|
MRA Head w/ Contrast
|
Professional
|
Both
|
$6,015.00
|
|
|
Service Code
|
CPT 70545 TC
|
| Hospital Charge Code |
1610825
|
|
Hospital Revenue Code
|
615
|
| Min. Negotiated Rate |
$170.04 |
| Max. Negotiated Rate |
$5,942.82 |
| Rate for Payer: Aetna Commercial |
$5,942.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,379.82
|
| Rate for Payer: Aetna Managed Medicare |
$170.04
|
| Rate for Payer: Anthem Medicare Advantage |
$170.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$170.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$170.04
|
| Rate for Payer: Cash Price |
$1,804.50
|
| Rate for Payer: Cash Price |
$1,804.50
|
| Rate for Payer: Cash Price |
$1,804.50
|
| Rate for Payer: Cigna Commercial |
$5,942.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,127.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$170.04
|
| Rate for Payer: Health EOS Commercial |
$5,692.60
|
| Rate for Payer: HFN Commercial |
$5,942.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$682.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$682.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$170.04
|
| Rate for Payer: Multiplan Commercial |
$5,004.48
|
| Rate for Payer: NAPHCARE Commercial |
$255.06
|
| Rate for Payer: Preferred Network Access Commercial |
$5,942.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,752.46
|
| Rate for Payer: Quartz Commercial |
$3,565.69
|
| Rate for Payer: Quartz Medicare Advantage |
$170.04
|
| Rate for Payer: The Alliance Commercial |
$646.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$170.04
|
| Rate for Payer: WEA Trust Commercial |
$3,440.58
|
| Rate for Payer: WPS Commercial |
$850.20
|
|
|
MRA Head w/ Contrast
|
Facility
|
OP
|
$6,015.00
|
|
|
Service Code
|
CPT 70545 TC
|
| Hospital Charge Code |
1610825
|
|
Hospital Revenue Code
|
615
|
| Min. Negotiated Rate |
$680.16 |
| Max. Negotiated Rate |
$5,755.15 |
| Rate for Payer: Aetna Commercial |
$5,630.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,379.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,751.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,315.47
|
| Rate for Payer: Cash Price |
$1,804.50
|
| Rate for Payer: Cash Price |
$1,804.50
|
| Rate for Payer: Cash Price |
$1,804.50
|
| Rate for Payer: Cash Price |
$1,804.50
|
| Rate for Payer: Cigna Commercial |
$5,755.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,500.73
|
| Rate for Payer: Health EOS Commercial |
$5,567.48
|
| Rate for Payer: HFN Commercial |
$5,755.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,691.70
|
| Rate for Payer: Multiplan Commercial |
$5,004.48
|
| Rate for Payer: NAPHCARE Commercial |
$3,753.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,755.15
|
| Rate for Payer: Quartz Beloit One Network |
$3,065.24
|
| Rate for Payer: Quartz Commercial |
$4,066.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,753.36
|
| Rate for Payer: The Alliance Commercial |
$680.16
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,440.58
|
| Rate for Payer: WPS Commercial |
$1,190.28
|
|
|
MRA Head w/o Contrast
|
Professional
|
Both
|
$4,293.00
|
|
|
Service Code
|
CPT 70544 TC
|
| Hospital Charge Code |
3072651
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$158.39 |
| Max. Negotiated Rate |
$4,241.48 |
| Rate for Payer: Aetna Commercial |
$4,241.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,839.66
|
| Rate for Payer: Aetna Managed Medicare |
$158.39
|
| Rate for Payer: Anthem Medicare Advantage |
$158.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$158.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$158.39
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cigna Commercial |
$4,241.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,232.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$158.39
|
| Rate for Payer: Health EOS Commercial |
$4,062.90
|
| Rate for Payer: HFN Commercial |
$4,241.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$637.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$637.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$158.39
|
| Rate for Payer: Multiplan Commercial |
$3,571.78
|
| Rate for Payer: NAPHCARE Commercial |
$237.59
|
| Rate for Payer: Preferred Network Access Commercial |
$4,241.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,964.48
|
| Rate for Payer: Quartz Commercial |
$2,544.89
|
| Rate for Payer: Quartz Medicare Advantage |
$158.39
|
| Rate for Payer: The Alliance Commercial |
$601.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$158.39
|
| Rate for Payer: WEA Trust Commercial |
$2,455.60
|
| Rate for Payer: WPS Commercial |
$791.96
|
|
|
MRA Head w/o Contrast
|
Professional
|
Both
|
$4,293.00
|
|
|
Service Code
|
CPT 70544 TC
