|
INJECTION PARVERTEBRAL FACET C/T 3RD OR ADD (+)
|
Facility
|
OP
|
$968.00
|
|
| Hospital Charge Code |
5262683
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.88 |
| Max. Negotiated Rate |
$926.18 |
| Rate for Payer: Aetna Commercial |
$906.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.78
|
| Rate for Payer: Aetna Managed Medicare |
$281.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$654.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$483.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.56
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cigna Commercial |
$926.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$563.38
|
| Rate for Payer: Health EOS Commercial |
$895.98
|
| Rate for Payer: HFN Commercial |
$926.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$755.04
|
| Rate for Payer: Multiplan Commercial |
$805.38
|
| Rate for Payer: NAPHCARE Commercial |
$604.03
|
| Rate for Payer: Preferred Network Access Commercial |
$926.18
|
| Rate for Payer: Quartz Beloit One Network |
$493.29
|
| Rate for Payer: Quartz Commercial |
$654.37
|
| Rate for Payer: Quartz Medicare Advantage |
$604.03
|
| Rate for Payer: The Alliance Commercial |
$503.36
|
| Rate for Payer: WEA Trust Commercial |
$553.70
|
| Rate for Payer: WPS Commercial |
$745.65
|
|
|
INJECTION PARVERTEBRAL FACET C/T 3RD OR ADD (+)
|
Facility
|
IP
|
$968.00
|
|
| Hospital Charge Code |
5262683
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$493.29 |
| Max. Negotiated Rate |
$926.18 |
| Rate for Payer: Aetna Commercial |
$906.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.56
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cigna Commercial |
$926.18
|
| Rate for Payer: Health EOS Commercial |
$895.98
|
| Rate for Payer: HFN Commercial |
$926.18
|
| Rate for Payer: Multiplan Commercial |
$805.38
|
| Rate for Payer: Preferred Network Access Commercial |
$926.18
|
| Rate for Payer: Quartz Beloit One Network |
$493.29
|
| Rate for Payer: Quartz Commercial |
$604.03
|
| Rate for Payer: WEA Trust Commercial |
$553.70
|
| Rate for Payer: WPS Commercial |
$745.65
|
|
|
INJECTION PARVERTEBRAL FACET C/T SINGLE LEVEL
|
Facility
|
OP
|
$1,620.00
|
|
| Hospital Charge Code |
5262681
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$471.74 |
| Max. Negotiated Rate |
$1,550.02 |
| Rate for Payer: Aetna Commercial |
$1,516.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,448.93
|
| Rate for Payer: Aetna Managed Medicare |
$471.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,095.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$842.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$808.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$892.94
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cigna Commercial |
$1,550.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$942.84
|
| Rate for Payer: Health EOS Commercial |
$1,499.47
|
| Rate for Payer: HFN Commercial |
$1,550.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,263.60
|
| Rate for Payer: Multiplan Commercial |
$1,347.84
|
| Rate for Payer: NAPHCARE Commercial |
$1,010.88
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.02
|
| Rate for Payer: Quartz Beloit One Network |
$825.55
|
| Rate for Payer: Quartz Commercial |
$1,095.12
|
| Rate for Payer: Quartz Medicare Advantage |
$1,010.88
|
| Rate for Payer: The Alliance Commercial |
$842.40
|
| Rate for Payer: WEA Trust Commercial |
$926.64
|
| Rate for Payer: WPS Commercial |
$1,247.89
|
|
|
INJECTION PARVERTEBRAL FACET C/T SINGLE LEVEL
|
Facility
|
IP
|
$1,620.00
|
|
| Hospital Charge Code |
5262681
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$825.55 |
| Max. Negotiated Rate |
$1,550.02 |
| Rate for Payer: Aetna Commercial |
$1,516.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,448.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$892.94
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cigna Commercial |
$1,550.02
|
| Rate for Payer: Health EOS Commercial |
$1,499.47
|
| Rate for Payer: HFN Commercial |
$1,550.02
|
| Rate for Payer: Multiplan Commercial |
$1,347.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.02
|
| Rate for Payer: Quartz Beloit One Network |
$825.55
|
| Rate for Payer: Quartz Commercial |
$1,010.88
|
| Rate for Payer: WEA Trust Commercial |
$926.64
|
| Rate for Payer: WPS Commercial |
$1,247.89
|
|
|
INJECTION PARVERTEBRAL FACET L/S 2ND LEVEL (+)
|
Facility
|
IP
|
$553.00
|
|
| Hospital Charge Code |
5262685
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.81 |
| Max. Negotiated Rate |
$529.11 |
| Rate for Payer: Aetna Commercial |
$517.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$494.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.81
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$529.11
|
| Rate for Payer: Health EOS Commercial |
