|
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 |
$2,554.62 |
| Max. Negotiated Rate |
$4,796.44 |
| Rate for Payer: Aetna Commercial |
$4,692.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,483.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,763.17
|
| Rate for Payer: Cash Price |
$1,503.90
|
| Rate for Payer: Cigna Commercial |
$4,796.44
|
| Rate for Payer: Health EOS Commercial |
$4,640.03
|
| Rate for Payer: HFN Commercial |
$4,796.44
|
| Rate for Payer: Multiplan Commercial |
$4,170.82
|
| Rate for Payer: Preferred Network Access Commercial |
$4,796.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,554.62
|
| Rate for Payer: Quartz Commercial |
$3,128.11
|
| Rate for Payer: WEA Trust Commercial |
$2,867.44
|
| Rate for Payer: WPS Commercial |
$3,861.51
|
|
|
MRI Spine Lumbar w/o Contrast
|
Facility
|
IP
|
$4,644.00
|
|
|
Service Code
|
CPT 72148
|
| Hospital Charge Code |
631287
|
| Min. Negotiated Rate |
$2,366.58 |
| Max. Negotiated Rate |
$4,443.38 |
| Rate for Payer: Aetna Commercial |
$4,346.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,153.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,559.77
|
| Rate for Payer: Cash Price |
$1,393.20
|
| Rate for Payer: Cigna Commercial |
$4,443.38
|
| Rate for Payer: Health EOS Commercial |
$4,298.49
|
| Rate for Payer: HFN Commercial |
$4,443.38
|
| Rate for Payer: Multiplan Commercial |
$3,863.81
|
| Rate for Payer: Preferred Network Access Commercial |
$4,443.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,366.58
|
| Rate for Payer: Quartz Commercial |
$2,897.86
|
| Rate for Payer: WEA Trust Commercial |
$2,656.37
|
| Rate for Payer: WPS Commercial |
$3,577.27
|
|
|
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 |
$489.38 |
| Max. Negotiated Rate |
$4,796.44 |
| Rate for Payer: Aetna Commercial |
$4,692.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,483.63
|
| Rate for Payer: Aetna Managed Medicare |
$1,459.79
|
| 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 |
$2,763.17
|
| 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 |
$4,796.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,917.57
|
| Rate for Payer: Health EOS Commercial |
$4,640.03
|
| Rate for Payer: HFN Commercial |
$4,796.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,910.14
|
| Rate for Payer: Multiplan Commercial |
$4,170.82
|
| Rate for Payer: NAPHCARE Commercial |
$3,128.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,796.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,554.62
|
| Rate for Payer: Quartz Commercial |
$3,388.79
|
| Rate for Payer: Quartz Medicare Advantage |
$3,128.11
|
| Rate for Payer: The Alliance Commercial |
$489.38
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,867.44
|
| Rate for Payer: WPS Commercial |
$856.42
|
|
|
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 |
$122.35 |
| Max. Negotiated Rate |
$4,952.84 |
| Rate for Payer: Aetna Commercial |
$4,952.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,483.63
|
| Rate for Payer: Aetna Managed Medicare |
$122.35
|
| Rate for Payer: Anthem Medicare Advantage |
$122.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$122.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$122.35
|
| 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 |
$4,952.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,606.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.35
|
| Rate for Payer: Health EOS Commercial |
$4,744.30
|
| Rate for Payer: HFN Commercial |
$4,952.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$495.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$495.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$122.35
|
| Rate for Payer: Multiplan Commercial |
$4,170.82
|
| Rate for Payer: NAPHCARE Commercial |
$183.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,952.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,293.95
|
| Rate for Payer: Quartz Commercial |
$2,971.71
|
| Rate for Payer: Quartz Medicare Advantage |
$122.35
|
| Rate for Payer: The Alliance Commercial |
$464.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.35
|
| Rate for Payer: WEA Trust Commercial |
$2,867.44
|
| Rate for Payer: WPS Commercial |
$611.73
|
|
|
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 |
$122.35 |
| Max. Negotiated Rate |
$4,952.84 |
| Rate for Payer: Aetna Commercial |
$4,952.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,483.63
|
| Rate for Payer: Aetna Managed Medicare |
$122.35
|
| Rate for Payer: Anthem Medicare Advantage |
$122.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$122.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$122.35
|
| 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 |
$4,952.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,606.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.35
|
| Rate for Payer: Health EOS Commercial |
$4,744.30
|
| Rate for Payer: HFN Commercial |
$4,952.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$495.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$495.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$122.35
|
| Rate for Payer: Multiplan Commercial |
$4,170.82
|
| Rate for Payer: NAPHCARE Commercial |
$183.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,952.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,293.95
|
| Rate for Payer: Quartz Commercial |
$2,971.71
|
| Rate for Payer: Quartz Medicare Advantage |
$122.35
