|
MRI Spine Cervical w/ + w/o Contrast
|
Facility
|
IP
|
$6,351.00
|
|
|
Service Code
|
CPT 72156 TC
|
| Hospital Charge Code |
1611263
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,111.99 |
| Max. Negotiated Rate |
$5,842.92 |
| Rate for Payer: Aetna Commercial |
$5,715.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,461.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,366.03
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cigna Commercial |
$5,842.92
|
| Rate for Payer: Health EOS Commercial |
$5,652.39
|
| Rate for Payer: HFN Commercial |
$5,842.92
|
| Rate for Payer: Multiplan Commercial |
$5,080.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,810.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,842.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,111.99
|
| Rate for Payer: Quartz Commercial |
$3,810.60
|
| Rate for Payer: WEA Trust Commercial |
$3,493.05
|
| Rate for Payer: WPS Commercial |
$4,704.19
|
|
|
MRI Spine Cervical w/ + w/o Contrast
|
Facility
|
OP
|
$6,235.00
|
|
|
Service Code
|
CPT 72156
|
| Hospital Charge Code |
629594
|
| Min. Negotiated Rate |
$380.12 |
| Max. Negotiated Rate |
$5,736.20 |
| Rate for Payer: Aetna Commercial |
$5,611.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.10
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,052.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,117.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,992.80
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,304.55
|
| 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 |
$1,870.50
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$5,736.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,489.11
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$5,549.15
|
| Rate for Payer: HFN Commercial |
$5,736.20
|
| 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 |
$4,988.00
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,736.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,055.15
|
| Rate for Payer: Quartz Commercial |
$4,052.75
|
| 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 |
$3,429.25
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$4,618.26
|
|
|
MRI Spine Cervical w/ + w/o Contrast
|
Professional
|
Both
|
$6,235.00
|
|
|
Service Code
|
CPT 72156
|
| Hospital Charge Code |
629594
|
| Min. Negotiated Rate |
$1,223.15 |
| Max. Negotiated Rate |
$5,923.25 |
| Rate for Payer: Aetna Commercial |
$5,923.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.10
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$5,923.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,117.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,741.00
|
| Rate for Payer: Health EOS Commercial |
$5,673.85
|
| Rate for Payer: HFN Commercial |
$5,923.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,223.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,223.15
|
| Rate for Payer: Multiplan Commercial |
$4,988.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,923.25
|
| Rate for Payer: Quartz Beloit One Network |
$2,743.40
|
| Rate for Payer: Quartz Commercial |
$3,553.95
|
| Rate for Payer: The Alliance Commercial |
$3,117.50
|
| Rate for Payer: WEA Trust Commercial |
$3,429.25
|
| Rate for Payer: WPS Commercial |
$4,618.26
|
|
|
MRI Spine Lumbar, Plexis w/o Contrast
|
Facility
|
OP
|
$5,965.00
|
|
|
Service Code
|
CPT 72148 TC
|
| Hospital Charge Code |
1611308
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$242.20 |
| 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 |
$242.20
|
| 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 |
$242.20
|
| 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 |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| 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 |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,338.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| 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 |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$4,772.00
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| 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 |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$3,280.75
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$4,418.28
|
|
|
MRI Spine Lumbar, Plexis w/o Contrast
|
Professional
|
Both
|
$5,965.00
|
|
|
Service Code
|
CPT 72148 TC
|
| Hospital Charge Code |
1611308
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$476.09 |
| 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 |
$476.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$476.09
|
| 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 Spine Lumbar, Plexis w/o Contrast
|
Facility
|
IP
|
$5,965.00
|
|
|
Service Code
|
CPT 72148 TC
|
| Hospital Charge Code |
1611308
|
|
Hospital Revenue Code
|
612
|
| 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 Spine Lumbar w/ Contrast
|
Professional
|
Both
|
$6,080.00
|
|
|
Service Code
|
CPT 72149
|
| Hospital Charge Code |
631283
|
| Min. Negotiated Rate |
$1,033.13 |
| Max. Negotiated Rate |
$5,776.00 |
| Rate for Payer: Aetna Commercial |
$5,776.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,228.80
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cigna Commercial |
$5,776.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,040.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,648.00
|
| Rate for Payer: Health EOS Commercial |
$5,532.80
|
| Rate for Payer: HFN Commercial |
$5,776.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,033.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,033.13
|
| Rate for Payer: Multiplan Commercial |
$4,864.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,776.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,675.20
|
| Rate for Payer: Quartz Commercial |
$3,465.60
|
| Rate for Payer: The Alliance Commercial |
$3,040.00
|
| Rate for Payer: WEA Trust Commercial |
$3,344.00
|
| Rate for Payer: WPS Commercial |
$4,503.46
|
|
|
MRI Spine Lumbar w/ Contrast
|
Facility
|
IP
|