$511.86
|
| Rate for Payer: HFN Commercial |
$529.11
|
| Rate for Payer: Multiplan Commercial |
$460.10
|
| Rate for Payer: Preferred Network Access Commercial |
$529.11
|
| Rate for Payer: Quartz Beloit One Network |
$281.81
|
| Rate for Payer: Quartz Commercial |
$345.07
|
| Rate for Payer: WEA Trust Commercial |
$316.32
|
| Rate for Payer: WPS Commercial |
$425.98
|
|
|
INJECTION PARVERTEBRAL FACET L/S 2ND LEVEL (+)
|
Facility
|
OP
|
$553.00
|
|
| Hospital Charge Code |
5262685
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$161.03 |
| Max. Negotiated Rate |
$529.11 |
| Rate for Payer: Aetna Commercial |
$517.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$494.60
|
| Rate for Payer: Aetna Managed Medicare |
$161.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$373.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.81
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$529.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$321.85
|
| Rate for Payer: Health EOS Commercial |
$511.86
|
| Rate for Payer: HFN Commercial |
$529.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$431.34
|
| Rate for Payer: Multiplan Commercial |
$460.10
|
| Rate for Payer: NAPHCARE Commercial |
$345.07
|
| Rate for Payer: Preferred Network Access Commercial |
$529.11
|
| Rate for Payer: Quartz Beloit One Network |
$281.81
|
| Rate for Payer: Quartz Commercial |
$373.83
|
| Rate for Payer: Quartz Medicare Advantage |
$345.07
|
| Rate for Payer: The Alliance Commercial |
$287.56
|
| Rate for Payer: WEA Trust Commercial |
$316.32
|
| Rate for Payer: WPS Commercial |
$425.98
|
|
|
INJECTION PARVERTEBRAL FACET L/S 3RD OR ADD (+)
|
Facility
|
OP
|
$553.00
|
|
| Hospital Charge Code |
5262686
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$161.03 |
| Max. Negotiated Rate |
$529.11 |
| Rate for Payer: Aetna Commercial |
$517.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$494.60
|
| Rate for Payer: Aetna Managed Medicare |
$161.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$373.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.81
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$529.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$321.85
|
| Rate for Payer: Health EOS Commercial |
$511.86
|
| Rate for Payer: HFN Commercial |
$529.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$431.34
|
| Rate for Payer: Multiplan Commercial |
$460.10
|
| Rate for Payer: NAPHCARE Commercial |
$345.07
|
| Rate for Payer: Preferred Network Access Commercial |
$529.11
|
| Rate for Payer: Quartz Beloit One Network |
$281.81
|
| Rate for Payer: Quartz Commercial |
$373.83
|
| Rate for Payer: Quartz Medicare Advantage |
$345.07
|
| Rate for Payer: The Alliance Commercial |
$287.56
|
| Rate for Payer: WEA Trust Commercial |
$316.32
|
| Rate for Payer: WPS Commercial |
$425.98
|
|
|
INJECTION PARVERTEBRAL FACET L/S 3RD OR ADD (+)
|
Facility
|
IP
|
$553.00
|
|
| Hospital Charge Code |
5262686
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.81 |
| Max. Negotiated Rate |
$529.11 |
| Rate for Payer: Aetna Commercial |
$517.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$494.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.81
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$529.11
|
| Rate for Payer: Health EOS Commercial |
$511.86
|
| Rate for Payer: HFN Commercial |
$529.11
|
| Rate for Payer: Multiplan Commercial |
$460.10
|
| Rate for Payer: Preferred Network Access Commercial |
$529.11
|
| Rate for Payer: Quartz Beloit One Network |
$281.81
|
| Rate for Payer: Quartz Commercial |
$345.07
|
| Rate for Payer: WEA Trust Commercial |
$316.32
|
| Rate for Payer: WPS Commercial |
$425.98
|
|
|
INJECTION PARVERTEBRAL FACET L/S SINGLE LEVEL
|
Facility
|
OP
|
$1,640.00
|
|
| Hospital Charge Code |
5262684
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$477.57 |
| Max. Negotiated Rate |
$1,569.15 |
| Rate for Payer: Aetna Commercial |
$1,535.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.82
|
| Rate for Payer: Aetna Managed Medicare |
$477.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,108.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$852.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$818.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.97
|
| Rate for Payer: Cash Price |
$492.00
|
| Rate for Payer: Cigna Commercial |
$1,569.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$954.48
|
| Rate for Payer: Health EOS Commercial |
$1,517.98
|
| Rate for Payer: HFN Commercial |
$1,569.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,279.20
|
| Rate for Payer: Multiplan Commercial |
$1,364.48
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.36
|
| Rate for Payer: Preferred Network Access Commercial |
$1,569.15
|
| Rate for Payer: Quartz Beloit One Network |
$835.74
|
