|
Injection, Pegfilgrastim 6mg J2505
|
Professional
|
Both
|
$7,835.00
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
3697518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.75 |
| Max. Negotiated Rate |
$7,443.25 |
| Rate for Payer: Aetna Commercial |
$7,443.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,738.10
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cigna Commercial |
$7,443.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$109.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.75
|
| Rate for Payer: Health EOS Commercial |
$7,129.85
|
| Rate for Payer: HFN Commercial |
$7,443.25
|
| Rate for Payer: Multiplan Commercial |
$6,268.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,443.25
|
| Rate for Payer: Quartz Beloit One Network |
$3,447.40
|
| Rate for Payer: Quartz Commercial |
$4,465.95
|
| Rate for Payer: The Alliance Commercial |
$3,917.50
|
| Rate for Payer: United Healthcare Medicaid |
$109.75
|
| Rate for Payer: WEA Trust Commercial |
$4,309.25
|
| Rate for Payer: WPS Commercial |
$274.38
|
|
|
Injection, Pegfilgrastim 6mg J2505
|
Facility
|
IP
|
$7,835.00
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
3697518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,839.15 |
| Max. Negotiated Rate |
$7,208.20 |
| Rate for Payer: Aetna Commercial |
$7,051.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,738.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,152.55
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cigna Commercial |
$7,208.20
|
| Rate for Payer: Health EOS Commercial |
$6,973.15
|
| Rate for Payer: HFN Commercial |
$7,208.20
|
| Rate for Payer: Multiplan Commercial |
$6,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,701.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,208.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,839.15
|
| Rate for Payer: Quartz Commercial |
$4,701.00
|
| Rate for Payer: WEA Trust Commercial |
$4,309.25
|
| Rate for Payer: WPS Commercial |
$5,803.38
|
|
|
Injection, Pegfilgrastim 6mg J2505
|
Facility
|
OP
|
$7,835.00
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
3697518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.68 |
| Max. Negotiated Rate |
$7,208.20 |
| Rate for Payer: Aetna Commercial |
$7,051.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,738.10
|
| Rate for Payer: Aetna Managed Medicare |
$50.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$109.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$109.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$109.75
|
| Rate for Payer: Anthem Medicare Advantage |
$50.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,152.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$50.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$50.68
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cigna Commercial |
$7,208.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$50.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$145.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$50.68
|
| Rate for Payer: Health EOS Commercial |
$6,973.15
|
| Rate for Payer: HFN Commercial |
$7,208.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$188.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$50.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$50.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$50.68
|
| Rate for Payer: Multiplan Commercial |
$6,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$76.02
|
| Rate for Payer: Preferred Network Access Commercial |
$7,208.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,839.15
|
| Rate for Payer: Quartz Commercial |
$5,092.75
|
| Rate for Payer: Quartz Medicare Advantage |
$50.68
|
| Rate for Payer: The Alliance Commercial |
$202.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.68
|
| Rate for Payer: WEA Trust Commercial |
$4,309.25
|
| Rate for Payer: Wellcare Medicare |
$50.68
|
| Rate for Payer: WPS Commercial |
$274.38
|
|
|
INJECTION PIRIFORMIS W/SEDATION
|
Facility
|
OP
|
$1,276.00
|
|
| Hospital Charge Code |
5294613
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$357.28 |
| Max. Negotiated Rate |
$5,104.00 |
| Rate for Payer: Aetna Commercial |
$1,148.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,097.36
|
| Rate for Payer: Aetna Managed Medicare |
$357.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$829.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$638.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$612.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$676.28
|
| Rate for Payer: Cash Price |
$382.80
|
| Rate for Payer: Cigna Commercial |
$1,173.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$714.05
|
| Rate for Payer: Health EOS Commercial |
$1,135.64
|
| Rate for Payer: HFN Commercial |
$1,173.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$957.00
|
| Rate for Payer: Multiplan Commercial |
$1,020.80
|
| Rate for Payer: NAPHCARE Commercial |
$765.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,173.92
|
| Rate for Payer: Quartz Beloit One Network |
$625.24
|
| Rate for Payer: Quartz Commercial |
$829.40
|
| Rate for Payer: Quartz Medicare Advantage |
$765.60
|
| Rate for Payer: The Alliance Commercial |
$5,104.00
|
| Rate for Payer: WEA Trust Commercial |
$701.80
|
| Rate for Payer: WPS Commercial |
$945.13
|
|
|
INJECTION PIRIFORMIS W/SEDATION
|
Facility
|
IP
|
$1,276.00
|
|
| Hospital Charge Code |
5294613
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$625.24 |
| Max. Negotiated Rate |
