|
MRI Sacrum/ SI Joint w + w/o
|
Facility
|
IP
|
$6,946.00
|
|
|
Service Code
|
CPT 72197 TC
|
| Hospital Charge Code |
1611237
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,403.54 |
| Max. Negotiated Rate |
$6,390.32 |
| Rate for Payer: Aetna Commercial |
$6,251.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,973.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,681.38
|
| Rate for Payer: Cash Price |
$2,083.80
|
| Rate for Payer: Cigna Commercial |
$6,390.32
|
| Rate for Payer: Health EOS Commercial |
$6,181.94
|
| Rate for Payer: HFN Commercial |
$6,390.32
|
| Rate for Payer: Multiplan Commercial |
$5,556.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,167.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,390.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,403.54
|
| Rate for Payer: Quartz Commercial |
$4,167.60
|
| Rate for Payer: WEA Trust Commercial |
$3,820.30
|
| Rate for Payer: WPS Commercial |
$5,144.90
|
|
|
MRI Sacrum/ SI Joint w + w/o
|
Facility
|
IP
|
$6,092.00
|
|
|
Service Code
|
CPT 72197
|
| Hospital Charge Code |
1608824
|
| Min. Negotiated Rate |
$2,985.08 |
| Max. Negotiated Rate |
$5,604.64 |
| Rate for Payer: Aetna Commercial |
$5,482.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,239.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,228.76
|
| Rate for Payer: Cash Price |
$1,827.60
|
| Rate for Payer: Cigna Commercial |
$5,604.64
|
| Rate for Payer: Health EOS Commercial |
$5,421.88
|
| Rate for Payer: HFN Commercial |
$5,604.64
|
| Rate for Payer: Multiplan Commercial |
$4,873.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,655.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,604.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,985.08
|
| Rate for Payer: Quartz Commercial |
$3,655.20
|
| Rate for Payer: WEA Trust Commercial |
$3,350.60
|
| Rate for Payer: WPS Commercial |
$4,512.34
|
|
|
MRI Sacrum/ SI Joint w + w/o
|
Professional
|
Both
|
$6,946.00
|
|
|
Service Code
|
CPT 72197 TC
|
| Hospital Charge Code |
1611237
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$933.61 |
| Max. Negotiated Rate |
$6,598.70 |
| Rate for Payer: Aetna Commercial |
$6,598.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,973.56
|
| Rate for Payer: Cash Price |
$2,083.80
|
| Rate for Payer: Cash Price |
$2,083.80
|
| Rate for Payer: Cash Price |
$2,083.80
|
| Rate for Payer: Cigna Commercial |
$6,598.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,473.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,167.60
|
| Rate for Payer: Health EOS Commercial |
$6,320.86
|
| Rate for Payer: HFN Commercial |
$6,598.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$933.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$933.61
|
| Rate for Payer: Multiplan Commercial |
$5,556.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,598.70
|
| Rate for Payer: Quartz Beloit One Network |
$3,056.24
|
| Rate for Payer: Quartz Commercial |
$3,959.22
|
| Rate for Payer: The Alliance Commercial |
$3,473.00
|
| Rate for Payer: WEA Trust Commercial |
$3,820.30
|
| Rate for Payer: WPS Commercial |
$5,144.90
|
|
|
MRI Sacrum/ SI Joint w + w/o
|
Facility
|
OP
|
$6,092.00
|
|
|
Service Code
|
CPT 72197
|
| Hospital Charge Code |
1608824
|
| Min. Negotiated Rate |
$380.12 |
| Max. Negotiated Rate |
$5,604.64 |
| Rate for Payer: Aetna Commercial |
$5,482.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,239.12
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,959.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,046.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,924.16
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,228.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$380.12
|
| Rate for Payer: Cash Price |
$1,827.60
|
| Rate for Payer: Cash Price |
$1,827.60
|
| Rate for Payer: Cigna Commercial |
$5,604.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,409.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$5,421.88
|
| Rate for Payer: HFN Commercial |
$5,604.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,414.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$380.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$380.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$380.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$380.12
|
| Rate for Payer: Multiplan Commercial |
$4,873.60
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,604.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,985.08
|
| Rate for Payer: Quartz Commercial |
$3,959.80
|
| Rate for Payer: Quartz Medicare Advantage |
$380.12
|
