|
INJECTION FOR HIP X-RAY 27095
|
Professional
|
Both
|
$1,213.00
|
|
|
Service Code
|
CPT 27095
|
| Hospital Charge Code |
3014015
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$124.53 |
| Max. Negotiated Rate |
$1,152.35 |
| Rate for Payer: Aetna Commercial |
$1,152.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,043.18
|
| Rate for Payer: Cash Price |
$363.90
|
| Rate for Payer: Cash Price |
$363.90
|
| Rate for Payer: Cash Price |
$363.90
|
| Rate for Payer: Cigna Commercial |
$1,152.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$124.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$727.80
|
| Rate for Payer: Health EOS Commercial |
$1,103.83
|
| Rate for Payer: HFN Commercial |
$1,152.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$275.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$275.16
|
| Rate for Payer: Multiplan Commercial |
$970.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,152.35
|
| Rate for Payer: Quartz Beloit One Network |
$533.72
|
| Rate for Payer: Quartz Commercial |
$691.41
|
| Rate for Payer: The Alliance Commercial |
$606.50
|
| Rate for Payer: United Healthcare Medicaid |
$124.53
|
| Rate for Payer: WEA Trust Commercial |
$667.15
|
| Rate for Payer: WPS Commercial |
$898.47
|
|
|
INJECTION FOR URETER X-RAY 50690
|
Professional
|
Both
|
$1,107.00
|
|
|
Service Code
|
CPT 50690
|
| Hospital Charge Code |
3014950
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$21.08 |
| Max. Negotiated Rate |
$1,051.65 |
| Rate for Payer: Aetna Commercial |
$1,051.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$952.02
|
| Rate for Payer: Cash Price |
$332.10
|
| Rate for Payer: Cash Price |
$332.10
|
| Rate for Payer: Cash Price |
$332.10
|
| Rate for Payer: Cigna Commercial |
$1,051.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$664.20
|
| Rate for Payer: Health EOS Commercial |
$1,007.37
|
| Rate for Payer: HFN Commercial |
$1,051.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$232.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$232.77
|
| Rate for Payer: Multiplan Commercial |
$885.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,051.65
|
| Rate for Payer: Quartz Beloit One Network |
$487.08
|
| Rate for Payer: Quartz Commercial |
$630.99
|
| Rate for Payer: The Alliance Commercial |
$553.50
|
| Rate for Payer: United Healthcare Medicaid |
$21.08
|
| Rate for Payer: WEA Trust Commercial |
$608.85
|
| Rate for Payer: WPS Commercial |
$819.95
|
|
|
Injection, hydroxyprogesterone caproate, (Makena) 10mg J1726
|
Professional
|
Both
|
$64.00
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
5438788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.16 |
| Max. Negotiated Rate |
$60.80 |
| Rate for Payer: Aetna Commercial |
$60.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.40
|
| Rate for Payer: Health EOS Commercial |
$58.24
|
| Rate for Payer: HFN Commercial |
$60.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.66
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: Preferred Network Access Commercial |
$60.80
|
| Rate for Payer: Quartz Beloit One Network |
$28.16
|
| Rate for Payer: Quartz Commercial |
$36.48
|
| Rate for Payer: The Alliance Commercial |
$32.00
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
Injection, hydroxyprogesterone caproate, (Makena) 10mg J1726
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
5438788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.36 |
| Max. Negotiated Rate |
$58.88 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$38.40
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
Injection, hydroxyprogesterone caproate, (Makena) 10mg J1726
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
5438788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.08 |
| Max. Negotiated Rate |
$58.88 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Aetna Managed Medicare |
$12.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.72
|
| Rate for Payer: Anthem Medicare Advantage |
$12.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.08
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.08
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.08
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.08
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.08
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$18.13
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$41.60
|
| Rate for Payer: Quartz Medicare Advantage |
$12.08
|
| Rate for Payer: The Alliance Commercial |