$6,194.00
|
|
|
Service Code
|
CPT 72149 TC
|
| Hospital Charge Code |
1611295
|
|
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 Spine Lumbar w/ Contrast
|
Facility
|
OP
|
$6,194.00
|
|
|
Service Code
|
CPT 72149 TC
|
| Hospital Charge Code |
1611295
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$380.12 |
| 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 |
$380.12
|
| 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 |
$380.12
|
| 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 |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$380.12
|
| 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 |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,466.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| 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 |
$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 |
$4,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| 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 |
$380.12
|
| Rate for Payer: The Alliance Commercial |
$1,520.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$380.12
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$3,406.70
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$4,587.90
|
|
|
MRI Spine Lumbar w/ Contrast
|
Professional
|
Both
|
$6,194.00
|
|
|
Service Code
|
CPT 72149 TC
|
| Hospital Charge Code |
1611295
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$735.19 |
| 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 |
$735.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$735.19
|
| 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 Spine Lumbar w/ Contrast
|
Facility
|
OP
|
$6,080.00
|
|
|
Service Code
|
CPT 72149
|
| Hospital Charge Code |
631283
|
| Min. Negotiated Rate |
$380.12 |
| Max. Negotiated Rate |
$5,593.60 |
| Rate for Payer: Aetna Commercial |
$5,472.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,228.80
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,952.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,040.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,918.40
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,222.40
|
| 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 |
$1,824.00
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cigna Commercial |
$5,593.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,402.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$5,411.20
|
| Rate for Payer: HFN Commercial |
$5,593.60
|
| 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 |
$4,864.00
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,593.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,979.20
|
| Rate for Payer: Quartz Commercial |
$3,952.00
|
| 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 |
$3,344.00
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$4,503.46
|
|
|
MRI Spine Lumbar w/ Contrast
|
Facility
|
IP
|
$6,080.00
|
|
|
Service Code
|
CPT 72149
|
| Hospital Charge Code |
631283
|
| Min. Negotiated Rate |
$2,979.20 |
| Max. Negotiated Rate |
$5,593.60 |
| Rate for Payer: Aetna Commercial |
$5,472.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,228.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,222.40
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cigna Commercial |
$5,593.60
|
| Rate for Payer: Health EOS Commercial |
$5,411.20
|
| Rate for Payer: HFN Commercial |
$5,593.60
|
| Rate for Payer: Multiplan Commercial |
$4,864.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,648.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,593.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,979.20
|
| Rate for Payer: Quartz Commercial |
$3,648.00
|
| Rate for Payer: WEA Trust Commercial |
$3,344.00
|
| Rate for Payer: WPS Commercial |
$4,503.46
|
|
|
MRI Spine Lumbar w/o Contrast
|
Facility
|
OP
|
$5,013.00
|
|
|
Service Code
|
CPT 72148 TC
|
| Hospital Charge Code |
1611297
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$4,611.96 |
| Rate for Payer: Aetna Commercial |
$4,511.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,311.18
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| 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 |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,656.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cigna Commercial |
$4,611.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,805.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$4,461.57
|
| Rate for Payer: HFN Commercial |
$4,611.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$4,010.40
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,611.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,456.37
|
| Rate for Payer: Quartz Commercial |
$3,258.45
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$2,757.15
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$3,713.13
|
|
|
MRI Spine Lumbar w/o Contrast
|
Professional
|
Both
|
$5,013.00
|
|
|
Service Code
|
CPT 72148 TC
|
| Hospital Charge Code |
3072642
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$476.09 |
| Max. Negotiated Rate |
$4,762.35 |
| Rate for Payer: Aetna Commercial |
$4,762.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,311.18
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cigna Commercial |
$4,762.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,506.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,007.80
|
| Rate for Payer: Health EOS Commercial |
$4,561.83
|
| Rate for Payer: HFN Commercial |
$4,762.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$476.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$476.09
|
| Rate for Payer: Multiplan Commercial |
$4,010.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,762.35
|
| Rate for Payer: Quartz Beloit One Network |
$2,205.72
|
| Rate for Payer: Quartz Commercial |
$2,857.41
|
| Rate for Payer: The Alliance Commercial |
$2,506.50
|
| Rate for Payer: WEA Trust Commercial |
$2,757.15
|
| Rate for Payer: WPS Commercial |
$3,713.13
|
|
|
MRI Spine Lumbar w/o Contrast
|
Professional