| Rate for Payer: The Alliance Commercial |
$1,520.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$380.12
|
| Rate for Payer: WEA Trust Commercial |
$3,350.60
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$4,512.34
|
|
|
MRI Shoulder w/ Contrast Bilateral
|
Facility
|
IP
|
$9,376.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
631221
|
| Min. Negotiated Rate |
$4,594.24 |
| Max. Negotiated Rate |
$8,625.92 |
| Rate for Payer: Aetna Commercial |
$8,438.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,063.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,969.28
|
| Rate for Payer: Cash Price |
$2,812.80
|
| Rate for Payer: Cigna Commercial |
$8,625.92
|
| Rate for Payer: Health EOS Commercial |
$8,344.64
|
| Rate for Payer: HFN Commercial |
$8,625.92
|
| Rate for Payer: Multiplan Commercial |
$7,500.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,625.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,625.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,594.24
|
| Rate for Payer: Quartz Commercial |
$5,625.60
|
| Rate for Payer: WEA Trust Commercial |
$5,156.80
|
| Rate for Payer: WPS Commercial |
$6,944.80
|
|
|
MRI Shoulder w/ Contrast Bilateral
|
Facility
|
OP
|
$5,965.00
|
|
|
Service Code
|
CPT 73222 TC,LT
|
| Hospital Charge Code |
1611249
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$791.40 |
| Max. Negotiated Rate |
$5,487.80 |
| Rate for Payer: Aetna Commercial |
$5,368.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,129.90
|
| Rate for Payer: Aetna Managed Medicare |
$791.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,161.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$791.40
|
| 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: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,487.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$791.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,338.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$791.40
|
| Rate for Payer: Health EOS Commercial |
$5,308.85
|
| Rate for Payer: HFN Commercial |
$5,487.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,944.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$791.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$791.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$791.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$791.40
|
| Rate for Payer: Multiplan Commercial |
$4,772.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,187.10
|
| Rate for Payer: Preferred Network Access Commercial |
$5,487.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,922.85
|
| Rate for Payer: Quartz Commercial |
$3,877.25
|
| Rate for Payer: Quartz Medicare Advantage |
$791.40
|
| Rate for Payer: The Alliance Commercial |
$3,165.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$791.40
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$3,280.75
|
| Rate for Payer: Wellcare Medicare |
$791.40
|
| Rate for Payer: WPS Commercial |
$4,418.28
|
|
|
MRI Shoulder w/ Contrast Bilateral
|
Facility
|
OP
|
$9,376.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
631221
|
| Min. Negotiated Rate |
$791.40 |
| Max. Negotiated Rate |
$8,625.92 |
| Rate for Payer: Aetna Commercial |
$8,438.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,063.36
|
| Rate for Payer: Aetna Managed Medicare |
$791.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,094.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,688.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,500.48
|
| Rate for Payer: Anthem Medicare Advantage |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,969.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$791.40
|
| Rate for Payer: Cash Price |
$2,812.80
|
| Rate for Payer: Cash Price |
$2,812.80
|
| Rate for Payer: Cigna Commercial |
$8,625.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$791.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,246.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$791.40
|
| Rate for Payer: Health EOS Commercial |
$8,344.64
|
| Rate for Payer: HFN Commercial |
$8,625.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,944.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$791.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$791.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$791.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$791.40
|
| Rate for Payer: Multiplan Commercial |
$7,500.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,187.10
|
| Rate for Payer: Preferred Network Access Commercial |
$8,625.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,594.24
|
| Rate for Payer: Quartz Commercial |
