance Commercial |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.82
|
| Rate for Payer: WEA Trust Commercial |
$2,064.15
|
| Rate for Payer: Wellcare Medicare |
$4.82
|
| Rate for Payer: WPS Commercial |
$11.56
|
|
|
Injection, Certolizumab Pegol, 1MG J0717
|
Professional
|
Both
|
$3,753.00
|
|
|
Service Code
|
HCPCS J0717
|
| Hospital Charge Code |
4036657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$3,565.35 |
| Rate for Payer: Aetna Commercial |
$3,565.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,227.58
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cigna Commercial |
$3,565.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.62
|
| Rate for Payer: Health EOS Commercial |
$3,415.23
|
| Rate for Payer: HFN Commercial |
$3,565.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.80
|
| Rate for Payer: Multiplan Commercial |
$3,002.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,565.35
|
| Rate for Payer: Quartz Beloit One Network |
$1,651.32
|
| Rate for Payer: Quartz Commercial |
$2,139.21
|
| Rate for Payer: The Alliance Commercial |
$1,876.50
|
| Rate for Payer: United Healthcare Medicaid |
$4.62
|
| Rate for Payer: WEA Trust Commercial |
$2,064.15
|
| Rate for Payer: WPS Commercial |
$11.56
|
|
|
Injection, Certolizumab Pegol, 1MG J0717
|
Facility
|
IP
|
$3,753.00
|
|
|
Service Code
|
HCPCS J0717
|
| Hospital Charge Code |
4036657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,838.97 |
| Max. Negotiated Rate |
$3,452.76 |
| Rate for Payer: Aetna Commercial |
$3,377.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,227.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,989.09
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cigna Commercial |
$3,452.76
|
| Rate for Payer: Health EOS Commercial |
$3,340.17
|
| Rate for Payer: HFN Commercial |
$3,452.76
|
| Rate for Payer: Multiplan Commercial |
$3,002.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,251.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,452.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,838.97
|
| Rate for Payer: Quartz Commercial |
$2,251.80
|
| Rate for Payer: WEA Trust Commercial |
$2,064.15
|
| Rate for Payer: WPS Commercial |
$2,779.85
|
|
|
Injection, Denosumab, 1mg J0897
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
3451580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$50.60 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
Injection, Denosumab, 1mg J0897
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
3451580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.20 |
| Max. Negotiated Rate |
$62.97 |
| Rate for Payer: Aetna Commercial |
$52.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.19
|
| Rate for Payer: Health EOS Commercial |
$50.05
|
| Rate for Payer: HFN Commercial |
$52.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.33
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: Preferred Network Access Commercial |
$52.25
|
| Rate for Payer: Quartz Beloit One Network |
$24.20
|
| Rate for Payer: Quartz Commercial |
$31.35
|
| Rate for Payer: The Alliance Commercial |
$27.50
|
| Rate for Payer: United Healthcare Medicaid |
$25.19
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$62.97
|
|
|
Injection, Denosumab, 1mg J0897
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
3451580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.19 |
| Max. Negotiated Rate |
$100.79 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Aetna Managed Medicare |
$25.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.19
|
| Rate for Payer: Anthem Medicare Advantage |
$25.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.20
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.20
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$35.75
|
| Rate for Payer: Quartz Medicare Advantage |
$25.20
|
| Rate for Payer: The Alliance Commercial |
$100.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.20
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: Wellcare Medicare |
$25.20
|
| Rate for Payer: WPS Commercial |
$62.97
|
|
|
Injection epidural blood/clot patch 62273
|
Professional
|
Both
|
$1,351.00
|
|
|
Service Code
|
CPT 62273
|
| Hospital Charge Code |
5308646
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$120.52 |
| Max. Negotiated Rate |
$1,283.45 |
| Rate for Payer: Aetna Commercial |
$1,283.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,161.86
|
| Rate for Payer: Cash Price |
$405.30
|