$48.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.08
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: Wellcare Medicare |
$12.08
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
Injection, Intralesional <= 7 Lesions 11900
|
Professional
|
Both
|
$161.00
|
|
|
Service Code
|
CPT 11900
|
| Hospital Charge Code |
1188858
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.69 |
| Max. Negotiated Rate |
$152.95 |
| Rate for Payer: Aetna Commercial |
$152.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$138.46
|
| Rate for Payer: Cash Price |
$48.30
|
| Rate for Payer: Cash Price |
$48.30
|
| Rate for Payer: Cash Price |
$48.30
|
| Rate for Payer: Cigna Commercial |
$152.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$23.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.60
|
| Rate for Payer: Health EOS Commercial |
$146.51
|
| Rate for Payer: HFN Commercial |
$152.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$100.68
|
| Rate for Payer: Multiplan Commercial |
$128.80
|
| Rate for Payer: Preferred Network Access Commercial |
$152.95
|
| Rate for Payer: Quartz Beloit One Network |
$70.84
|
| Rate for Payer: Quartz Commercial |
$91.77
|
| Rate for Payer: The Alliance Commercial |
$80.50
|
| Rate for Payer: United Healthcare Medicaid |
$23.69
|
| Rate for Payer: WEA Trust Commercial |
$88.55
|
| Rate for Payer: WPS Commercial |
$119.25
|
|
|
Injection of sclerosing solution; multiple veins, same leg 36471
|
Professional
|
Both
|
$577.00
|
|
|
Service Code
|
CPT 36471
|
| Hospital Charge Code |
1190870
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$74.72 |
| Max. Negotiated Rate |
$548.15 |
| Rate for Payer: Aetna Commercial |
$548.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$496.22
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$548.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$346.20
|
| Rate for Payer: Health EOS Commercial |
$525.07
|
| Rate for Payer: HFN Commercial |
$548.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$244.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$244.49
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: Preferred Network Access Commercial |
$548.15
|
| Rate for Payer: Quartz Beloit One Network |
$253.88
|
| Rate for Payer: Quartz Commercial |
$328.89
|
| Rate for Payer: The Alliance Commercial |
$288.50
|
| Rate for Payer: United Healthcare Medicaid |
$74.72
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
Injection of sclerosing solution; single vein 36470
|
Professional
|
Both
|
$446.00
|
|
|
Service Code
|
CPT 36470
|
| Hospital Charge Code |
1190871
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.81 |
| Max. Negotiated Rate |
$423.70 |
| Rate for Payer: Aetna Commercial |
$423.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$383.56
|
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cigna Commercial |
$423.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$267.60
|
| Rate for Payer: Health EOS Commercial |
$405.86
|
| Rate for Payer: HFN Commercial |
$423.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.37
|
| Rate for Payer: Multiplan Commercial |
$356.80
|
| Rate for Payer: Preferred Network Access Commercial |
$423.70
|
| Rate for Payer: Quartz Beloit One Network |
$196.24
|
| Rate for Payer: Quartz Commercial |
$254.22
|
| Rate for Payer: The Alliance Commercial |
$223.00
|
| Rate for Payer: United Healthcare Medicaid |
$49.81
|
| Rate for Payer: WEA Trust Commercial |
$245.30
|
| Rate for Payer: WPS Commercial |
$330.35
|
|
|
Injection of Tendon Sheath or Ligament; Single 20550
|
Professional
|
Both
|
$88.00
|
|
|
Service Code
|
CPT 20550
|
| Hospital Charge Code |
1188964
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.97 |
| Max. Negotiated Rate |
$130.47 |
| Rate for Payer: Aetna Commercial |
$83.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.68
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$83.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.80
|
| Rate for Payer: Health EOS Commercial |
$80.08
|
| Rate for Payer: HFN Commercial |
$83.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.47
|
| Rate for Payer: Multiplan Commercial |
$70.40
|
| Rate for Payer: Preferred Network Access Commercial |
$83.60
|
| Rate for Payer: Quartz Beloit One Network |
$38.72
|
| Rate for Payer: Quartz Commercial |
$50.16
|
| Rate for Payer: The Alliance Commercial |
$44.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.97
|
| Rate for Payer: WEA Trust Commercial |
$48.40
|
| Rate for Payer: WPS Commercial |
$65.18
|
|
|