$6,094.40
|
| Rate for Payer: Quartz Medicare Advantage |
$791.40
|
| Rate for Payer: The Alliance Commercial |
$3,165.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$791.40
|
| Rate for Payer: WEA Trust Commercial |
$5,156.80
|
| Rate for Payer: Wellcare Medicare |
$791.40
|
| Rate for Payer: WPS Commercial |
$6,944.80
|
|
|
MRI Shoulder w/ Contrast Bilateral
|
Facility
|
IP
|
$5,965.00
|
|
|
Service Code
|
CPT 73222 TC,LT
|
| Hospital Charge Code |
1611249
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,922.85 |
| Max. Negotiated Rate |
$5,487.80 |
| Rate for Payer: Aetna Commercial |
$5,368.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,129.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,161.45
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,487.80
|
| Rate for Payer: Health EOS Commercial |
$5,308.85
|
| Rate for Payer: HFN Commercial |
$5,487.80
|
| Rate for Payer: Multiplan Commercial |
$4,772.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,579.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,487.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,922.85
|
| Rate for Payer: Quartz Commercial |
$3,579.00
|
| Rate for Payer: WEA Trust Commercial |
$3,280.75
|
| Rate for Payer: WPS Commercial |
$4,418.28
|
|
|
MRI Shoulder w/ Contrast Bilateral
|
Professional
|
Both
|
$9,376.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
631221
|
| Min. Negotiated Rate |
$1,219.97 |
| Max. Negotiated Rate |
$8,907.20 |
| Rate for Payer: Aetna Commercial |
$8,907.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,063.36
|
| Rate for Payer: Cash Price |
$2,812.80
|
| Rate for Payer: Cash Price |
$2,812.80
|
| Rate for Payer: Cash Price |
$2,812.80
|
| Rate for Payer: Cigna Commercial |
$8,907.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,688.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,625.60
|
| Rate for Payer: Health EOS Commercial |
$8,532.16
|
| Rate for Payer: HFN Commercial |
$8,907.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,219.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,219.97
|
| Rate for Payer: Multiplan Commercial |
$7,500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,907.20
|
| Rate for Payer: Quartz Beloit One Network |
$4,125.44
|
| Rate for Payer: Quartz Commercial |
$5,344.32
|
| Rate for Payer: The Alliance Commercial |
$4,688.00
|
| Rate for Payer: WEA Trust Commercial |
$5,156.80
|
| Rate for Payer: WPS Commercial |
$6,944.80
|
|
|
MRI Shoulder w/ Contrast Bilateral
|
Professional
|
Both
|
$5,965.00
|
|
|
Service Code
|
CPT 73222 TC,LT
|
| Hospital Charge Code |
1611249
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,219.97 |
| Max. Negotiated Rate |
$5,666.75 |
| Rate for Payer: Aetna Commercial |
$5,666.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,129.90
|
| 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 |
$5,666.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,982.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,579.00
|
| Rate for Payer: Health EOS Commercial |
$5,428.15
|
| Rate for Payer: HFN Commercial |
$5,666.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,219.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,219.97
|
| Rate for Payer: Multiplan Commercial |
$4,772.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,666.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,624.60
|
| Rate for Payer: Quartz Commercial |
$3,400.05
|
| Rate for Payer: The Alliance Commercial |
$2,982.50
|
| Rate for Payer: WEA Trust Commercial |
$3,280.75
|
| Rate for Payer: WPS Commercial |
$4,418.28
|
|
|
MRI Shoulder w/ Contrast Left
|
Professional
|
Both
|
$6,194.00
|
|
|
Service Code
|
CPT 73222 LT,TC
|
| Hospital Charge Code |
1611251
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,219.97 |
| Max. Negotiated Rate |
$5,884.30 |
| Rate for Payer: Aetna Commercial |
$5,884.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,326.84
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,884.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,097.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,716.40
|
| Rate for Payer: Health EOS Commercial |
$5,636.54
|
| Rate for Payer: HFN Commercial |
$5,884.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,219.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,219.97
|
| Rate for Payer: Multiplan Commercial |
$4,955.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,884.30
|
| Rate for Payer: Quartz Beloit One Network |
$2,725.36
|
| Rate for Payer: Quartz Commercial |
$3,530.58
|
| Rate for Payer: The Alliance Commercial |
