|
Inj PTC
|
Professional
|
Both
|
$3,168.00
|
|
|
Service Code
|
CPT 47500
|
| Hospital Charge Code |
3072743
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,393.92 |
| Max. Negotiated Rate |
$3,009.60 |
| Rate for Payer: Aetna Commercial |
$3,009.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,724.48
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$3,009.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,584.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,900.80
|
| Rate for Payer: Health EOS Commercial |
$2,882.88
|
| Rate for Payer: HFN Commercial |
$3,009.60
|
| Rate for Payer: Multiplan Commercial |
$2,534.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,009.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,393.92
|
| Rate for Payer: Quartz Commercial |
$1,805.76
|
| Rate for Payer: The Alliance Commercial |
$1,584.00
|
| Rate for Payer: WEA Trust Commercial |
$1,742.40
|
| Rate for Payer: WPS Commercial |
$2,346.54
|
|
|
Inj PTC
|
Facility
|
OP
|
$3,168.00
|
|
|
Service Code
|
CPT 47500
|
| Hospital Charge Code |
3072743
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$887.04 |
| Max. Negotiated Rate |
$12,672.00 |
| Rate for Payer: Aetna Commercial |
$2,851.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,724.48
|
| Rate for Payer: Aetna Managed Medicare |
$887.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,059.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,584.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,520.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,679.04
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$2,914.56
|
| Rate for Payer: Health EOS Commercial |
$2,819.52
|
| Rate for Payer: HFN Commercial |
$2,914.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,376.00
|
| Rate for Payer: Multiplan Commercial |
$2,534.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,900.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,914.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,552.32
|
| Rate for Payer: Quartz Commercial |
$2,059.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,900.80
|
| Rate for Payer: The Alliance Commercial |
$12,672.00
|
| Rate for Payer: WEA Trust Commercial |
$1,742.40
|
| Rate for Payer: WPS Commercial |
$2,346.54
|
|
|
Inj PTC
|
Facility
|
IP
|
$3,168.00
|
|
|
Service Code
|
CPT 47500
|
| Hospital Charge Code |
3072743
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,552.32 |
| Max. Negotiated Rate |
$2,914.56 |
| Rate for Payer: Aetna Commercial |
$2,851.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,724.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,679.04
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$2,914.56
|
| Rate for Payer: Health EOS Commercial |
$2,819.52
|
| Rate for Payer: HFN Commercial |
$2,914.56
|
| Rate for Payer: Multiplan Commercial |
$2,534.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,900.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,914.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,552.32
|
| Rate for Payer: Quartz Commercial |
$1,900.80
|
| Rate for Payer: WEA Trust Commercial |
$1,742.40
|
| Rate for Payer: WPS Commercial |
$2,346.54
|
|
|
Inj Pyelopgraphy
|
Facility
|
IP
|
$1,146.00
|
|
|
Service Code
|
CPT 50394
|
| Hospital Charge Code |
3072747
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$561.54 |
| Max. Negotiated Rate |
$1,054.32 |
| Rate for Payer: Aetna Commercial |
$1,031.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$985.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$607.38
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cigna Commercial |
$1,054.32
|
| Rate for Payer: Health EOS Commercial |
$1,019.94
|
| Rate for Payer: HFN Commercial |
$1,054.32
|
| Rate for Payer: Multiplan Commercial |
$916.80
|
| Rate for Payer: NAPHCARE Commercial |
$687.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,054.32
|
| Rate for Payer: Quartz Beloit One Network |
$561.54
|
| Rate for Payer: Quartz Commercial |
$687.60
|
| Rate for Payer: WEA Trust Commercial |
$630.30
|
| Rate for Payer: WPS Commercial |
$848.84
|
|
|
Inj Pyelopgraphy
|
Facility
|
OP
|
$1,146.00
|
|
|
Service Code
|
CPT 50394
|
| Hospital Charge Code |
3072747
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$320.88 |
| Max. Negotiated Rate |
$4,584.00 |
| Rate for Payer: Aetna Commercial |