Injection Paravert F Jnt C/T 1 Level 64490
|
Professional
|
Both
|
$1,041.00
|
|
|
Service Code
|
CPT 64490
|
| Hospital Charge Code |
5232645
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$137.06 |
| Max. Negotiated Rate |
$988.95 |
| Rate for Payer: Aetna Commercial |
$988.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$895.26
|
| Rate for Payer: Cash Price |
$312.30
|
| Rate for Payer: Cash Price |
$312.30
|
| Rate for Payer: Cash Price |
$312.30
|
| Rate for Payer: Cigna Commercial |
$988.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$624.60
|
| Rate for Payer: Health EOS Commercial |
$947.31
|
| Rate for Payer: HFN Commercial |
$988.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$356.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$356.42
|
| Rate for Payer: Multiplan Commercial |
$832.80
|
| Rate for Payer: Preferred Network Access Commercial |
$988.95
|
| Rate for Payer: Quartz Beloit One Network |
$458.04
|
| Rate for Payer: Quartz Commercial |
$593.37
|
| Rate for Payer: The Alliance Commercial |
$520.50
|
| Rate for Payer: United Healthcare Medicaid |
$137.06
|
| Rate for Payer: WEA Trust Commercial |
$572.55
|
| Rate for Payer: WPS Commercial |
$771.07
|
|
|
Injection Paravert F Jnt C/T 1 Level 6449050
|
Professional
|
Both
|
$2,081.00
|
|
|
Service Code
|
CPT 64490 50
|
| Hospital Charge Code |
5232646
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$137.06 |
| Max. Negotiated Rate |
$1,976.95 |
| Rate for Payer: Aetna Commercial |
$1,976.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,789.66
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,976.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,248.60
|
| Rate for Payer: Health EOS Commercial |
$1,893.71
|
| Rate for Payer: HFN Commercial |
$1,976.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$356.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$356.42
|
| Rate for Payer: Multiplan Commercial |
$1,664.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,976.95
|
| Rate for Payer: Quartz Beloit One Network |
$915.64
|
| Rate for Payer: Quartz Commercial |
$1,186.17
|
| Rate for Payer: The Alliance Commercial |
$1,040.50
|
| Rate for Payer: United Healthcare Medicaid |
$137.06
|
| Rate for Payer: WEA Trust Commercial |
$1,144.55
|
| Rate for Payer: WPS Commercial |
$1,541.40
|
|
|
Injection Paravert F Jnt C/T 2 Level 64491
|
Professional
|
Both
|
$780.00
|
|
|
Service Code
|
CPT 64491
|
| Hospital Charge Code |
5232647
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.69 |
| Max. Negotiated Rate |
$741.00 |
| Rate for Payer: Aetna Commercial |
$741.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$670.80
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$741.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$468.00
|
| Rate for Payer: Health EOS Commercial |
$709.80
|
| Rate for Payer: HFN Commercial |
$741.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$202.16
|
| Rate for Payer: Multiplan Commercial |
$624.00
|
| Rate for Payer: Preferred Network Access Commercial |
$741.00
|
| Rate for Payer: Quartz Beloit One Network |
$343.20
|
| Rate for Payer: Quartz Commercial |
$444.60
|
| Rate for Payer: The Alliance Commercial |
$390.00
|
| Rate for Payer: United Healthcare Medicaid |
$67.69
|
| Rate for Payer: WEA Trust Commercial |
$429.00
|
| Rate for Payer: WPS Commercial |
$577.75
|
|
|
Injection Paravert F Jnt C/T 2 Level 6449150
|
Professional
|
Both
|
$1,560.00
|
|
|
Service Code
|
CPT 64491 50
|
| Hospital Charge Code |
5232648
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.69 |
| Max. Negotiated Rate |
$1,482.00 |
| Rate for Payer: Aetna Commercial |
$1,482.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,341.60
|
| Rate for Payer: Cash Price |
$468.00
|
| Rate for Payer: Cash Price |
$468.00
|
| Rate for Payer: Cash Price |
$468.00
|
| Rate for Payer: Cigna Commercial |
$1,482.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$936.00
|
| Rate for Payer: Health EOS Commercial |
$1,419.60
|
| Rate for Payer: HFN Commercial |
$1,482.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$202.16
|
| Rate for Payer: Multiplan Commercial |
$1,248.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,482.00
|
| Rate for Payer: Quartz Beloit One Network |
$686.40
|
| Rate for Payer: Quartz Commercial |
$889.20
|
| Rate for Payer: The Alliance Commercial |
$780.00
|
| Rate for Payer: United Healthcare Medicaid |
$67.69
|
| Rate for Payer: WEA Trust Commercial |
$858.00
|
| Rate for Payer: WPS Commercial |