|
| Hospital Charge Code |
3073259
|
|
Hospital Revenue Code
|
615
|
| Min. Negotiated Rate |
$158.39 |
| Max. Negotiated Rate |
$4,241.48 |
| Rate for Payer: Aetna Commercial |
$4,241.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,839.66
|
| Rate for Payer: Aetna Managed Medicare |
$158.39
|
| Rate for Payer: Anthem Medicare Advantage |
$158.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$158.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$158.39
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cigna Commercial |
$4,241.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,232.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$158.39
|
| Rate for Payer: Health EOS Commercial |
$4,062.90
|
| Rate for Payer: HFN Commercial |
$4,241.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$637.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$637.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$158.39
|
| Rate for Payer: Multiplan Commercial |
$3,571.78
|
| Rate for Payer: NAPHCARE Commercial |
$237.59
|
| Rate for Payer: Preferred Network Access Commercial |
$4,241.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,964.48
|
| Rate for Payer: Quartz Commercial |
$2,544.89
|
| Rate for Payer: Quartz Medicare Advantage |
$158.39
|
| Rate for Payer: The Alliance Commercial |
$601.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$158.39
|
| Rate for Payer: WEA Trust Commercial |
$2,455.60
|
| Rate for Payer: WPS Commercial |
$791.96
|
|
|
MRA Head w/o Contrast
|
Facility
|
OP
|
$4,293.00
|
|
|
Service Code
|
CPT 70544 TC
|
| Hospital Charge Code |
3072651
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$633.57 |
| Max. Negotiated Rate |
$4,107.54 |
| Rate for Payer: Aetna Commercial |
$4,018.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,839.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,250.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,366.30
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cigna Commercial |
$4,107.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,498.53
|
| Rate for Payer: Health EOS Commercial |
$3,973.60
|
| Rate for Payer: HFN Commercial |
$4,107.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,348.54
|
| Rate for Payer: Multiplan Commercial |
$3,571.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,678.83
|
| Rate for Payer: Preferred Network Access Commercial |
$4,107.54
|
| Rate for Payer: Quartz Beloit One Network |
$2,187.71
|
| Rate for Payer: Quartz Commercial |
$2,902.07
|
| Rate for Payer: Quartz Medicare Advantage |
$2,678.83
|
| Rate for Payer: The Alliance Commercial |
$633.57
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,455.60
|
| Rate for Payer: WPS Commercial |
$1,108.74
|
|
|
MRA Head w/o Contrast
|
Facility
|
IP
|
$4,293.00
|
|
|
Service Code
|
CPT 70544 TC
|
| Hospital Charge Code |
3072651
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,187.71 |
| Max. Negotiated Rate |
$4,107.54 |
| Rate for Payer: Aetna Commercial |
$4,018.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,839.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,366.30
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cigna Commercial |
$4,107.54
|
| Rate for Payer: Health EOS Commercial |
$3,973.60
|
| Rate for Payer: HFN Commercial |
$4,107.54
|
| Rate for Payer: Multiplan Commercial |
$3,571.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,107.54
|
| Rate for Payer: Quartz Beloit One Network |
$2,187.71
|
| Rate for Payer: Quartz Commercial |
$2,678.83
|
| Rate for Payer: WEA Trust Commercial |
$2,455.60
|
| Rate for Payer: WPS Commercial |
$3,306.90
|
|
|
MRA Head w/o Contrast
|
Facility
|
OP
|
$4,293.00
|
|
|
Service Code
|
CPT 70544 TC
|
| Hospital Charge Code |
3073259
|
|
Hospital Revenue Code
|
615
|
| Min. Negotiated Rate |
$633.57 |
| Max. Negotiated Rate |
$4,107.54 |
| Rate for Payer: Aetna Commercial |
$4,018.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,839.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,250.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,366.30
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cigna Commercial |
$4,107.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,498.53
|
| Rate for Payer: Health EOS Commercial |
$3,973.60
|
| Rate for Payer: HFN Commercial |
$4,107.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,348.54
|
| Rate for Payer: Multiplan Commercial |
$3,571.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,678.83
|
| Rate for Payer: Preferred Network Access Commercial |
$4,107.54
|
| Rate for Payer: Quartz Beloit One Network |
$2,187.71
|
| Rate for Payer: Quartz Commercial |
$2,902.07
|
| Rate for Payer: Quartz Medicare Advantage |
$2,678.83