$1,173.92 |
| Rate for Payer: Aetna Commercial |
$1,148.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,097.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$676.28
|
| Rate for Payer: Cash Price |
$382.80
|
| Rate for Payer: Cigna Commercial |
$1,173.92
|
| Rate for Payer: Health EOS Commercial |
$1,135.64
|
| Rate for Payer: HFN Commercial |
$1,173.92
|
| Rate for Payer: Multiplan Commercial |
$1,020.80
|
| Rate for Payer: NAPHCARE Commercial |
$765.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,173.92
|
| Rate for Payer: Quartz Beloit One Network |
$625.24
|
| Rate for Payer: Quartz Commercial |
$765.60
|
| Rate for Payer: WEA Trust Commercial |
$701.80
|
| Rate for Payer: WPS Commercial |
$945.13
|
|
|
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
|
$4,218.22
|
|
|
Service Code
|
CPT 50431
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$675.19 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Managed Medicare |
$675.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$675.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$675.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$675.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$675.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$675.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,511.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$675.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$675.19
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$675.19
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$675.19
|
| Rate for Payer: NAPHCARE Commercial |
$1,012.78
|
| Rate for Payer: Quartz Medicare Advantage |
$675.19
|
| Rate for Payer: The Alliance Commercial |
$2,700.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$675.19
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$675.19
|
|
|
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
|
$13,678.24
|
|
|
Service Code
|
CPT 47531
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,419.56 |
| Max. Negotiated Rate |
$13,678.24 |
| Rate for Payer: Aetna Managed Medicare |
$3,419.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,419.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,419.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,419.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,419.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,419.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,720.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,419.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,419.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,419.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,419.56
|
| Rate for Payer: NAPHCARE Commercial |
$5,129.34
|
| Rate for Payer: Quartz Medicare Advantage |
$3,419.56
|
| Rate for Payer: The Alliance Commercial |
$13,678.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,419.56
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,419.56
|
|
|
INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 51600
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,218.22 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
|
|
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT ANESTHESIA
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 27093
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,218.22 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
|
|
INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 51610
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,218.22 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
|
|
INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 27096
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,183.00 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
|
|
INJECTION PROCEDURE FOR URETEROGRAPHY OR URETEROPYELOGRAPHY THROUGH URETEROSTOMY OR INDWELLING URETERAL CATHETER
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 50684
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,218.22 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
|
|
Injection Procedure Thrombin
|
Facility
|
IP
|
$4,560.00
|
|
|
Service Code
|
CPT 36002
|
| Hospital Charge Code |
5314050
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$2,234.40 |
| Max. Negotiated Rate |
$4,195.20 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,736.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
Injection Procedure Thrombin
|
Facility
|
OP
|
$4,560.00
|
|
|
Service Code
|
CPT 36002
|
| Hospital Charge Code |
5314050
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$620.92 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Aetna Managed Medicare |
$620.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,964.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,280.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,188.80
|
| Rate for Payer: Anthem Medicare Advantage |
$620.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$620.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$620.92
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$620.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$620.92
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,309.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$620.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$620.92
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$620.92
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$620.92
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$931.38