| Rate for Payer: Quartz Commercial |
$1,108.64
|
| Rate for Payer: Quartz Medicare Advantage |
$1,023.36
|
| Rate for Payer: The Alliance Commercial |
$852.80
|
| Rate for Payer: WEA Trust Commercial |
$938.08
|
| Rate for Payer: WPS Commercial |
$1,263.29
|
|
|
INJECTION PARVERTEBRAL FACET L/S SINGLE LEVEL
|
Facility
|
IP
|
$1,640.00
|
|
| Hospital Charge Code |
5262684
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$835.74 |
| Max. Negotiated Rate |
$1,569.15 |
| Rate for Payer: Aetna Commercial |
$1,535.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.97
|
| Rate for Payer: Cash Price |
$492.00
|
| Rate for Payer: Cigna Commercial |
$1,569.15
|
| Rate for Payer: Health EOS Commercial |
$1,517.98
|
| Rate for Payer: HFN Commercial |
$1,569.15
|
| Rate for Payer: Multiplan Commercial |
$1,364.48
|
| Rate for Payer: Preferred Network Access Commercial |
$1,569.15
|
| Rate for Payer: Quartz Beloit One Network |
$835.74
|
| Rate for Payer: Quartz Commercial |
$1,023.36
|
| Rate for Payer: WEA Trust Commercial |
$938.08
|
| Rate for Payer: WPS Commercial |
$1,263.29
|
|
|
Injection, Pegfilgrastim 6mg J2505
|
Facility
|
IP
|
$7,835.00
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
3697518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,992.72 |
| Max. Negotiated Rate |
$7,496.53 |
| Rate for Payer: Aetna Commercial |
$7,333.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,007.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,318.65
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cigna Commercial |
$7,496.53
|
| Rate for Payer: Health EOS Commercial |
$7,252.08
|
| Rate for Payer: HFN Commercial |
$7,496.53
|
| Rate for Payer: Multiplan Commercial |
$6,518.72
|
| Rate for Payer: Preferred Network Access Commercial |
$7,496.53
|
| Rate for Payer: Quartz Beloit One Network |
$3,992.72
|
| Rate for Payer: Quartz Commercial |
$4,889.04
|
| Rate for Payer: WEA Trust Commercial |
$4,481.62
|
| Rate for Payer: WPS Commercial |
$6,035.30
|
|
|
Injection, Pegfilgrastim 6mg J2505
|
Facility
|
OP
|
$7,835.00
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
3697518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.14 |
| Max. Negotiated Rate |
$7,496.53 |
| Rate for Payer: Aetna Commercial |
$7,333.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,007.62
|
| Rate for Payer: Aetna Managed Medicare |
$127.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$114.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$114.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$114.14
|
| Rate for Payer: Anthem Medicare Advantage |
$127.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,318.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$127.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$127.75
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cigna Commercial |
$7,496.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$127.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$127.75
|
| Rate for Payer: Health EOS Commercial |
$7,252.08
|
| Rate for Payer: HFN Commercial |
$7,496.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$475.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$127.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$127.75
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$127.75
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$127.75
|
| Rate for Payer: Multiplan Commercial |
$6,518.72
|
| Rate for Payer: NAPHCARE Commercial |
$191.63
|
| Rate for Payer: Preferred Network Access Commercial |
$7,496.53
|
| Rate for Payer: Quartz Beloit One Network |
$3,992.72
|
| Rate for Payer: Quartz Commercial |
$5,296.46
|
| Rate for Payer: Quartz Medicare Advantage |
$127.75
|
| Rate for Payer: The Alliance Commercial |
$511.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.75
|
| Rate for Payer: WEA Trust Commercial |
$4,481.62
|
| Rate for Payer: Wellcare Medicare |
$127.75
|
| Rate for Payer: WPS Commercial |
$285.36
|
|
|
Injection, Pegfilgrastim 6mg J2505
|
Professional
|
Both
|
$7,835.00
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
3697518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.14 |
| Max. Negotiated Rate |
$7,740.98 |
| Rate for Payer: Aetna Commercial |
$7,740.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,007.62
|
| Rate for Payer: Aetna Managed Medicare |
$127.75
|
| Rate for Payer: Anthem Medicare Advantage |
$127.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$127.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$127.75
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cigna Commercial |
$7,740.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$127.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.14
|
| Rate for Payer: Health EOS Commercial |
$7,415.04
|
| Rate for Payer: HFN Commercial |