$1,031.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$985.56
|
| Rate for Payer: Aetna Managed Medicare |
$320.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$744.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$573.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$550.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$607.38
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cigna Commercial |
$1,054.32
|
| Rate for Payer: Health EOS Commercial |
$1,019.94
|
| Rate for Payer: HFN Commercial |
$1,054.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$859.50
|
| Rate for Payer: Multiplan Commercial |
$916.80
|
| Rate for Payer: NAPHCARE Commercial |
$687.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,054.32
|
| Rate for Payer: Quartz Beloit One Network |
$561.54
|
| Rate for Payer: Quartz Commercial |
$744.90
|
| Rate for Payer: Quartz Medicare Advantage |
$687.60
|
| Rate for Payer: The Alliance Commercial |
$4,584.00
|
| Rate for Payer: WEA Trust Commercial |
$630.30
|
| Rate for Payer: WPS Commercial |
$848.84
|
|
|
Inj Pyelopgraphy
|
Professional
|
Both
|
$1,146.00
|
|
|
Service Code
|
CPT 50394
|
| Hospital Charge Code |
3072747
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$504.24 |
| Max. Negotiated Rate |
$1,088.70 |
| Rate for Payer: Aetna Commercial |
$1,088.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$985.56
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cigna Commercial |
$1,088.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$573.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$687.60
|
| Rate for Payer: Health EOS Commercial |
$1,042.86
|
| Rate for Payer: HFN Commercial |
$1,088.70
|
| Rate for Payer: Multiplan Commercial |
$916.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,088.70
|
| Rate for Payer: Quartz Beloit One Network |
$504.24
|
| Rate for Payer: Quartz Commercial |
$653.22
|
| Rate for Payer: The Alliance Commercial |
$573.00
|
| Rate for Payer: WEA Trust Commercial |
$630.30
|
| Rate for Payer: WPS Commercial |
$848.84
|
|
|
Inj (s), diag, or TA, Parav Facet 0216T50
|
Professional
|
Both
|
$784.00
|
|
|
Service Code
|
CPT 0216T 50
|
| Hospital Charge Code |
3382932
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$344.96 |
| Max. Negotiated Rate |
$744.80 |
| Rate for Payer: Aetna Commercial |
$744.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$674.24
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cigna Commercial |
$744.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$392.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$470.40
|
| Rate for Payer: Health EOS Commercial |
$713.44
|
| Rate for Payer: HFN Commercial |
$744.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$617.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$617.86
|
| Rate for Payer: Multiplan Commercial |
$627.20
|
| Rate for Payer: Preferred Network Access Commercial |
$744.80
|
| Rate for Payer: Quartz Beloit One Network |
$344.96
|
| Rate for Payer: Quartz Commercial |
$446.88
|
| Rate for Payer: The Alliance Commercial |
$392.00
|
| Rate for Payer: WEA Trust Commercial |
$431.20
|
| Rate for Payer: WPS Commercial |
$580.71
|
|
|
Inj (s), diag, or TA, Parav Facet 0216T50
|
Facility
|
OP
|
$784.00
|
|
|
Service Code
|
CPT 0216T 50
|
| Hospital Charge Code |
3382932
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$384.16 |
| Max. Negotiated Rate |
$3,603.64 |
| Rate for Payer: Aetna Commercial |
$705.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$674.24
|
| 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 Blue Cross PPO |
$415.52
|
| 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: Cash Price |
$235.20
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cigna Commercial |
$721.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$900.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$438.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$900.91
|
| Rate for Payer: Health EOS Commercial |
$697.76
|
| Rate for Payer: HFN Commercial |
$721.28
|
| 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: Multiplan Commercial |
$627.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,351.36
|
| Rate for Payer: Preferred Network Access Commercial |
$721.28
|
| Rate for Payer: Quartz Beloit One Network |
$384.16
|
| Rate for Payer: Quartz Commercial |
$509.60
|
| 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: WEA Trust Commercial |