$3,097.00
|
| Rate for Payer: WEA Trust Commercial |
$3,406.70
|
| Rate for Payer: WPS Commercial |
$4,587.90
|
|
|
MRI Shoulder w/ Contrast Left
|
Facility
|
IP
|
$4,687.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
631227
|
| Min. Negotiated Rate |
$2,296.63 |
| Max. Negotiated Rate |
$4,312.04 |
| Rate for Payer: Aetna Commercial |
$4,218.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,030.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,484.11
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cigna Commercial |
$4,312.04
|
| Rate for Payer: Health EOS Commercial |
$4,171.43
|
| Rate for Payer: HFN Commercial |
$4,312.04
|
| Rate for Payer: Multiplan Commercial |
$3,749.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,812.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,312.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,296.63
|
| Rate for Payer: Quartz Commercial |
$2,812.20
|
| Rate for Payer: WEA Trust Commercial |
$2,577.85
|
| Rate for Payer: WPS Commercial |
$3,471.66
|
|
|
MRI Shoulder w/ Contrast Left
|
Facility
|
OP
|
$6,194.00
|
|
|
Service Code
|
CPT 73222 LT,TC
|
| Hospital Charge Code |
1611251
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$791.40 |
| Max. Negotiated Rate |
$5,698.48 |
| Rate for Payer: Aetna Commercial |
$5,574.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,326.84
|
| Rate for Payer: Aetna Managed Medicare |
$791.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,282.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$791.40
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,698.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$791.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,466.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$791.40
|
| Rate for Payer: Health EOS Commercial |
$5,512.66
|
| Rate for Payer: HFN Commercial |
$5,698.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,944.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$791.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$791.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$791.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$791.40
|
| Rate for Payer: Multiplan Commercial |
$4,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,187.10
|
| Rate for Payer: Preferred Network Access Commercial |
$5,698.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,035.06
|
| Rate for Payer: Quartz Commercial |
$4,026.10
|
| Rate for Payer: Quartz Medicare Advantage |
$791.40
|
| Rate for Payer: The Alliance Commercial |
$3,165.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$791.40
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$3,406.70
|
| Rate for Payer: Wellcare Medicare |
$791.40
|
| Rate for Payer: WPS Commercial |
$4,587.90
|
|
|
MRI Shoulder w/ Contrast Left
|
Facility
|
IP
|
$6,194.00
|
|
|
Service Code
|
CPT 73222 LT,TC
|
| Hospital Charge Code |
1611251
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,035.06 |
| Max. Negotiated Rate |
$5,698.48 |
| Rate for Payer: Aetna Commercial |
$5,574.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,326.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,282.82
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,698.48
|
| Rate for Payer: Health EOS Commercial |
$5,512.66
|
| Rate for Payer: HFN Commercial |
$5,698.48
|
| Rate for Payer: Multiplan Commercial |
$4,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,716.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,698.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,035.06
|
| Rate for Payer: Quartz Commercial |
$3,716.40
|
| Rate for Payer: WEA Trust Commercial |
$3,406.70
|
| Rate for Payer: WPS Commercial |
$4,587.90
|
|
|
MRI Shoulder w/ Contrast Left
|
Professional
|
Both
|
$4,687.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
631227
|
| Min. Negotiated Rate |
$1,219.97 |
| Max. Negotiated Rate |
$4,452.65 |
| Rate for Payer: Aetna Commercial |
$4,452.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,030.82
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cigna Commercial |
$4,452.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,343.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,812.20
|
| Rate for Payer: Health EOS Commercial |
$4,265.17
|
| Rate for Payer: HFN Commercial |
$4,452.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,219.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,219.97
|
| Rate for Payer: Multiplan Commercial |
$3,749.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,452.65
|
| Rate for Payer: Quartz Beloit One Network |
$2,062.28
|