| Rate for Payer: Cash Price |
$405.30
|
| Rate for Payer: Cash Price |
$405.30
|
| Rate for Payer: Cigna Commercial |
$1,283.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$810.60
|
| Rate for Payer: Health EOS Commercial |
$1,229.41
|
| Rate for Payer: HFN Commercial |
$1,283.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$381.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$381.17
|
| Rate for Payer: Multiplan Commercial |
$1,080.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,283.45
|
| Rate for Payer: Quartz Beloit One Network |
$594.44
|
| Rate for Payer: Quartz Commercial |
$770.07
|
| Rate for Payer: The Alliance Commercial |
$675.50
|
| Rate for Payer: United Healthcare Medicaid |
$120.52
|
| Rate for Payer: WEA Trust Commercial |
$743.05
|
| Rate for Payer: WPS Commercial |
$1,000.69
|
|
|
Injection Eye Drug 6702850
|
Professional
|
Both
|
$1,396.00
|
|
|
Service Code
|
CPT 67028 50
|
| Hospital Charge Code |
3153484
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$170.72 |
| Max. Negotiated Rate |
$1,326.20 |
| Rate for Payer: Aetna Commercial |
$1,326.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,200.56
|
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cigna Commercial |
$1,326.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$170.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$837.60
|
| Rate for Payer: Health EOS Commercial |
$1,270.36
|
| Rate for Payer: HFN Commercial |
$1,326.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$310.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$310.18
|
| Rate for Payer: Multiplan Commercial |
$1,116.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,326.20
|
| Rate for Payer: Quartz Beloit One Network |
$614.24
|
| Rate for Payer: Quartz Commercial |
$795.72
|
| Rate for Payer: The Alliance Commercial |
$698.00
|
| Rate for Payer: United Healthcare Medicaid |
$170.72
|
| Rate for Payer: WEA Trust Commercial |
$767.80
|
| Rate for Payer: WPS Commercial |
$1,034.02
|
|
|
Injection Facet US, Second Level 0217T50
|
Facility
|
OP
|
$391.00
|
|
|
Service Code
|
CPT 0217T 50
|
| Hospital Charge Code |
3382939
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$109.48 |
| Max. Negotiated Rate |
$1,564.00 |
| Rate for Payer: Aetna Commercial |
$351.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$336.26
|
| Rate for Payer: Aetna Managed Medicare |
$109.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$254.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$195.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$187.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$207.23
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$359.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.80
|
| Rate for Payer: Health EOS Commercial |
$347.99
|
| Rate for Payer: HFN Commercial |
$359.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$293.25
|
| Rate for Payer: Multiplan Commercial |
$312.80
|
| Rate for Payer: NAPHCARE Commercial |
$234.60
|
| Rate for Payer: Preferred Network Access Commercial |
$359.72
|
| Rate for Payer: Quartz Beloit One Network |
$191.59
|
| Rate for Payer: Quartz Commercial |
$254.15
|
| Rate for Payer: Quartz Medicare Advantage |
$234.60
|
| Rate for Payer: The Alliance Commercial |
$1,564.00
|
| Rate for Payer: WEA Trust Commercial |
$215.05
|
| Rate for Payer: WPS Commercial |
$289.61
|
|
|
Injection Facet US, Second Level 0217T50
|
Professional
|
Both
|
$391.00
|
|
|
Service Code
|
CPT 0217T 50
|
| Hospital Charge Code |
3382939
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$172.04 |
| Max. Negotiated Rate |
$371.45 |
| Rate for Payer: Aetna Commercial |
$371.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$336.26
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$371.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$195.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$234.60
|
| Rate for Payer: Health EOS Commercial |
$355.81
|
| Rate for Payer: HFN Commercial |
$371.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$316.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$316.61
|
| Rate for Payer: Multiplan Commercial |
$312.80
|
| Rate for Payer: Preferred Network Access Commercial |
$371.45
|
| Rate for Payer: Quartz Beloit One Network |
$172.04
|
| Rate for Payer: Quartz Commercial |
$222.87
|
| Rate for Payer: The Alliance Commercial |
$195.50
|
| Rate for Payer: WEA Trust Commercial |
$215.05
|
| Rate for Payer: WPS Commercial |
$289.61
|
|
|