|
| Rate for Payer: The Alliance Commercial |
$633.57
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,455.60
|
| Rate for Payer: WPS Commercial |
$1,108.74
|
|
|
MRA Head w/o Contrast
|
Facility
|
IP
|
$4,293.00
|
|
|
Service Code
|
CPT 70544 TC
|
| Hospital Charge Code |
3073259
|
|
Hospital Revenue Code
|
615
|
| Min. Negotiated Rate |
$2,187.71 |
| Max. Negotiated Rate |
$4,107.54 |
| Rate for Payer: Aetna Commercial |
$4,018.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,839.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,366.30
|
| Rate for Payer: Cash Price |
$1,287.90
|
| Rate for Payer: Cigna Commercial |
$4,107.54
|
| Rate for Payer: Health EOS Commercial |
$3,973.60
|
| Rate for Payer: HFN Commercial |
$4,107.54
|
| Rate for Payer: Multiplan Commercial |
$3,571.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,107.54
|
| Rate for Payer: Quartz Beloit One Network |
$2,187.71
|
| Rate for Payer: Quartz Commercial |
$2,678.83
|
| Rate for Payer: WEA Trust Commercial |
$2,455.60
|
| Rate for Payer: WPS Commercial |
$3,306.90
|
|
|
MRA LE w or w/o Contrast
|
Facility
|
IP
|
$4,802.00
|
|
|
Service Code
|
CPT 73725 TC
|
| Hospital Charge Code |
4054124
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,447.10 |
| Max. Negotiated Rate |
$4,594.55 |
| Rate for Payer: Aetna Commercial |
$4,494.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,294.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,646.86
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cigna Commercial |
$4,594.55
|
| Rate for Payer: Health EOS Commercial |
$4,444.73
|
| Rate for Payer: HFN Commercial |
$4,594.55
|
| Rate for Payer: Multiplan Commercial |
$3,995.26
|
| Rate for Payer: Preferred Network Access Commercial |
$4,594.55
|
| Rate for Payer: Quartz Beloit One Network |
$2,447.10
|
| Rate for Payer: Quartz Commercial |
$2,996.45
|
| Rate for Payer: WEA Trust Commercial |
$2,746.74
|
| Rate for Payer: WPS Commercial |
$3,698.98
|
|
|
MRA LE w or w/o Contrast
|
Facility
|
OP
|
$4,802.00
|
|
|
Service Code
|
CPT 73725 TC
|
| Hospital Charge Code |
4054124
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,009.38 |
| Max. Negotiated Rate |
$4,594.55 |
| Rate for Payer: Aetna Commercial |
$4,494.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,294.91
|
| Rate for Payer: Aetna Managed Medicare |
$1,398.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,646.86
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cigna Commercial |
$4,594.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,794.76
|
| Rate for Payer: Health EOS Commercial |
$4,444.73
|
| Rate for Payer: HFN Commercial |
$4,594.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,745.56
|
| Rate for Payer: Multiplan Commercial |
$3,995.26
|
| Rate for Payer: NAPHCARE Commercial |
$2,996.45
|
| Rate for Payer: Preferred Network Access Commercial |
$4,594.55
|
| Rate for Payer: Quartz Beloit One Network |
$2,447.10
|
| Rate for Payer: Quartz Commercial |
$3,246.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,996.45
|
| Rate for Payer: The Alliance Commercial |
$1,009.38
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,746.74
|
| Rate for Payer: WPS Commercial |
$1,766.42
|
|
|
MRA LE w or w/o Contrast
|
Professional
|
Both
|
$4,802.00
|
|
|
Service Code
|
CPT 73725 TC
|
| Hospital Charge Code |
4054124
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$252.35 |
| Max. Negotiated Rate |
$4,744.38 |
| Rate for Payer: Aetna Commercial |
$4,744.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,294.91
|
| Rate for Payer: Aetna Managed Medicare |
$252.35
|
| Rate for Payer: Anthem Medicare Advantage |
$252.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$252.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$252.35
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cigna Commercial |
$4,744.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,497.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$252.35
|
| Rate for Payer: Health EOS Commercial |
$4,544.61
|
| Rate for Payer: HFN Commercial |
$4,744.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,023.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,023.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$252.35
|
| Rate for Payer: Multiplan Commercial |
$3,995.26
|
| Rate for Payer: NAPHCARE Commercial |
$378.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,744.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,197.40
|
| Rate for Payer: Quartz Commercial |
$2,846.63
|
| Rate for Payer: Quartz Medicare Advantage |
$252.35
|
| Rate for Payer: The Alliance Commercial |
$958.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$252.35
|
| Rate for Payer: WEA Trust Commercial |