| Rate for Payer: Quartz Commercial |
$2,671.59
|
| Rate for Payer: The Alliance Commercial |
$2,343.50
|
| Rate for Payer: WEA Trust Commercial |
$2,577.85
|
| Rate for Payer: WPS Commercial |
$3,471.66
|
|
|
MRI Shoulder w/ Contrast Left
|
Facility
|
OP
|
$4,687.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
631227
|
| Min. Negotiated Rate |
$791.40 |
| Max. Negotiated Rate |
$4,312.04 |
| Rate for Payer: Aetna Commercial |
$4,218.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,030.82
|
| Rate for Payer: Aetna Managed Medicare |
$791.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,046.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,343.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,249.76
|
| Rate for Payer: Anthem Medicare Advantage |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,484.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$791.40
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cigna Commercial |
$4,312.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$791.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,622.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$791.40
|
| Rate for Payer: Health EOS Commercial |
$4,171.43
|
| Rate for Payer: HFN Commercial |
$4,312.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,944.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$791.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$791.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$791.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$791.40
|
| Rate for Payer: Multiplan Commercial |
$3,749.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,187.10
|
| Rate for Payer: Preferred Network Access Commercial |
$4,312.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,296.63
|
| Rate for Payer: Quartz Commercial |
$3,046.55
|
| Rate for Payer: Quartz Medicare Advantage |
$791.40
|
| Rate for Payer: The Alliance Commercial |
$3,165.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$791.40
|
| Rate for Payer: WEA Trust Commercial |
$2,577.85
|
| Rate for Payer: Wellcare Medicare |
$791.40
|
| Rate for Payer: WPS Commercial |
$3,471.66
|
|
|
MRI Shoulder w/ Contrast Right
|
Professional
|
Both
|
$4,687.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
631233
|
| Min. Negotiated Rate |
$1,219.97 |
| Max. Negotiated Rate |
$4,452.65 |
| Rate for Payer: Aetna Commercial |
$4,452.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,030.82
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cigna Commercial |
$4,452.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,343.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,812.20
|
| Rate for Payer: Health EOS Commercial |
$4,265.17
|
| Rate for Payer: HFN Commercial |
$4,452.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,219.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,219.97
|
| Rate for Payer: Multiplan Commercial |
$3,749.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,452.65
|
| Rate for Payer: Quartz Beloit One Network |
$2,062.28
|
| Rate for Payer: Quartz Commercial |
$2,671.59
|
| Rate for Payer: The Alliance Commercial |
$2,343.50
|
| Rate for Payer: WEA Trust Commercial |
$2,577.85
|
| Rate for Payer: WPS Commercial |
$3,471.66
|
|
|
MRI Shoulder w/ Contrast Right
|
Facility
|
OP
|
$4,687.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
631233
|
| Min. Negotiated Rate |
$791.40 |
| Max. Negotiated Rate |
$4,312.04 |
| Rate for Payer: Aetna Commercial |
$4,218.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,030.82
|
| Rate for Payer: Aetna Managed Medicare |
$791.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,046.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,343.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,249.76
|
| Rate for Payer: Anthem Medicare Advantage |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,484.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$791.40
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cigna Commercial |
$4,312.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$791.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,622.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$791.40
|
| Rate for Payer: Health EOS Commercial |
$4,171.43
|
| Rate for Payer: HFN Commercial |
$4,312.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,944.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$791.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$791.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$791.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$791.40
|
| Rate for Payer: Multiplan Commercial |