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,964.00
|
| Rate for Payer: Quartz Medicare Advantage |
$620.92
|
| Rate for Payer: The Alliance Commercial |
$2,483.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$620.92
|
| Rate for Payer: United Healthcare PPO |
$3,420.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: Wellcare Medicare |
$620.92
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
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
|
$4,218.22
|
|
|
Service Code
|
CPT 64494
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,218.22 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
|
|
INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 64493
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$900.91 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Managed Medicare |
$900.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$900.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$900.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$900.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$900.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$900.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,351.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$900.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$900.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$900.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$900.91
|
| Rate for Payer: NAPHCARE Commercial |
$1,351.36
|
| Rate for Payer: Quartz Medicare Advantage |
$900.91
|
| Rate for Payer: The Alliance Commercial |
$3,603.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$900.91
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$900.91
|
|
|
Injection; Single or Multiple Trigger Points 2055250
|
Professional
|
Both
|
$194.00
|
|
|
Service Code
|
CPT 20552 50
|
| Hospital Charge Code |
5273115
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Aetna Commercial |
$184.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$184.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$176.54
|
| Rate for Payer: HFN Commercial |
$184.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$126.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.34
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: Preferred Network Access Commercial |
$184.30
|
| Rate for Payer: Quartz Beloit One Network |
$85.36
|
| Rate for Payer: Quartz Commercial |
$110.58
|
| Rate for Payer: The Alliance Commercial |
$97.00
|
| Rate for Payer: United Healthcare Medicaid |
$25.89
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 62321
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$683.53 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Managed Medicare |
$683.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$683.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$683.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$683.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$683.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$683.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,542.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$683.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$683.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$683.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$683.53
|
| Rate for Payer: NAPHCARE Commercial |
$1,025.30
|
| Rate for Payer: Quartz Medicare Advantage |
$683.53
|
| Rate for Payer: The Alliance Commercial |
$2,734.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$683.53
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$683.53
|
|
|
INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 62323
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$683.53 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Managed Medicare |
$683.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$683.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$683.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$683.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$683.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$683.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,542.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$683.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$683.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$683.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$683.53
|
| Rate for Payer: NAPHCARE Commercial |
$1,025.30
|
| Rate for Payer: Quartz Medicare Advantage |
$683.53
|
| Rate for Payer: The Alliance Commercial |
$2,734.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$683.53
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$683.53
|
|
|
Injection(s); Single or Multiple Trigger Points 20552
|
Professional
|
Both
|
$97.00
|
|
|
Service Code
|
CPT 20552
|
| Hospital Charge Code |
1188966
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$126.34 |
| Rate for Payer: Aetna Commercial |
$92.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.42
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$92.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Health EOS Commercial |
$88.27
|
| Rate for Payer: HFN Commercial |
$92.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$126.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.34
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.15
|
| Rate for Payer: Quartz Beloit One Network |
$42.68
|
| Rate for Payer: Quartz Commercial |
$55.29
|
| Rate for Payer: The Alliance Commercial |
$48.50
|
| Rate for Payer: United Healthcare Medicaid |
$25.89