$431.20
|
| Rate for Payer: Wellcare Medicare |
$900.91
|
| Rate for Payer: WPS Commercial |
$580.71
|
|
|
Inj (s), diag, or TA, Parav Facet 0216T50
|
Facility
|
IP
|
$784.00
|
|
|
Service Code
|
CPT 0216T 50
|
| Hospital Charge Code |
3382932
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$384.16 |
| Max. Negotiated Rate |
$721.28 |
| Rate for Payer: Aetna Commercial |
$705.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$674.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$415.52
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cigna Commercial |
$721.28
|
| Rate for Payer: Health EOS Commercial |
$697.76
|
| Rate for Payer: HFN Commercial |
$721.28
|
| Rate for Payer: Multiplan Commercial |
$627.20
|
| Rate for Payer: NAPHCARE Commercial |
$470.40
|
| Rate for Payer: Preferred Network Access Commercial |
$721.28
|
| Rate for Payer: Quartz Beloit One Network |
$384.16
|
| Rate for Payer: Quartz Commercial |
$470.40
|
| Rate for Payer: WEA Trust Commercial |
$431.20
|
| Rate for Payer: WPS Commercial |
$580.71
|
|
|
Inj Shoulder Arthrography
|
Professional
|
Both
|
$568.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
3072740
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$41.09 |
| Max. Negotiated Rate |
$539.60 |
| Rate for Payer: Aetna Commercial |
$539.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.48
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$539.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$340.80
|
| Rate for Payer: Health EOS Commercial |
$516.88
|
| Rate for Payer: HFN Commercial |
$539.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$169.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$169.37
|
| Rate for Payer: Multiplan Commercial |
$454.40
|
| Rate for Payer: Preferred Network Access Commercial |
$539.60
|
| Rate for Payer: Quartz Beloit One Network |
$249.92
|
| Rate for Payer: Quartz Commercial |
$323.76
|
| Rate for Payer: The Alliance Commercial |
$284.00
|
| Rate for Payer: United Healthcare Medicaid |
$41.09
|
| Rate for Payer: WEA Trust Commercial |
$312.40
|
| Rate for Payer: WPS Commercial |
$420.72
|
|
|
Inj Shoulder Arthrography
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
3072740
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$278.32 |
| Max. Negotiated Rate |
$522.56 |
| Rate for Payer: Aetna Commercial |
$511.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.04
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$522.56
|
| Rate for Payer: Health EOS Commercial |
$505.52
|
| Rate for Payer: HFN Commercial |
$522.56
|
| Rate for Payer: Multiplan Commercial |
$454.40
|
| Rate for Payer: NAPHCARE Commercial |
$340.80
|
| Rate for Payer: Preferred Network Access Commercial |
$522.56
|
| Rate for Payer: Quartz Beloit One Network |
$278.32
|
| Rate for Payer: Quartz Commercial |
$340.80
|
| Rate for Payer: WEA Trust Commercial |
$312.40
|
| Rate for Payer: WPS Commercial |
$420.72
|
|
|
Inj Shoulder Arthrography
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
3072740
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$159.04 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$511.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.48
|
| Rate for Payer: Aetna Managed Medicare |
$159.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$369.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$284.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.04
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$522.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Health EOS Commercial |
$505.52
|
| Rate for Payer: HFN Commercial |
$522.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$426.00
|
| Rate for Payer: Multiplan Commercial |
$454.40
|
| Rate for Payer: NAPHCARE Commercial |
$340.80
|
| Rate for Payer: Preferred Network Access Commercial |
$522.56
|
| Rate for Payer: Quartz Beloit One Network |
$278.32
|
| Rate for Payer: Quartz Commercial |
$369.20
|
| Rate for Payer: Quartz Medicare Advantage |
$340.80
|
| Rate for Payer: The Alliance Commercial |
$2,272.00
|
| Rate for Payer: WEA Trust Commercial |
$312.40
|
| Rate for Payer: WPS Commercial |
$420.72
|
|
|
Inj SI Joint Arthrgrphy &/Anes 27096
|
Professional
|
Both
|
$263.00
|
|
|
Service Code
|
CPT 27096
|
| Hospital Charge Code |
5232766
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$115.72 |