$3,749.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,187.10
|
| Rate for Payer: Preferred Network Access Commercial |
$4,312.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,296.63
|
| Rate for Payer: Quartz Commercial |
$3,046.55
|
| Rate for Payer: Quartz Medicare Advantage |
$791.40
|
| Rate for Payer: The Alliance Commercial |
$3,165.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$791.40
|
| Rate for Payer: WEA Trust Commercial |
$2,577.85
|
| Rate for Payer: Wellcare Medicare |
$791.40
|
| Rate for Payer: WPS Commercial |
$3,471.66
|
|
|
MRI Shoulder w/ Contrast Right
|
Facility
|
OP
|
$6,194.00
|
|
|
Service Code
|
CPT 73222 TC,RT
|
| Hospital Charge Code |
1611253
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$791.40 |
| Max. Negotiated Rate |
$5,698.48 |
| Rate for Payer: Aetna Commercial |
$5,574.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,326.84
|
| Rate for Payer: Aetna Managed Medicare |
$791.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,282.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$791.40
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,698.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$791.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,466.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$791.40
|
| Rate for Payer: Health EOS Commercial |
$5,512.66
|
| Rate for Payer: HFN Commercial |
$5,698.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,944.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$791.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$791.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$791.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$791.40
|
| Rate for Payer: Multiplan Commercial |
$4,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,187.10
|
| Rate for Payer: Preferred Network Access Commercial |
$5,698.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,035.06
|
| Rate for Payer: Quartz Commercial |
$4,026.10
|
| Rate for Payer: Quartz Medicare Advantage |
$791.40
|
| Rate for Payer: The Alliance Commercial |
$3,165.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$791.40
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$3,406.70
|
| Rate for Payer: Wellcare Medicare |
$791.40
|
| Rate for Payer: WPS Commercial |
$4,587.90
|
|
|
MRI Shoulder w/ Contrast Right
|
Professional
|
Both
|
$6,194.00
|
|
|
Service Code
|
CPT 73222 TC,RT
|
| Hospital Charge Code |
1611253
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,219.97 |
| Max. Negotiated Rate |
$5,884.30 |
| Rate for Payer: Aetna Commercial |
$5,884.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,326.84
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,884.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,097.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,716.40
|
| Rate for Payer: Health EOS Commercial |
$5,636.54
|
| Rate for Payer: HFN Commercial |
$5,884.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,219.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,219.97
|
| Rate for Payer: Multiplan Commercial |
$4,955.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,884.30
|
| Rate for Payer: Quartz Beloit One Network |
$2,725.36
|
| Rate for Payer: Quartz Commercial |
$3,530.58
|
| Rate for Payer: The Alliance Commercial |
$3,097.00
|
| Rate for Payer: WEA Trust Commercial |
$3,406.70
|
| Rate for Payer: WPS Commercial |
$4,587.90
|
|
|
MRI Shoulder w/ Contrast Right
|
Facility
|
IP
|
$4,687.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
631233
|
| Min. Negotiated Rate |
$2,296.63 |
| Max. Negotiated Rate |
$4,312.04 |
| Rate for Payer: Aetna Commercial |
$4,218.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,030.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,484.11
|
| Rate for Payer: Cash Price |
$1,406.10
|
| Rate for Payer: Cigna Commercial |
$4,312.04
|
| Rate for Payer: Health EOS Commercial |
$4,171.43
|
| Rate for Payer: HFN Commercial |
$4,312.04
|
| Rate for Payer: Multiplan Commercial |
$3,749.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,812.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,312.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,296.63
|
| Rate for Payer: Quartz Commercial |
$2,812.20
|
| Rate for Payer: WEA Trust Commercial |
$2,577.85
|
| Rate for Payer: WPS Commercial |
$3,471.66
|
|
|
MRI Shoulder w/ Contrast Right
|
Facility
|
IP
|
$6,194.00
|
|
|
Service Code
|
CPT 73222 TC,RT
|
| Hospital Charge Code |
1611253
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,035.06 |
| Max. Negotiated Rate |
$5,698.48 |