$7,740.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$127.75
|
| Rate for Payer: Multiplan Commercial |
$6,518.72
|
| Rate for Payer: NAPHCARE Commercial |
$191.63
|
| Rate for Payer: Preferred Network Access Commercial |
$7,740.98
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.30
|
| Rate for Payer: Quartz Commercial |
$4,644.59
|
| Rate for Payer: Quartz Medicare Advantage |
$127.75
|
| Rate for Payer: The Alliance Commercial |
$351.32
|
| Rate for Payer: United Healthcare Medicaid |
$127.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.75
|
| Rate for Payer: WEA Trust Commercial |
$4,481.62
|
| Rate for Payer: WPS Commercial |
$285.36
|
|
|
INJECTION PIRIFORMIS W/SEDATION
|
Facility
|
OP
|
$1,276.00
|
|
| Hospital Charge Code |
5294613
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$371.57 |
| Max. Negotiated Rate |
$1,220.88 |
| Rate for Payer: Aetna Commercial |
$1,194.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,141.25
|
| Rate for Payer: Aetna Managed Medicare |
$371.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$862.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$663.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$636.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$703.33
|
| Rate for Payer: Cash Price |
$382.80
|
| Rate for Payer: Cigna Commercial |
$1,220.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$742.63
|
| Rate for Payer: Health EOS Commercial |
$1,181.07
|
| Rate for Payer: HFN Commercial |
$1,220.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$995.28
|
| Rate for Payer: Multiplan Commercial |
$1,061.63
|
| Rate for Payer: NAPHCARE Commercial |
$796.22
|
| Rate for Payer: Preferred Network Access Commercial |
$1,220.88
|
| Rate for Payer: Quartz Beloit One Network |
$650.25
|
| Rate for Payer: Quartz Commercial |
$862.58
|
| Rate for Payer: Quartz Medicare Advantage |
$796.22
|
| Rate for Payer: The Alliance Commercial |
$663.52
|
| Rate for Payer: WEA Trust Commercial |
$729.87
|
| Rate for Payer: WPS Commercial |
$982.90
|
|
|
INJECTION PIRIFORMIS W/SEDATION
|
Facility
|
IP
|
$1,276.00
|
|
| Hospital Charge Code |
5294613
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$650.25 |
| Max. Negotiated Rate |
$1,220.88 |
| Rate for Payer: Aetna Commercial |
$1,194.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,141.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$703.33
|
| Rate for Payer: Cash Price |
$382.80
|
| Rate for Payer: Cigna Commercial |
$1,220.88
|
| Rate for Payer: Health EOS Commercial |
$1,181.07
|
| Rate for Payer: HFN Commercial |
$1,220.88
|
| Rate for Payer: Multiplan Commercial |
$1,061.63
|
| Rate for Payer: Preferred Network Access Commercial |
$1,220.88
|
| Rate for Payer: Quartz Beloit One Network |
$650.25
|
| Rate for Payer: Quartz Commercial |
$796.22
|
| Rate for Payer: WEA Trust Commercial |
$729.87
|
| Rate for Payer: WPS Commercial |
$982.90
|
|
|
INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 50431
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$733.82 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Managed Medicare |
$733.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Anthem Medicare Advantage |
$733.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$733.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$733.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$733.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$733.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,729.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$733.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$733.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$733.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$733.82
|
| Rate for Payer: NAPHCARE Commercial |
$1,100.74
|
| Rate for Payer: Quartz Medicare Advantage |
$733.82
|
| Rate for Payer: The Alliance Commercial |
$2,935.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$733.82
|
| Rate for Payer: United Healthcare PPO |
$2,347.28
|
| Rate for Payer: Wellcare Medicare |
$733.82
|
|
|
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY, PERCUTANEOUS, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS
|
Facility
|
OP
|
$15,071.89
|
|
|
Service Code
|
CPT 47531
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,767.97 |
| Max. Negotiated Rate |
$15,071.89 |
| Rate for Payer: Aetna Managed Medicare |
$3,767.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,767.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,767.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,767.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,767.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,767.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,016.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,767.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,767.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,767.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,767.97