| Max. Negotiated Rate |
$281.38 |
| Rate for Payer: Aetna Commercial |
$249.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$226.18
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cigna Commercial |
$249.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$151.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$157.80
|
| Rate for Payer: Health EOS Commercial |
$239.33
|
| Rate for Payer: HFN Commercial |
$249.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$281.38
|
| Rate for Payer: Multiplan Commercial |
$210.40
|
| Rate for Payer: Preferred Network Access Commercial |
$249.85
|
| Rate for Payer: Quartz Beloit One Network |
$115.72
|
| Rate for Payer: Quartz Commercial |
$149.91
|
| Rate for Payer: The Alliance Commercial |
$131.50
|
| Rate for Payer: United Healthcare Medicaid |
$151.33
|
| Rate for Payer: WEA Trust Commercial |
$144.65
|
| Rate for Payer: WPS Commercial |
$194.80
|
|
|
Inj SI Joint Arthrgrphy &/Anes 2709650
|
Professional
|
Both
|
$826.00
|
|
|
Service Code
|
CPT 27096 50
|
| Hospital Charge Code |
5273237
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$151.33 |
| Max. Negotiated Rate |
$784.70 |
| Rate for Payer: Aetna Commercial |
$784.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$710.36
|
| Rate for Payer: Cash Price |
$247.80
|
| Rate for Payer: Cash Price |
$247.80
|
| Rate for Payer: Cash Price |
$247.80
|
| Rate for Payer: Cigna Commercial |
$784.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$151.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$495.60
|
| Rate for Payer: Health EOS Commercial |
$751.66
|
| Rate for Payer: HFN Commercial |
$784.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$281.38
|
| Rate for Payer: Multiplan Commercial |
$660.80
|
| Rate for Payer: Preferred Network Access Commercial |
$784.70
|
| Rate for Payer: Quartz Beloit One Network |
$363.44
|
| Rate for Payer: Quartz Commercial |
$470.82
|
| Rate for Payer: The Alliance Commercial |
$413.00
|
| Rate for Payer: United Healthcare Medicaid |
$151.33
|
| Rate for Payer: WEA Trust Commercial |
$454.30
|
| Rate for Payer: WPS Commercial |
$611.82
|
|
|
Inj Sinogram
|
Facility
|
IP
|
$851.00
|
|
|
Service Code
|
CPT 20501
|
| Hospital Charge Code |
3072750
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$416.99 |
| Max. Negotiated Rate |
$782.92 |
| Rate for Payer: Aetna Commercial |
$765.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$731.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$451.03
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cigna Commercial |
$782.92
|
| Rate for Payer: Health EOS Commercial |
$757.39
|
| Rate for Payer: HFN Commercial |
$782.92
|
| Rate for Payer: Multiplan Commercial |
$680.80
|
| Rate for Payer: NAPHCARE Commercial |
$510.60
|
| Rate for Payer: Preferred Network Access Commercial |
$782.92
|
| Rate for Payer: Quartz Beloit One Network |
$416.99
|
| Rate for Payer: Quartz Commercial |
$510.60
|
| Rate for Payer: WEA Trust Commercial |
$468.05
|
| Rate for Payer: WPS Commercial |
$630.34
|
|
|
Inj Sinogram
|
Professional
|
Both
|
$851.00
|
|
|
Service Code
|
CPT 20501
|
| Hospital Charge Code |
3072750
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$43.08 |
| Max. Negotiated Rate |
$808.45 |
| Rate for Payer: Aetna Commercial |
$808.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$731.86
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cigna Commercial |
$808.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$510.60
|
| Rate for Payer: Health EOS Commercial |
$774.41
|
| Rate for Payer: HFN Commercial |
$808.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$125.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$125.95
|
| Rate for Payer: Multiplan Commercial |
$680.80
|
| Rate for Payer: Preferred Network Access Commercial |
$808.45
|
| Rate for Payer: Quartz Beloit One Network |
$374.44
|
| Rate for Payer: Quartz Commercial |
$485.07
|
| Rate for Payer: The Alliance Commercial |
$425.50
|
| Rate for Payer: United Healthcare Medicaid |
$43.08
|
| Rate for Payer: WEA Trust Commercial |
$468.05
|
| Rate for Payer: WPS Commercial |
$630.34
|
|
|
Inj Sinogram
|
Facility
|
OP
|
$851.00
|
|
|
Service Code
|
CPT 20501
|
| Hospital Charge Code |
3072750
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$238.28 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$765.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$731.86