$1,155.49
|
|
|
INJECTION PARVERTEBRAL FACET C/T 2ND LEVEL (+)
|
Facility
|
OP
|
$968.00
|
|
| Hospital Charge Code |
5262682
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$271.04 |
| Max. Negotiated Rate |
$3,872.00 |
| Rate for Payer: Aetna Commercial |
$871.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$832.48
|
| Rate for Payer: Aetna Managed Medicare |
$271.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$629.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$484.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$464.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$513.04
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cigna Commercial |
$890.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$541.69
|
| Rate for Payer: Health EOS Commercial |
$861.52
|
| Rate for Payer: HFN Commercial |
$890.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$726.00
|
| Rate for Payer: Multiplan Commercial |
$774.40
|
| Rate for Payer: NAPHCARE Commercial |
$580.80
|
| Rate for Payer: Preferred Network Access Commercial |
$890.56
|
| Rate for Payer: Quartz Beloit One Network |
$474.32
|
| Rate for Payer: Quartz Commercial |
$629.20
|
| Rate for Payer: Quartz Medicare Advantage |
$580.80
|
| Rate for Payer: The Alliance Commercial |
$3,872.00
|
| Rate for Payer: WEA Trust Commercial |
$532.40
|
| Rate for Payer: WPS Commercial |
$717.00
|
|
|
INJECTION PARVERTEBRAL FACET C/T 2ND LEVEL (+)
|
Facility
|
IP
|
$968.00
|
|
| Hospital Charge Code |
5262682
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$474.32 |
| Max. Negotiated Rate |
$890.56 |
| Rate for Payer: Aetna Commercial |
$871.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$832.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$513.04
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cigna Commercial |
$890.56
|
| Rate for Payer: Health EOS Commercial |
$861.52
|
| Rate for Payer: HFN Commercial |
$890.56
|
| Rate for Payer: Multiplan Commercial |
$774.40
|
| Rate for Payer: NAPHCARE Commercial |
$580.80
|
| Rate for Payer: Preferred Network Access Commercial |
$890.56
|
| Rate for Payer: Quartz Beloit One Network |
$474.32
|
| Rate for Payer: Quartz Commercial |
$580.80
|
| Rate for Payer: WEA Trust Commercial |
$532.40
|
| Rate for Payer: WPS Commercial |
$717.00
|
|
|
INJECTION PARVERTEBRAL FACET C/T 3RD OR ADD (+)
|
Facility
|
IP
|
$968.00
|
|
| Hospital Charge Code |
5262683
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$474.32 |
| Max. Negotiated Rate |
$890.56 |
| Rate for Payer: Aetna Commercial |
$871.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$832.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$513.04
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cigna Commercial |
$890.56
|
| Rate for Payer: Health EOS Commercial |
$861.52
|
| Rate for Payer: HFN Commercial |
$890.56
|
| Rate for Payer: Multiplan Commercial |
$774.40
|
| Rate for Payer: NAPHCARE Commercial |
$580.80
|
| Rate for Payer: Preferred Network Access Commercial |
$890.56
|
| Rate for Payer: Quartz Beloit One Network |
$474.32
|
| Rate for Payer: Quartz Commercial |
$580.80
|
| Rate for Payer: WEA Trust Commercial |
$532.40
|
| Rate for Payer: WPS Commercial |
$717.00
|
|
|
INJECTION PARVERTEBRAL FACET C/T 3RD OR ADD (+)
|
Facility
|
OP
|
$968.00
|
|
| Hospital Charge Code |
5262683
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$271.04 |
| Max. Negotiated Rate |
$3,872.00 |
| Rate for Payer: Aetna Commercial |
$871.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$832.48
|
| Rate for Payer: Aetna Managed Medicare |
$271.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$629.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$484.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$464.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$513.04
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cigna Commercial |
$890.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$541.69
|
| Rate for Payer: Health EOS Commercial |
$861.52
|
| Rate for Payer: HFN Commercial |
$890.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$726.00
|
| Rate for Payer: Multiplan Commercial |
$774.40
|
| Rate for Payer: NAPHCARE Commercial |
$580.80
|
| Rate for Payer: Preferred Network Access Commercial |
$890.56
|
| Rate for Payer: Quartz Beloit One Network |
$474.32
|
| Rate for Payer: Quartz Commercial |
$629.20
|
| Rate for Payer: Quartz Medicare Advantage |
$580.80
|
| Rate for Payer: The Alliance Commercial |
$3,872.00
|
| Rate for Payer: WEA Trust Commercial |