$2,746.74
|
| Rate for Payer: WPS Commercial |
$1,261.73
|
|
|
MRA Lower Ext Bilat & MRA Abd Aorta w/
|
Professional
|
Both
|
$4,802.00
|
|
| Hospital Charge Code |
1610827
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,197.40 |
| Max. Negotiated Rate |
$4,744.38 |
| Rate for Payer: Aetna Commercial |
$4,744.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,294.91
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cigna Commercial |
$4,744.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,497.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,996.45
|
| Rate for Payer: Health EOS Commercial |
$4,544.61
|
| Rate for Payer: HFN Commercial |
$4,744.38
|
| Rate for Payer: Multiplan Commercial |
$3,995.26
|
| Rate for Payer: Preferred Network Access Commercial |
$4,744.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,197.40
|
| Rate for Payer: Quartz Commercial |
$2,846.63
|
| Rate for Payer: The Alliance Commercial |
$2,497.04
|
| Rate for Payer: WEA Trust Commercial |
$2,746.74
|
| Rate for Payer: WPS Commercial |
$3,698.98
|
|
|
MRA Lower Ext Bilat & MRA Abd Aorta w/
|
Facility
|
IP
|
$4,802.00
|
|
| Hospital Charge Code |
1610827
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,447.10 |
| Max. Negotiated Rate |
$4,594.55 |
| Rate for Payer: Aetna Commercial |
$4,494.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,294.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,646.86
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cigna Commercial |
$4,594.55
|
| Rate for Payer: Health EOS Commercial |
$4,444.73
|
| Rate for Payer: HFN Commercial |
$4,594.55
|
| Rate for Payer: Multiplan Commercial |
$3,995.26
|
| Rate for Payer: Preferred Network Access Commercial |
$4,594.55
|
| Rate for Payer: Quartz Beloit One Network |
$2,447.10
|
| Rate for Payer: Quartz Commercial |
$2,996.45
|
| Rate for Payer: WEA Trust Commercial |
$2,746.74
|
| Rate for Payer: WPS Commercial |
$3,698.98
|
|
|
MRA Lower Ext Bilat & MRA Abd Aorta w/
|
Facility
|
OP
|
$4,802.00
|
|
| Hospital Charge Code |
1610827
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,398.34 |
| Max. Negotiated Rate |
$4,594.55 |
| Rate for Payer: Aetna Commercial |
$4,494.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,294.91
|
| Rate for Payer: Aetna Managed Medicare |
$1,398.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,646.86
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cigna Commercial |
$4,594.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,794.76
|
| Rate for Payer: Health EOS Commercial |
$4,444.73
|
| Rate for Payer: HFN Commercial |
$4,594.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,745.56
|
| Rate for Payer: Multiplan Commercial |
$3,995.26
|
| Rate for Payer: NAPHCARE Commercial |
$2,996.45
|
| Rate for Payer: Preferred Network Access Commercial |
$4,594.55
|
| Rate for Payer: Quartz Beloit One Network |
$2,447.10
|
| Rate for Payer: Quartz Commercial |
$3,246.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,996.45
|
| Rate for Payer: The Alliance Commercial |
$2,497.04
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,746.74
|
| Rate for Payer: WPS Commercial |
$3,698.98
|
|
|
MRA Lower Extremity w/ Bilat
|
Facility
|
IP
|
$4,802.00
|
|
|
Service Code
|
HCPCS C8912 TC
|
| Hospital Charge Code |
3072761
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,447.10 |
| Max. Negotiated Rate |
$4,594.55 |
| Rate for Payer: Aetna Commercial |
$4,494.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,294.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,646.86
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cigna Commercial |
$4,594.55
|
| Rate for Payer: Health EOS Commercial |
$4,444.73
|
| Rate for Payer: HFN Commercial |
$4,594.55
|
| Rate for Payer: Multiplan Commercial |
$3,995.26
|
| Rate for Payer: Preferred Network Access Commercial |
$4,594.55
|
| Rate for Payer: Quartz Beloit One Network |
$2,447.10
|
| Rate for Payer: Quartz Commercial |
$2,996.45
|
| Rate for Payer: WEA Trust Commercial |
$2,746.74
|
| Rate for Payer: WPS Commercial |
$3,698.98
|
|
|
MRA Lower Extremity w/ Bilat
|
Facility
|
OP
|
$4,802.00
|
|
|
Service Code
|
HCPCS C8912 TC
|
| Hospital Charge Code |
3072761
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,398.34 |
| Max. Negotiated Rate |
$4,594.55 |
| Rate for Payer: Aetna Commercial |
$4,494.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,294.91
|
| Rate for Payer: Aetna Managed Medicare |
$1,398.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,646.86
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cigna Commercial |
$4,594.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,794.76
|
| Rate for Payer: Health EOS Commercial |