Injection Facet US, Second Level 0217T50
|
Facility
|
IP
|
$391.00
|
|
|
Service Code
|
CPT 0217T 50
|
| Hospital Charge Code |
3382939
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$191.59 |
| Max. Negotiated Rate |
$359.72 |
| Rate for Payer: Aetna Commercial |
$351.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$336.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$207.23
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$359.72
|
| Rate for Payer: Health EOS Commercial |
$347.99
|
| Rate for Payer: HFN Commercial |
$359.72
|
| Rate for Payer: Multiplan Commercial |
$312.80
|
| Rate for Payer: NAPHCARE Commercial |
$234.60
|
| Rate for Payer: Preferred Network Access Commercial |
$359.72
|
| Rate for Payer: Quartz Beloit One Network |
$191.59
|
| Rate for Payer: Quartz Commercial |
$234.60
|
| Rate for Payer: WEA Trust Commercial |
$215.05
|
| Rate for Payer: WPS Commercial |
$289.61
|
|
|
Injection Foramen Epidural C/T 64479
|
Professional
|
Both
|
$1,387.00
|
|
|
Service Code
|
CPT 64479
|
| Hospital Charge Code |
5232639
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$218.91 |
| Max. Negotiated Rate |
$1,317.65 |
| Rate for Payer: Aetna Commercial |
$1,317.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,192.82
|
| Rate for Payer: Cash Price |
$416.10
|
| Rate for Payer: Cash Price |
$416.10
|
| Rate for Payer: Cash Price |
$416.10
|
| Rate for Payer: Cigna Commercial |
$1,317.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$218.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$832.20
|
| Rate for Payer: Health EOS Commercial |
$1,262.17
|
| Rate for Payer: HFN Commercial |
$1,317.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$442.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$442.87
|
| Rate for Payer: Multiplan Commercial |
$1,109.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,317.65
|
| Rate for Payer: Quartz Beloit One Network |
$610.28
|
| Rate for Payer: Quartz Commercial |
$790.59
|
| Rate for Payer: The Alliance Commercial |
$693.50
|
| Rate for Payer: United Healthcare Medicaid |
$218.91
|
| Rate for Payer: WEA Trust Commercial |
$762.85
|
| Rate for Payer: WPS Commercial |
$1,027.35
|
|
|
Injection Foramen Epidural L/S 64483
|
Professional
|
Both
|
$1,320.00
|
|
|
Service Code
|
CPT 64483
|
| Hospital Charge Code |
5226606
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$201.80 |
| Max. Negotiated Rate |
$1,254.00 |
| Rate for Payer: Aetna Commercial |
$1,254.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,135.20
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$1,254.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$201.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$792.00
|
| Rate for Payer: Health EOS Commercial |
$1,201.20
|
| Rate for Payer: HFN Commercial |
$1,254.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$377.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$377.15
|
| Rate for Payer: Multiplan Commercial |
$1,056.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,254.00
|
| Rate for Payer: Quartz Beloit One Network |
$580.80
|
| Rate for Payer: Quartz Commercial |
$752.40
|
| Rate for Payer: The Alliance Commercial |
$660.00
|
| Rate for Payer: United Healthcare Medicaid |
$201.80
|
| Rate for Payer: WEA Trust Commercial |
$726.00
|
| Rate for Payer: WPS Commercial |
$977.72
|
|
|
Injection Foramen Epidural L/S 6448350
|
Professional
|
Both
|
$2,640.00
|
|
|
Service Code
|
CPT 64483 50
|
| Hospital Charge Code |
5226612
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$201.80 |
| Max. Negotiated Rate |
$2,508.00 |
| Rate for Payer: Aetna Commercial |
$2,508.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,270.40
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cigna Commercial |
$2,508.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$201.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,584.00
|
| Rate for Payer: Health EOS Commercial |
$2,402.40
|
| Rate for Payer: HFN Commercial |
$2,508.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$377.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$377.15
|
| Rate for Payer: Multiplan Commercial |
$2,112.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,508.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,161.60
|
| Rate for Payer: Quartz Commercial |
$1,504.80
|
| Rate for Payer: The Alliance Commercial |
$1,320.00
|
| Rate for Payer: United Healthcare Medicaid |
$201.80
|
| Rate for Payer: WEA Trust Commercial |