$532.40
|
| Rate for Payer: WPS Commercial |
$717.00
|
|
|
INJECTION PARVERTEBRAL FACET C/T SINGLE LEVEL
|
Facility
|
OP
|
$1,620.00
|
|
| Hospital Charge Code |
5262681
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$453.60 |
| Max. Negotiated Rate |
$6,480.00 |
| Rate for Payer: Aetna Commercial |
$1,458.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,393.20
|
| Rate for Payer: Aetna Managed Medicare |
$453.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,053.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$810.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$777.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$858.60
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cigna Commercial |
$1,490.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$906.55
|
| Rate for Payer: Health EOS Commercial |
$1,441.80
|
| Rate for Payer: HFN Commercial |
$1,490.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,215.00
|
| Rate for Payer: Multiplan Commercial |
$1,296.00
|
| Rate for Payer: NAPHCARE Commercial |
$972.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,490.40
|
| Rate for Payer: Quartz Beloit One Network |
$793.80
|
| Rate for Payer: Quartz Commercial |
$1,053.00
|
| Rate for Payer: Quartz Medicare Advantage |
$972.00
|
| Rate for Payer: The Alliance Commercial |
$6,480.00
|
| Rate for Payer: WEA Trust Commercial |
$891.00
|
| Rate for Payer: WPS Commercial |
$1,199.93
|
|
|
INJECTION PARVERTEBRAL FACET C/T SINGLE LEVEL
|
Facility
|
IP
|
$1,620.00
|
|
| Hospital Charge Code |
5262681
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$793.80 |
| Max. Negotiated Rate |
$1,490.40 |
| Rate for Payer: Aetna Commercial |
$1,458.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,393.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$858.60
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cigna Commercial |
$1,490.40
|
| Rate for Payer: Health EOS Commercial |
$1,441.80
|
| Rate for Payer: HFN Commercial |
$1,490.40
|
| Rate for Payer: Multiplan Commercial |
$1,296.00
|
| Rate for Payer: NAPHCARE Commercial |
$972.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,490.40
|
| Rate for Payer: Quartz Beloit One Network |
$793.80
|
| Rate for Payer: Quartz Commercial |
$972.00
|
| Rate for Payer: WEA Trust Commercial |
$891.00
|
| Rate for Payer: WPS Commercial |
$1,199.93
|
|
|
INJECTION PARVERTEBRAL FACET L/S 2ND LEVEL (+)
|
Facility
|
OP
|
$553.00
|
|
| Hospital Charge Code |
5262685
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$154.84 |
| Max. Negotiated Rate |
$2,212.00 |
| Rate for Payer: Aetna Commercial |
$497.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.58
|
| Rate for Payer: Aetna Managed Medicare |
$154.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$359.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$276.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$265.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.09
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$508.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$309.46
|
| Rate for Payer: Health EOS Commercial |
$492.17
|
| Rate for Payer: HFN Commercial |
$508.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$414.75
|
| Rate for Payer: Multiplan Commercial |
$442.40
|
| Rate for Payer: NAPHCARE Commercial |
$331.80
|
| Rate for Payer: Preferred Network Access Commercial |
$508.76
|
| Rate for Payer: Quartz Beloit One Network |
$270.97
|
| Rate for Payer: Quartz Commercial |
$359.45
|
| Rate for Payer: Quartz Medicare Advantage |
$331.80
|
| Rate for Payer: The Alliance Commercial |
$2,212.00
|
| Rate for Payer: WEA Trust Commercial |
$304.15
|
| Rate for Payer: WPS Commercial |
$409.61
|
|
|
INJECTION PARVERTEBRAL FACET L/S 2ND LEVEL (+)
|
Facility
|
IP
|
$553.00
|
|
| Hospital Charge Code |
5262685
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$270.97 |
| Max. Negotiated Rate |
$508.76 |
| Rate for Payer: Aetna Commercial |
$497.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.09
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$508.76
|
| Rate for Payer: Health EOS Commercial |
$492.17
|
| Rate for Payer: HFN Commercial |
$508.76
|
| Rate for Payer: Multiplan Commercial |
$442.40
|
| Rate for Payer: NAPHCARE Commercial |
$331.80
|
| Rate for Payer: Preferred Network Access Commercial |
$508.76
|
| Rate for Payer: Quartz Beloit One Network |
$270.97
|
| Rate for Payer: Quartz Commercial |
$331.80
|
| Rate for Payer: WEA Trust Commercial |
$304.15
|
| Rate for Payer: WPS Commercial |