$4,444.73
|
| Rate for Payer: HFN Commercial |
$4,594.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,745.56
|
| Rate for Payer: Multiplan Commercial |
$3,995.26
|
| Rate for Payer: NAPHCARE Commercial |
$2,996.45
|
| Rate for Payer: Preferred Network Access Commercial |
$4,594.55
|
| Rate for Payer: Quartz Beloit One Network |
$2,447.10
|
| Rate for Payer: Quartz Commercial |
$3,246.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,996.45
|
| Rate for Payer: The Alliance Commercial |
$2,497.04
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,746.74
|
| Rate for Payer: WPS Commercial |
$3,698.98
|
|
|
MRA Lower Extremity w/ Bilat
|
Professional
|
Both
|
$4,802.00
|
|
|
Service Code
|
HCPCS C8912 TC
|
| Hospital Charge Code |
3072761
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,197.40 |
| Max. Negotiated Rate |
$4,744.38 |
| Rate for Payer: Aetna Commercial |
$4,744.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,294.91
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cigna Commercial |
$4,744.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,497.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,996.45
|
| Rate for Payer: Health EOS Commercial |
$4,544.61
|
| Rate for Payer: HFN Commercial |
$4,744.38
|
| Rate for Payer: Multiplan Commercial |
$3,995.26
|
| Rate for Payer: Preferred Network Access Commercial |
$4,744.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,197.40
|
| Rate for Payer: Quartz Commercial |
$2,846.63
|
| Rate for Payer: The Alliance Commercial |
$2,497.04
|
| Rate for Payer: WEA Trust Commercial |
$2,746.74
|
| Rate for Payer: WPS Commercial |
$3,698.98
|
|
|
MRA Lower Extremity w/ Left
|
Facility
|
OP
|
$5,965.00
|
|
|
Service Code
|
CPT 73725 TC,LT
|
| Hospital Charge Code |
1610838
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,737.01 |
| Max. Negotiated Rate |
$5,707.31 |
| Rate for Payer: Aetna Commercial |
$5,583.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,737.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.91
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,707.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,471.63
|
| Rate for Payer: Health EOS Commercial |
$5,521.20
|
| Rate for Payer: HFN Commercial |
$5,707.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,652.70
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: NAPHCARE Commercial |
$3,722.16
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.76
|
| Rate for Payer: Quartz Commercial |
$4,032.34
|
| Rate for Payer: Quartz Medicare Advantage |
$3,722.16
|
| Rate for Payer: The Alliance Commercial |
$3,101.80
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
|
MRA Lower Extremity w/ Left
|
Facility
|
IP
|
$5,965.00
|
|
|
Service Code
|
CPT 73725 TC,LT
|
| Hospital Charge Code |
1610838
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,039.76 |
| Max. Negotiated Rate |
$5,707.31 |
| Rate for Payer: Aetna Commercial |
$5,583.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.91
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,707.31
|
| Rate for Payer: Health EOS Commercial |
$5,521.20
|
| Rate for Payer: HFN Commercial |
$5,707.31
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.76
|
| Rate for Payer: Quartz Commercial |
$3,722.16
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
|
MRA Lower Extremity w/ Left
|
Professional
|
Both
|
$5,965.00
|
|
|
Service Code
|
CPT 73725 TC,LT
|
| Hospital Charge Code |
1610838
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,334.95 |
| Max. Negotiated Rate |
$5,893.42 |
| Rate for Payer: Aetna Commercial |
$5,893.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,893.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,101.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,722.16
|
| Rate for Payer: Health EOS Commercial |
$5,645.28
|
| Rate for Payer: HFN Commercial |
$5,893.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,334.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,334.95
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: Preferred Network Access Commercial |
$5,893.42
|
| Rate for Payer: Quartz Beloit One Network |
$2,729.58
|
| Rate for Payer: Quartz Commercial |
$3,536.05
|
| Rate for Payer: The Alliance Commercial |
$3,101.80
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
|
MRA Lower Extremity w/ Right
|
Facility
|
OP
|
$5,965.00
|
|
|
Service Code
|
CPT 73725 TC,RT
|
| Hospital Charge Code |
1610840
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,737.01 |
| Max. Negotiated Rate |
$5,707.31 |
| Rate for Payer: Aetna Commercial |
$5,583.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,737.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.91