|
| Rate for Payer: WEA Trust Commercial |
$53.35
|
| Rate for Payer: WPS Commercial |
$71.85
|
|
|
Injection(s); Single or Multiple Trigger Points, =>3 muscles 20553
|
Professional
|
Both
|
$740.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
3013705
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$703.00 |
| Rate for Payer: Aetna Commercial |
$703.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$636.40
|
| Rate for Payer: Cash Price |
$222.00
|
| Rate for Payer: Cash Price |
$222.00
|
| Rate for Payer: Cash Price |
$222.00
|
| Rate for Payer: Cigna Commercial |
$703.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$444.00
|
| Rate for Payer: Health EOS Commercial |
$673.40
|
| Rate for Payer: HFN Commercial |
$703.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$143.25
|
| Rate for Payer: Multiplan Commercial |
$592.00
|
| Rate for Payer: Preferred Network Access Commercial |
$703.00
|
| Rate for Payer: Quartz Beloit One Network |
$325.60
|
| Rate for Payer: Quartz Commercial |
$421.80
|
| Rate for Payer: The Alliance Commercial |
$370.00
|
| Rate for Payer: United Healthcare Medicaid |
$25.89
|
| Rate for Payer: WEA Trust Commercial |
$407.00
|
| Rate for Payer: WPS Commercial |
$548.12
|
|
|
Injection(s); Single or Multiple Trigger Points, =>3 muscles 2055350
|
Professional
|
Both
|
$1,485.00
|
|
|
Service Code
|
CPT 20553 50
|
| Hospital Charge Code |
5543183
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$1,410.75 |
| Rate for Payer: Aetna Commercial |
$1,410.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,277.10
|
| Rate for Payer: Cash Price |
$445.50
|
| Rate for Payer: Cash Price |
$445.50
|
| Rate for Payer: Cash Price |
$445.50
|
| Rate for Payer: Cigna Commercial |
$1,410.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$891.00
|
| Rate for Payer: Health EOS Commercial |
$1,351.35
|
| Rate for Payer: HFN Commercial |
$1,410.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$143.25
|
| Rate for Payer: Multiplan Commercial |
$1,188.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,410.75
|
| Rate for Payer: Quartz Beloit One Network |
$653.40
|
| Rate for Payer: Quartz Commercial |
$846.45
|
| Rate for Payer: The Alliance Commercial |
$742.50
|
| Rate for Payer: United Healthcare Medicaid |
$25.89
|
| Rate for Payer: WEA Trust Commercial |
$816.75
|
| Rate for Payer: WPS Commercial |
$1,099.94
|
|
|
Injection(s); Single Tendon Sheath 20551
|
Professional
|
Both
|
$264.00
|
|
|
Service Code
|
CPT 20551
|
| Hospital Charge Code |
1188965
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$250.80 |
| Rate for Payer: Aetna Commercial |
$250.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.04
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$250.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$158.40
|
| Rate for Payer: Health EOS Commercial |
$240.24
|
| Rate for Payer: HFN Commercial |
$250.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$131.63
|
| Rate for Payer: Multiplan Commercial |
$211.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.80
|
| Rate for Payer: Quartz Beloit One Network |
$116.16
|
| Rate for Payer: Quartz Commercial |
$150.48
|
| Rate for Payer: The Alliance Commercial |
$132.00
|
| Rate for Payer: United Healthcare Medicaid |
$25.89
|
| Rate for Payer: WEA Trust Commercial |
$145.20
|
| Rate for Payer: WPS Commercial |
$195.54
|
|
|
Injection Therapeutic, Carpal Tunnel 20526
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
CPT 20526
|
| Hospital Charge Code |
1188967
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$242.25 |
| Rate for Payer: Aetna Commercial |
$242.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$219.30
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$242.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.00
|
| Rate for Payer: Health EOS Commercial |
$232.05
|
| Rate for Payer: HFN Commercial |
$242.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$187.76
|
| Rate for Payer: Multiplan Commercial |
$204.00
|
| Rate for Payer: Preferred Network Access Commercial |
$242.25
|
| Rate for Payer: Quartz Beloit One Network |
$112.20
|
| Rate for Payer: Quartz Commercial |
$145.35
|
| Rate for Payer: The Alliance Commercial |
$127.50
|
| Rate for Payer: United Healthcare Medicaid |
$25.89
|
| Rate for Payer: WEA Trust Commercial |
$140.25
|
| Rate for Payer: WPS Commercial |
$188.88
|
|
|
Injection Therapy of Veins 3647150
|
Professional
|
Both
|
$1,154.00
|
|
|
Service Code
|
CPT 36471 50
|
| Hospital Charge Code |
3970712
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$74.72 |
| Max. Negotiated Rate |
$1,096.30 |
| Rate for Payer: Aetna Commercial |
$1,096.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$992.44
|
| Rate for Payer: Cash Price |
$346.20
|
| Rate for Payer: Cash Price |
$346.20
|
| Rate for Payer: Cash Price |
$346.20
|
| Rate for Payer: Cigna Commercial |
$1,096.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$692.40
|
| Rate for Payer: Health EOS Commercial |
$1,050.14
|
| Rate for Payer: HFN Commercial |
$1,096.30
|
| 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 |
$923.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.30
|
| Rate for Payer: Quartz Beloit One Network |
$507.76
|
| Rate for Payer: Quartz Commercial |
$657.78
|
| Rate for Payer: The Alliance Commercial |
$577.00
|
| Rate for Payer: United Healthcare Medicaid |
$74.72
|
| Rate for Payer: WEA Trust Commercial |
$634.70
|
| Rate for Payer: WPS Commercial |
$854.77
|
|