|
Both
|
$4,644.00
|
|
|
Service Code
|
CPT 72148
|
| Hospital Charge Code |
631287
|
| Min. Negotiated Rate |
$723.23 |
| Max. Negotiated Rate |
$4,411.80 |
| Rate for Payer: Aetna Commercial |
$4,411.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,993.84
|
| Rate for Payer: Cash Price |
$1,393.20
|
| Rate for Payer: Cash Price |
$1,393.20
|
| Rate for Payer: Cash Price |
$1,393.20
|
| Rate for Payer: Cigna Commercial |
$4,411.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,322.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,786.40
|
| Rate for Payer: Health EOS Commercial |
$4,226.04
|
| Rate for Payer: HFN Commercial |
$4,411.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$723.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$723.23
|
| Rate for Payer: Multiplan Commercial |
$3,715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,411.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.36
|
| Rate for Payer: Quartz Commercial |
$2,647.08
|
| Rate for Payer: The Alliance Commercial |
$2,322.00
|
| Rate for Payer: WEA Trust Commercial |
$2,554.20
|
| Rate for Payer: WPS Commercial |
$3,439.81
|
|
|
MRI Spine Lumbar w/o Contrast
|
Facility
|
OP
|
$4,644.00
|
|
|
Service Code
|
CPT 72148
|
| Hospital Charge Code |
631287
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$4,272.48 |
| Rate for Payer: Aetna Commercial |
$4,179.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,993.84
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,018.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,322.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,229.12
|
| Rate for Payer: Anthem Medicare Advantage |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,461.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$1,393.20
|
| Rate for Payer: Cash Price |
$1,393.20
|
| Rate for Payer: Cigna Commercial |
$4,272.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,598.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$4,133.16
|
| Rate for Payer: HFN Commercial |
$4,272.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$3,715.20
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,272.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,275.56
|
| Rate for Payer: Quartz Commercial |
$3,018.60
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: WEA Trust Commercial |
$2,554.20
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$3,439.81
|
|
|
MRI Spine Lumbar w/o Contrast
|
Facility
|
OP
|
$5,013.00
|
|
|
Service Code
|
CPT 72148 TC
|
| Hospital Charge Code |
3072642
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$4,611.96 |
| Rate for Payer: Aetna Commercial |
$4,511.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,311.18
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| 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 |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,656.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cigna Commercial |
$4,611.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,805.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$4,461.57
|
| Rate for Payer: HFN Commercial |
$4,611.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$4,010.40
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,611.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,456.37
|
| Rate for Payer: Quartz Commercial |
$3,258.45
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$2,757.15
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$3,713.13
|
|
|
MRI Spine Lumbar w/o Contrast
|
Professional
|
Both
|
$5,013.00
|
|
|
Service Code
|
CPT 72148 TC
|
| Hospital Charge Code |
1611297
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$476.09 |
| Max. Negotiated Rate |
$4,762.35 |
| Rate for Payer: Aetna Commercial |
$4,762.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,311.18
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cigna Commercial |
$4,762.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,506.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,007.80
|
| Rate for Payer: Health EOS Commercial |
$4,561.83
|
| Rate for Payer: HFN Commercial |
$4,762.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$476.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$476.09
|
| Rate for Payer: Multiplan Commercial |
$4,010.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,762.35
|
| Rate for Payer: Quartz Beloit One Network |
$2,205.72
|
| Rate for Payer: Quartz Commercial |
$2,857.41
|
| Rate for Payer: The Alliance Commercial |
$2,506.50
|
| Rate for Payer: WEA Trust Commercial |
$2,757.15
|
| Rate for Payer: WPS Commercial |
$3,713.13
|
|
|
MRI Spine Lumbar w/o Contrast
|
Facility
|
IP
|
$4,644.00
|
|
|
Service Code
|
CPT 72148
|
| Hospital Charge Code |
631287
|
| Min. Negotiated Rate |
$2,275.56 |
| Max. Negotiated Rate |
$4,272.48 |
| Rate for Payer: Aetna Commercial |
$4,179.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,993.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,461.32
|
| Rate for Payer: Cash Price |
$1,393.20
|
| Rate for Payer: Cigna Commercial |
$4,272.48
|
| Rate for Payer: Health EOS Commercial |
$4,133.16
|
| Rate for Payer: HFN Commercial |
$4,272.48
|
| Rate for Payer: Multiplan Commercial |
$3,715.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,786.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,272.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,275.56
|
| Rate for Payer: Quartz Commercial |
$2,786.40
|
| Rate for Payer: WEA Trust Commercial |
$2,554.20
|
| Rate for Payer: WPS Commercial |
$3,439.81
|
|
|
MRI Spine Lumbar w/o Contrast
|
Facility
|
IP
|
$5,013.00
|
|
|
Service Code
|
CPT 72148 TC
|
| Hospital Charge Code |
1611297
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,456.37 |
| Max. Negotiated Rate |
$4,611.96 |
| Rate for Payer: Aetna Commercial |
$4,511.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,311.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,656.89