| Rate for Payer: Aetna Commercial |
$5,574.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,326.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,282.82
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,698.48
|
| Rate for Payer: Health EOS Commercial |
$5,512.66
|
| Rate for Payer: HFN Commercial |
$5,698.48
|
| Rate for Payer: Multiplan Commercial |
$4,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,716.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,698.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,035.06
|
| Rate for Payer: Quartz Commercial |
$3,716.40
|
| Rate for Payer: WEA Trust Commercial |
$3,406.70
|
| Rate for Payer: WPS Commercial |
$4,587.90
|
|
|
MRI Shoulder w/ Contrast Right
|
Facility
|
OP
|
$5,965.00
|
|
|
Service Code
|
CPT 73222 TC,RT
|
| Hospital Charge Code |
2980044
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$791.40 |
| Max. Negotiated Rate |
$5,487.80 |
| Rate for Payer: Aetna Commercial |
$5,368.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,129.90
|
| Rate for Payer: Aetna Managed Medicare |
$791.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,161.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$791.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$791.40
|
| 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: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,487.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$791.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,338.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$791.40
|
| Rate for Payer: Health EOS Commercial |
$5,308.85
|
| Rate for Payer: HFN Commercial |
$5,487.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,944.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$791.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$791.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$791.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$791.40
|
| Rate for Payer: Multiplan Commercial |
$4,772.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,187.10
|
| Rate for Payer: Preferred Network Access Commercial |
$5,487.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,922.85
|
| Rate for Payer: Quartz Commercial |
$3,877.25
|
| Rate for Payer: Quartz Medicare Advantage |
$791.40
|
| Rate for Payer: The Alliance Commercial |
$3,165.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$791.40
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$3,280.75
|
| Rate for Payer: Wellcare Medicare |
$791.40
|
| Rate for Payer: WPS Commercial |
$4,418.28
|
|
|
MRI Shoulder w/ Contrast Right
|
Professional
|
Both
|
$5,965.00
|
|
|
Service Code
|
CPT 73222 TC,RT
|
| Hospital Charge Code |
2980044
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,219.97 |
| Max. Negotiated Rate |
$5,666.75 |
| Rate for Payer: Aetna Commercial |
$5,666.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,129.90
|
| 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 |
$5,666.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,982.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,579.00
|
| Rate for Payer: Health EOS Commercial |
$5,428.15
|
| Rate for Payer: HFN Commercial |
$5,666.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,219.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,219.97
|
| Rate for Payer: Multiplan Commercial |
$4,772.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,666.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,624.60
|
| Rate for Payer: Quartz Commercial |
$3,400.05
|
| Rate for Payer: The Alliance Commercial |
$2,982.50
|
| Rate for Payer: WEA Trust Commercial |
$3,280.75
|
| Rate for Payer: WPS Commercial |
$4,418.28
|
|
|
MRI Shoulder w/ Contrast Right
|
Facility
|
IP
|
$5,965.00
|
|
|
Service Code
|
CPT 73222 TC,RT
|
| Hospital Charge Code |
2980044
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,922.85 |
| Max. Negotiated Rate |
$5,487.80 |
| Rate for Payer: Aetna Commercial |
$5,368.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,129.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,161.45
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,487.80
|
| Rate for Payer: Health EOS Commercial |
$5,308.85
|
| Rate for Payer: HFN Commercial |
$5,487.80
|
| Rate for Payer: Multiplan Commercial |
$4,772.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,579.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,487.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,922.85
|
| Rate for Payer: Quartz Commercial |
$3,579.00
|
| Rate for Payer: WEA Trust Commercial |
$3,280.75
|
| Rate for Payer: WPS Commercial |
$4,418.28
|
|