$409.61
|
|
|
INJECTION PARVERTEBRAL FACET L/S 3RD OR ADD (+)
|
Facility
|
IP
|
$553.00
|
|
| Hospital Charge Code |
5262686
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$270.97 |
| Max. Negotiated Rate |
$508.76 |
| Rate for Payer: Aetna Commercial |
$497.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.09
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$508.76
|
| Rate for Payer: Health EOS Commercial |
$492.17
|
| Rate for Payer: HFN Commercial |
$508.76
|
| Rate for Payer: Multiplan Commercial |
$442.40
|
| Rate for Payer: NAPHCARE Commercial |
$331.80
|
| Rate for Payer: Preferred Network Access Commercial |
$508.76
|
| Rate for Payer: Quartz Beloit One Network |
$270.97
|
| Rate for Payer: Quartz Commercial |
$331.80
|
| Rate for Payer: WEA Trust Commercial |
$304.15
|
| Rate for Payer: WPS Commercial |
$409.61
|
|
|
INJECTION PARVERTEBRAL FACET L/S 3RD OR ADD (+)
|
Facility
|
OP
|
$553.00
|
|
| Hospital Charge Code |
5262686
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$154.84 |
| Max. Negotiated Rate |
$2,212.00 |
| Rate for Payer: Aetna Commercial |
$497.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.58
|
| Rate for Payer: Aetna Managed Medicare |
$154.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$359.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$276.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$265.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.09
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$508.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$309.46
|
| Rate for Payer: Health EOS Commercial |
$492.17
|
| Rate for Payer: HFN Commercial |
$508.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$414.75
|
| Rate for Payer: Multiplan Commercial |
$442.40
|
| Rate for Payer: NAPHCARE Commercial |
$331.80
|
| Rate for Payer: Preferred Network Access Commercial |
$508.76
|
| Rate for Payer: Quartz Beloit One Network |
$270.97
|
| Rate for Payer: Quartz Commercial |
$359.45
|
| Rate for Payer: Quartz Medicare Advantage |
$331.80
|
| Rate for Payer: The Alliance Commercial |
$2,212.00
|
| Rate for Payer: WEA Trust Commercial |
$304.15
|
| Rate for Payer: WPS Commercial |
$409.61
|
|
|
INJECTION PARVERTEBRAL FACET L/S SINGLE LEVEL
|
Facility
|
IP
|
$1,640.00
|
|
| Hospital Charge Code |
5262684
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$803.60 |
| Max. Negotiated Rate |
$1,508.80 |
| Rate for Payer: Aetna Commercial |
$1,476.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,410.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$869.20
|
| Rate for Payer: Cash Price |
$492.00
|
| Rate for Payer: Cigna Commercial |
$1,508.80
|
| Rate for Payer: Health EOS Commercial |
$1,459.60
|
| Rate for Payer: HFN Commercial |
$1,508.80
|
| Rate for Payer: Multiplan Commercial |
$1,312.00
|
| Rate for Payer: NAPHCARE Commercial |
$984.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,508.80
|
| Rate for Payer: Quartz Beloit One Network |
$803.60
|
| Rate for Payer: Quartz Commercial |
$984.00
|
| Rate for Payer: WEA Trust Commercial |
$902.00
|
| Rate for Payer: WPS Commercial |
$1,214.75
|
|
|
INJECTION PARVERTEBRAL FACET L/S SINGLE LEVEL
|
Facility
|
OP
|
$1,640.00
|
|
| Hospital Charge Code |
5262684
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$459.20 |
| Max. Negotiated Rate |
$6,560.00 |
| Rate for Payer: Aetna Commercial |
$1,476.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,410.40
|
| Rate for Payer: Aetna Managed Medicare |
$459.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,066.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$820.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$787.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$869.20
|
| Rate for Payer: Cash Price |
$492.00
|
| Rate for Payer: Cigna Commercial |
$1,508.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$917.74
|
| Rate for Payer: Health EOS Commercial |
$1,459.60
|
| Rate for Payer: HFN Commercial |
$1,508.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,230.00
|
| Rate for Payer: Multiplan Commercial |
$1,312.00
|
| Rate for Payer: NAPHCARE Commercial |
$984.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,508.80
|
| Rate for Payer: Quartz Beloit One Network |
$803.60
|
| Rate for Payer: Quartz Commercial |
$1,066.00
|
| Rate for Payer: Quartz Medicare Advantage |
$984.00
|
| Rate for Payer: The Alliance Commercial |
$6,560.00
|
| Rate for Payer: WEA Trust Commercial |
$902.00
|
| Rate for Payer: WPS Commercial |
$1,214.75
|
|