$1,452.00
|
| Rate for Payer: WPS Commercial |
$1,955.45
|
|
|
Injection Foramen Epidural L/S Add-on 64484
|
Professional
|
Both
|
$639.00
|
|
|
Service Code
|
CPT 64484
|
| Hospital Charge Code |
5232772
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$117.58 |
| Max. Negotiated Rate |
$607.05 |
| Rate for Payer: Aetna Commercial |
$607.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$549.54
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cigna Commercial |
$607.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$383.40
|
| Rate for Payer: Health EOS Commercial |
$581.49
|
| Rate for Payer: HFN Commercial |
$607.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$175.55
|
| Rate for Payer: Multiplan Commercial |
$511.20
|
| Rate for Payer: Preferred Network Access Commercial |
$607.05
|
| Rate for Payer: Quartz Beloit One Network |
$281.16
|
| Rate for Payer: Quartz Commercial |
$364.23
|
| Rate for Payer: The Alliance Commercial |
$319.50
|
| Rate for Payer: United Healthcare Medicaid |
$117.58
|
| Rate for Payer: WEA Trust Commercial |
$351.45
|
| Rate for Payer: WPS Commercial |
$473.31
|
|
|
Injection Foramen Epidural L/S Add-on 6448450
|
Professional
|
Both
|
$1,277.00
|
|
|
Service Code
|
CPT 64484 50
|
| Hospital Charge Code |
5232773
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$117.58 |
| Max. Negotiated Rate |
$1,213.15 |
| Rate for Payer: Aetna Commercial |
$1,213.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,098.22
|
| Rate for Payer: Cash Price |
$383.10
|
| Rate for Payer: Cash Price |
$383.10
|
| Rate for Payer: Cash Price |
$383.10
|
| Rate for Payer: Cigna Commercial |
$1,213.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$766.20
|
| Rate for Payer: Health EOS Commercial |
$1,162.07
|
| Rate for Payer: HFN Commercial |
$1,213.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$175.55
|
| Rate for Payer: Multiplan Commercial |
$1,021.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,213.15
|
| Rate for Payer: Quartz Beloit One Network |
$561.88
|
| Rate for Payer: Quartz Commercial |
$727.89
|
| Rate for Payer: The Alliance Commercial |
$638.50
|
| Rate for Payer: United Healthcare Medicaid |
$117.58
|
| Rate for Payer: WEA Trust Commercial |
$702.35
|
| Rate for Payer: WPS Commercial |
$945.87
|
|
|
INJECTION FOR BLADDER X-RAY 51600
|
Professional
|
Both
|
$984.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
3014973
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.91 |
| Max. Negotiated Rate |
$934.80 |
| Rate for Payer: Aetna Commercial |
$934.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$846.24
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$934.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$590.40
|
| Rate for Payer: Health EOS Commercial |
$895.44
|
| Rate for Payer: HFN Commercial |
$934.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$147.62
|
| Rate for Payer: Multiplan Commercial |
$787.20
|
| Rate for Payer: Preferred Network Access Commercial |
$934.80
|
| Rate for Payer: Quartz Beloit One Network |
$432.96
|
| Rate for Payer: Quartz Commercial |
$560.88
|
| Rate for Payer: The Alliance Commercial |
$492.00
|
| Rate for Payer: United Healthcare Medicaid |
$24.91
|
| Rate for Payer: WEA Trust Commercial |
$541.20
|
| Rate for Payer: WPS Commercial |
$728.85
|
|
|
INJECTION FOR BLADDER X-RAY 51610
|
Professional
|
Both
|
$1,042.00
|
|
|
Service Code
|
CPT 51610
|
| Hospital Charge Code |
3014974
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.91 |
| Max. Negotiated Rate |
$989.90 |
| Rate for Payer: Aetna Commercial |
$989.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.12
|
| Rate for Payer: Cash Price |
$312.60
|
| Rate for Payer: Cash Price |
$312.60
|
| Rate for Payer: Cash Price |
$312.60
|
| Rate for Payer: Cigna Commercial |
$989.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$625.20
|
| Rate for Payer: Health EOS Commercial |
$948.22
|
| Rate for Payer: HFN Commercial |
$989.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$213.39
|
| Rate for Payer: Multiplan Commercial |
$833.60
|
| Rate for Payer: Preferred Network Access Commercial |
$989.90
|
| Rate for Payer: Quartz Beloit One Network |
$458.48
|
| Rate for Payer: Quartz Commercial |
$593.94
|
| Rate for Payer: The Alliance Commercial |
$521.00
|
| Rate for Payer: United Healthcare Medicaid |
$24.91
|
| Rate for Payer: WEA Trust Commercial |
$573.10
|
| Rate for Payer: WPS Commercial |
$771.81
|
|