|
| Rate for Payer: Aetna Managed Medicare |
$238.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$553.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$425.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$408.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$451.03
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cigna Commercial |
$782.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Health EOS Commercial |
$757.39
|
| Rate for Payer: HFN Commercial |
$782.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$638.25
|
| Rate for Payer: Multiplan Commercial |
$680.80
|
| Rate for Payer: NAPHCARE Commercial |
$510.60
|
| Rate for Payer: Preferred Network Access Commercial |
$782.92
|
| Rate for Payer: Quartz Beloit One Network |
$416.99
|
| Rate for Payer: Quartz Commercial |
$553.15
|
| Rate for Payer: Quartz Medicare Advantage |
$510.60
|
| Rate for Payer: The Alliance Commercial |
$3,404.00
|
| Rate for Payer: WEA Trust Commercial |
$468.05
|
| Rate for Payer: WPS Commercial |
$630.34
|
|
|
Inj Tendon Sheath/Ligament 20550
|
Professional
|
Both
|
$88.00
|
|
|
Service Code
|
CPT 20550
|
| Hospital Charge Code |
4494905
|
|
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
|
|
|
Inj Tendon Sheath/Ligament 2055050
|
Professional
|
Both
|
$178.00
|
|
|
Service Code
|
CPT 20550 50
|
| Hospital Charge Code |
3850018
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.97 |
| Max. Negotiated Rate |
$169.10 |
| Rate for Payer: Aetna Commercial |
$169.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$169.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$106.80
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$169.10
|
| 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 |
$142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.10
|
| Rate for Payer: Quartz Beloit One Network |
$78.32
|
| Rate for Payer: Quartz Commercial |
$101.46
|
| Rate for Payer: The Alliance Commercial |
$89.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.97
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
Inj Treatment Nerve 64600
|
Professional
|
Both
|
$449.00
|
|
|
Service Code
|
CPT 64600
|
| Hospital Charge Code |
5232708
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$197.56 |
| Max. Negotiated Rate |
$749.07 |
| Rate for Payer: Aetna Commercial |
$426.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$386.14
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$426.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$733.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$269.40
|
| Rate for Payer: Health EOS Commercial |
$408.59
|
| Rate for Payer: HFN Commercial |
$426.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$749.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$749.07
|
| Rate for Payer: Multiplan Commercial |
$359.20
|
| Rate for Payer: Preferred Network Access Commercial |
$426.55
|
| Rate for Payer: Quartz Beloit One Network |
$197.56
|
| Rate for Payer: Quartz Commercial |
$255.93
|
| Rate for Payer: The Alliance Commercial |
$224.50
|
| Rate for Payer: United Healthcare Medicaid |
$733.32
|
| Rate for Payer: WEA Trust Commercial |
$246.95
|
| Rate for Payer: WPS Commercial |
$332.57
|
|
|
Inj T-Tube Cholangiogram
|
Facility
|
OP
|
$1,631.00
|
|
|
Service Code
|
CPT 47531
|
| Hospital Charge Code |
3072742
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$799.19 |
| Max. Negotiated Rate |
$13,678.24 |
| Rate for Payer: Aetna Commercial |
$1,467.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,402.66
|
| 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 Blue Cross PPO |
$864.43
|
| 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: Cash Price |
$489.30
|
| Rate for Payer: Cash Price |
$489.30
|
| Rate for Payer: Cash Price |
$489.30
|
| Rate for Payer: Cigna Commercial |
$1,500.52
|
| 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: Health EOS Commercial |
$1,451.59
|
| Rate for Payer: HFN Commercial |
$1,500.52
|
| 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: Multiplan Commercial |
$1,304.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,129.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,500.52
|
| Rate for Payer: Quartz Beloit One Network |
$799.19
|
| Rate for Payer: Quartz Commercial |
$1,060.15
|
| 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: WEA Trust Commercial |