|
| Rate for Payer: NAPHCARE Commercial |
$5,651.96
|
| Rate for Payer: Quartz Medicare Advantage |
$3,767.97
|
| Rate for Payer: The Alliance Commercial |
$15,071.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,767.97
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,767.97
|
|
|
INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 51600
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$145.97 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: The Alliance Commercial |
$145.97
|
|
|
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT ANESTHESIA
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 27093
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$224.14 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: The Alliance Commercial |
$224.14
|
|
|
INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 51610
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$225.39 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: The Alliance Commercial |
$225.39
|
|
|
INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 27096
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$289.95 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: The Alliance Commercial |
$289.95
|
| Rate for Payer: United Healthcare PPO |
$2,347.28
|
|
|
INJECTION PROCEDURE FOR URETEROGRAPHY OR URETEROPYELOGRAPHY THROUGH URETEROSTOMY OR INDWELLING URETERAL CATHETER
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 50684
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$183.46 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: The Alliance Commercial |
$183.46
|
|
|
Injection Procedure Thrombin
|
Facility
|
OP
|
$4,560.00
|
|
|
Service Code
|
CPT 36002
|
| Hospital Charge Code |
5314050
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$660.17 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$4,268.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,078.46
|
| Rate for Payer: Aetna Managed Medicare |
$660.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,082.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,371.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,276.35
|
| Rate for Payer: Anthem Medicare Advantage |
$660.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,513.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$660.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$660.17
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,363.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$660.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$660.17
|
| Rate for Payer: Health EOS Commercial |
$4,220.74
|
| Rate for Payer: HFN Commercial |
$4,363.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,455.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$660.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$660.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$660.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$660.17
|
| Rate for Payer: Multiplan Commercial |
$3,793.92
|
| Rate for Payer: NAPHCARE Commercial |
$990.26
|
| Rate for Payer: Preferred Network Access Commercial |
$4,363.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,323.78
|
| Rate for Payer: Quartz Commercial |
$3,082.56
|
| Rate for Payer: Quartz Medicare Advantage |
$660.17
|
| Rate for Payer: The Alliance Commercial |
$2,640.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$660.17
|
| Rate for Payer: United Healthcare PPO |
$3,556.80
|
| Rate for Payer: WEA Trust Commercial |
$2,608.32
|
| Rate for Payer: Wellcare Medicare |
$660.17
|
| Rate for Payer: WPS Commercial |
$3,512.57
|
|
|
Injection Procedure Thrombin
|
Facility
|
IP
|
$4,560.00
|
|
|
Service Code
|
CPT 36002
|
| Hospital Charge Code |
5314050
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$2,323.78 |
| Max. Negotiated Rate |
$4,363.01 |
| Rate for Payer: Aetna Commercial |
$4,268.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,078.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,513.47
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,363.01
|
| Rate for Payer: Health EOS Commercial |
$4,220.74
|
| Rate for Payer: HFN Commercial |
$4,363.01
|
| Rate for Payer: Multiplan Commercial |
$3,793.92
|
| Rate for Payer: Preferred Network Access Commercial |
$4,363.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,323.78
|
| Rate for Payer: Quartz Commercial |
$2,845.44
|
| Rate for Payer: WEA Trust Commercial |
$2,608.32
|
| Rate for Payer: WPS Commercial |
$3,512.57
|
|
|
INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 64494
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$172.89 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: The Alliance Commercial |
$172.89
|
|