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,707.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,471.63
|
| Rate for Payer: Health EOS Commercial |
$5,521.20
|
| Rate for Payer: HFN Commercial |
$5,707.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,652.70
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: NAPHCARE Commercial |
$3,722.16
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.76
|
| Rate for Payer: Quartz Commercial |
$4,032.34
|
| Rate for Payer: Quartz Medicare Advantage |
$3,722.16
|
| Rate for Payer: The Alliance Commercial |
$3,101.80
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
|
MRA Lower Extremity w/ Right
|
Facility
|
IP
|
$5,965.00
|
|
|
Service Code
|
CPT 73725 TC,RT
|
| Hospital Charge Code |
1610840
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,039.76 |
| Max. Negotiated Rate |
$5,707.31 |
| Rate for Payer: Aetna Commercial |
$5,583.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.91
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,707.31
|
| Rate for Payer: Health EOS Commercial |
$5,521.20
|
| Rate for Payer: HFN Commercial |
$5,707.31
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.76
|
| Rate for Payer: Quartz Commercial |
$3,722.16
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
|
MRA Lower Extremity w/ Right
|
Professional
|
Both
|
$5,965.00
|
|
|
Service Code
|
CPT 73725 TC,RT
|
| Hospital Charge Code |
1610840
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,334.95 |
| Max. Negotiated Rate |
$5,893.42 |
| Rate for Payer: Aetna Commercial |
$5,893.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,893.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,101.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,722.16
|
| Rate for Payer: Health EOS Commercial |
$5,645.28
|
| Rate for Payer: HFN Commercial |
$5,893.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,334.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,334.95
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: Preferred Network Access Commercial |
$5,893.42
|
| Rate for Payer: Quartz Beloit One Network |
$2,729.58
|
| Rate for Payer: Quartz Commercial |
$3,536.05
|
| Rate for Payer: The Alliance Commercial |
$3,101.80
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
|
MRA Lower Ext w/ Contrast
|
Professional
|
Both
|
$4,802.00
|
|
|
Service Code
|
CPT 73725 RT,TC
|
| Hospital Charge Code |
3072655
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,334.95 |
| Max. Negotiated Rate |
$4,744.38 |
| Rate for Payer: Aetna Commercial |
$4,744.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,294.91
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cigna Commercial |
$4,744.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,497.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,996.45
|
| Rate for Payer: Health EOS Commercial |
$4,544.61
|
| Rate for Payer: HFN Commercial |
$4,744.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,334.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,334.95
|
| Rate for Payer: Multiplan Commercial |
$3,995.26
|
| Rate for Payer: Preferred Network Access Commercial |
$4,744.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,197.40
|
| Rate for Payer: Quartz Commercial |
$2,846.63
|
| Rate for Payer: The Alliance Commercial |
$2,497.04
|
| Rate for Payer: WEA Trust Commercial |
$2,746.74
|
| Rate for Payer: WPS Commercial |
$3,698.98
|
|
|
MRA Lower Ext w/ Contrast
|
Facility
|
OP
|
$4,802.00
|
|
|
Service Code
|
CPT 73725 RT,TC
|
| Hospital Charge Code |
3072655
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,398.34 |
| Max. Negotiated Rate |
$4,594.55 |
| Rate for Payer: Aetna Commercial |
$4,494.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,294.91
|
| Rate for Payer: Aetna Managed Medicare |
$1,398.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,646.86
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cash Price |
$1,440.60
|
| Rate for Payer: Cigna Commercial |
$4,594.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,794.76
|
| Rate for Payer: Health EOS Commercial |
$4,444.73
|
| Rate for Payer: HFN Commercial |
$4,594.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,745.56
|
| Rate for Payer: Multiplan Commercial |
$3,995.26
|
| Rate for Payer: NAPHCARE Commercial |
$2,996.45
|
| Rate for Payer: Preferred Network Access Commercial |
$4,594.55
|
| Rate for Payer: Quartz Beloit One Network |
$2,447.10
|
| Rate for Payer: Quartz Commercial |
$3,246.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,996.45
|
| Rate for Payer: The Alliance Commercial |
$2,497.04
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,746.74
|
| Rate for Payer: WPS Commercial |
$3,698.98
|
|