$897.05
|
| Rate for Payer: Wellcare Medicare |
$3,419.56
|
| Rate for Payer: WPS Commercial |
$1,208.08
|
|
|
Inj T-Tube Cholangiogram
|
Facility
|
IP
|
$1,631.00
|
|
|
Service Code
|
CPT 47531
|
| Hospital Charge Code |
3072742
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$799.19 |
| Max. Negotiated Rate |
$1,500.52 |
| Rate for Payer: Aetna Commercial |
$1,467.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,402.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$864.43
|
| Rate for Payer: Cash Price |
$489.30
|
| Rate for Payer: Cigna Commercial |
$1,500.52
|
| Rate for Payer: Health EOS Commercial |
$1,451.59
|
| Rate for Payer: HFN Commercial |
$1,500.52
|
| Rate for Payer: Multiplan Commercial |
$1,304.80
|
| Rate for Payer: NAPHCARE Commercial |
$978.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,500.52
|
| Rate for Payer: Quartz Beloit One Network |
$799.19
|
| Rate for Payer: Quartz Commercial |
$978.60
|
| Rate for Payer: WEA Trust Commercial |
$897.05
|
| Rate for Payer: WPS Commercial |
$1,208.08
|
|
|
Inj Wrist Arthrography
|
Facility
|
OP
|
$769.00
|
|
|
Service Code
|
CPT 25246
|
| Hospital Charge Code |
3072741
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$215.32 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$692.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$661.34
|
| Rate for Payer: Aetna Managed Medicare |
$215.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$499.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$384.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$369.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$407.57
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$707.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Health EOS Commercial |
$684.41
|
| Rate for Payer: HFN Commercial |
$707.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$576.75
|
| Rate for Payer: Multiplan Commercial |
$615.20
|
| Rate for Payer: NAPHCARE Commercial |
$461.40
|
| Rate for Payer: Preferred Network Access Commercial |
$707.48
|
| Rate for Payer: Quartz Beloit One Network |
$376.81
|
| Rate for Payer: Quartz Commercial |
$499.85
|
| Rate for Payer: Quartz Medicare Advantage |
$461.40
|
| Rate for Payer: The Alliance Commercial |
$3,076.00
|
| Rate for Payer: WEA Trust Commercial |
$422.95
|
| Rate for Payer: WPS Commercial |
$569.60
|
|
|
Inj Wrist Arthrography
|
Facility
|
IP
|
$769.00
|
|
|
Service Code
|
CPT 25246
|
| Hospital Charge Code |
3072741
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$376.81 |
| Max. Negotiated Rate |
$707.48 |
| Rate for Payer: Aetna Commercial |
$692.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$661.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$407.57
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$707.48
|
| Rate for Payer: Health EOS Commercial |
$684.41
|
| Rate for Payer: HFN Commercial |
$707.48
|
| Rate for Payer: Multiplan Commercial |
$615.20
|
| Rate for Payer: NAPHCARE Commercial |
$461.40
|
| Rate for Payer: Preferred Network Access Commercial |
$707.48
|
| Rate for Payer: Quartz Beloit One Network |
$376.81
|
| Rate for Payer: Quartz Commercial |
$461.40
|
| Rate for Payer: WEA Trust Commercial |
$422.95
|
| Rate for Payer: WPS Commercial |
$569.60
|
|
|
Inj Wrist Arthrography
|
Professional
|
Both
|
$769.00
|
|
|
Service Code
|
CPT 25246
|
| Hospital Charge Code |
3072741
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$60.63 |
| Max. Negotiated Rate |
$730.55 |
| Rate for Payer: Aetna Commercial |
$730.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$661.34
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$730.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$461.40
|
| Rate for Payer: Health EOS Commercial |
$699.79
|
| Rate for Payer: HFN Commercial |
$730.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$249.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$249.85
|
| Rate for Payer: Multiplan Commercial |
$615.20
|
| Rate for Payer: Preferred Network Access Commercial |
$730.55
|
| Rate for Payer: Quartz Beloit One Network |
$338.36
|
| Rate for Payer: Quartz Commercial |
$438.33
|
| Rate for Payer: The Alliance Commercial |
$384.50
|
| Rate for Payer: United Healthcare Medicaid |
$60.63
|
| Rate for Payer: WEA Trust Commercial |
$422.95
|
| Rate for Payer: WPS Commercial |
$569.60
|
|