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cigna Commercial |
$4,611.96
|
| Rate for Payer: Health EOS Commercial |
$4,461.57
|
| Rate for Payer: HFN Commercial |
$4,611.96
|
| Rate for Payer: Multiplan Commercial |
$4,010.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,007.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,611.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,456.37
|
| Rate for Payer: Quartz Commercial |
$3,007.80
|
| Rate for Payer: WEA Trust Commercial |
$2,757.15
|
| Rate for Payer: WPS Commercial |
$3,713.13
|
|
|
MRI Spine Lumbar w/o Contrast
|
Facility
|
IP
|
$5,013.00
|
|
|
Service Code
|
CPT 72148 TC
|
| Hospital Charge Code |
3072642
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,456.37 |
| Max. Negotiated Rate |
$4,611.96 |
| Rate for Payer: Aetna Commercial |
$4,511.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,311.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,656.89
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cigna Commercial |
$4,611.96
|
| Rate for Payer: Health EOS Commercial |
$4,461.57
|
| Rate for Payer: HFN Commercial |
$4,611.96
|
| Rate for Payer: Multiplan Commercial |
$4,010.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,007.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,611.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,456.37
|
| Rate for Payer: Quartz Commercial |
$3,007.80
|
| Rate for Payer: WEA Trust Commercial |
$2,757.15
|
| Rate for Payer: WPS Commercial |
$3,713.13
|
|
|
MRI Spine Lumbar w/ + w/o Contrast
|
Professional
|
Both
|
$6,235.00
|
|
|
Service Code
|
CPT 72158
|
| Hospital Charge Code |
631277
|
| Min. Negotiated Rate |
$1,220.85 |
| Max. Negotiated Rate |
$5,923.25 |
| Rate for Payer: Aetna Commercial |
$5,923.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.10
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$5,923.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,117.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,741.00
|
| Rate for Payer: Health EOS Commercial |
$5,673.85
|
| Rate for Payer: HFN Commercial |
$5,923.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,220.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,220.85
|
| Rate for Payer: Multiplan Commercial |
$4,988.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,923.25
|
| Rate for Payer: Quartz Beloit One Network |
$2,743.40
|
| Rate for Payer: Quartz Commercial |
$3,553.95
|
| Rate for Payer: The Alliance Commercial |
$3,117.50
|
| Rate for Payer: WEA Trust Commercial |
$3,429.25
|
| Rate for Payer: WPS Commercial |
$4,618.26
|
|
|
MRI Spine Lumbar w/ + w/o Contrast
|
Facility
|
OP
|
$6,235.00
|
|
|
Service Code
|
CPT 72158
|
| Hospital Charge Code |
631277
|
| Min. Negotiated Rate |
$380.12 |
| Max. Negotiated Rate |
$5,736.20 |
| Rate for Payer: Aetna Commercial |
$5,611.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.10
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,052.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,117.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,992.80
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,304.55
|
| 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 |
$1,870.50
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$5,736.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,489.11
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$5,549.15
|
| Rate for Payer: HFN Commercial |
$5,736.20
|
| 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 |
$4,988.00
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,736.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,055.15
|
| Rate for Payer: Quartz Commercial |
$4,052.75
|
| 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 |
$3,429.25
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$4,618.26
|
|
|
MRI Spine Lumbar w/ + w/o Contrast
|
Facility
|
IP
|
$6,351.00
|
|
|
Service Code
|
CPT 72158 TC
|
| Hospital Charge Code |
1611293
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,111.99 |
| Max. Negotiated Rate |
$5,842.92 |
| Rate for Payer: Aetna Commercial |
$5,715.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,461.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,366.03
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cigna Commercial |
$5,842.92
|
| Rate for Payer: Health EOS Commercial |
$5,652.39
|
| Rate for Payer: HFN Commercial |
$5,842.92
|
| Rate for Payer: Multiplan Commercial |
$5,080.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,810.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,842.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,111.99
|
| Rate for Payer: Quartz Commercial |
$3,810.60
|
| Rate for Payer: WEA Trust Commercial |
$3,493.05
|
| Rate for Payer: WPS Commercial |
$4,704.19
|
|
|
MRI Spine Lumbar w/ + w/o Contrast
|
Facility
|
OP
|
$6,351.00
|
|
|
Service Code
|
CPT 72158 TC
|
| Hospital Charge Code |
1611293
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$380.12 |
| Max. Negotiated Rate |
$5,842.92 |
| Rate for Payer: Aetna Commercial |
$5,715.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,461.86
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| 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 |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,366.03
|
| 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 |
$1,905.30
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cigna Commercial |
$5,842.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,554.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$5,652.39
|
| Rate for Payer: HFN Commercial |
$5,842.92
|
| 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 |
$5,080.80
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,842.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,111.99
|
| Rate for Payer: Quartz Commercial |
$4,128.15
|
| 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: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$3,493.05
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$4,704.19
|
|