|
| Rate for Payer: The Alliance Commercial |
$464.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.35
|
| Rate for Payer: WEA Trust Commercial |
$2,867.44
|
| Rate for Payer: WPS Commercial |
$611.73
|
|
|
MRI Spine Lumbar w/o Contrast
|
Facility
|
OP
|
$4,644.00
|
|
|
Service Code
|
CPT 72148
|
| Hospital Charge Code |
631287
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$4,443.38 |
| Rate for Payer: Aetna Commercial |
$4,346.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,153.59
|
| Rate for Payer: Aetna Managed Medicare |
$251.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,139.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,414.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,318.28
|
| Rate for Payer: Anthem Medicare Advantage |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,559.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$251.10
|
| Rate for Payer: Cash Price |
$1,393.20
|
| Rate for Payer: Cash Price |
$1,393.20
|
| Rate for Payer: Cigna Commercial |
$4,443.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$251.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,702.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$251.10
|
| Rate for Payer: Health EOS Commercial |
$4,298.49
|
| Rate for Payer: HFN Commercial |
$4,443.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$934.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$251.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$251.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$251.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$251.10
|
| Rate for Payer: Multiplan Commercial |
$3,863.81
|
| Rate for Payer: NAPHCARE Commercial |
$376.65
|
| Rate for Payer: Preferred Network Access Commercial |
$4,443.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,366.58
|
| Rate for Payer: Quartz Commercial |
$3,139.34
|
| Rate for Payer: Quartz Medicare Advantage |
$251.10
|
| Rate for Payer: The Alliance Commercial |
$1,004.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$251.10
|
| Rate for Payer: WEA Trust Commercial |
$2,656.37
|
| Rate for Payer: Wellcare Medicare |
$251.10
|
| Rate for Payer: WPS Commercial |
$3,577.27
|
|
|
MRI Spine Lumbar w/o Contrast
|
Professional
|
Both
|
$4,644.00
|
|
|
Service Code
|
CPT 72148
|
| Hospital Charge Code |
631287
|
| Min. Negotiated Rate |
$190.86 |
| Max. Negotiated Rate |
$4,588.27 |
| Rate for Payer: Aetna Commercial |
$4,588.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,153.59
|
| Rate for Payer: Aetna Managed Medicare |
$190.86
|
| Rate for Payer: Anthem Medicare Advantage |
$190.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$190.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$190.86
|
| 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 |
$4,588.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,414.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$190.86
|
| Rate for Payer: Health EOS Commercial |
$4,395.08
|
| Rate for Payer: HFN Commercial |
$4,588.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$752.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$752.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$190.86
|
| Rate for Payer: Multiplan Commercial |
$3,863.81
|
| Rate for Payer: NAPHCARE Commercial |
$286.29
|
| Rate for Payer: Preferred Network Access Commercial |
$4,588.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.09
|
| Rate for Payer: Quartz Commercial |
$2,752.96
|
| Rate for Payer: Quartz Medicare Advantage |
$190.86
|
| Rate for Payer: The Alliance Commercial |
$725.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$190.86
|
| Rate for Payer: WEA Trust Commercial |
$2,656.37
|
| Rate for Payer: WPS Commercial |
$954.30
|
|
|
MRI Spine Lumbar w/ + w/o Contrast
|
Professional
|
Both
|
$6,235.00
|
|
|
Service Code
|
CPT 72158
|
| Hospital Charge Code |
631277
|
| Min. Negotiated Rate |
$316.78 |
| Max. Negotiated Rate |
$6,160.18 |
| Rate for Payer: Aetna Commercial |
$6,160.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,576.58
|
| Rate for Payer: Aetna Managed Medicare |
$316.78
|
| Rate for Payer: Anthem Medicare Advantage |
$316.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$316.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$316.78
|
| 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 |
$6,160.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$316.78
|
| Rate for Payer: Health EOS Commercial |
$5,900.80
|
| Rate for Payer: HFN Commercial |
$6,160.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,269.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,269.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$316.78
|
| Rate for Payer: Multiplan Commercial |
$5,187.52
|
| Rate for Payer: NAPHCARE Commercial |
$475.18
|
| Rate for Payer: Preferred Network Access Commercial |
$6,160.18
|
| Rate for Payer: Quartz Beloit One Network |
$2,853.14
|
| Rate for Payer: Quartz Commercial |
$3,696.11
|
| Rate for Payer: Quartz Medicare Advantage |
$316.78
|
| Rate for Payer: The Alliance Commercial |
$1,203.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$316.78
|
| Rate for Payer: WEA Trust Commercial |
$3,566.42
|
| Rate for Payer: WPS Commercial |
$1,583.92
|
|
|
MRI Spine Lumbar w/ + w/o Contrast
|
Professional
|
Both
|
$6,351.00
|
|
|
Service Code
|
CPT 72158 TC
|
| Hospital Charge Code |
1611293
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$211.31 |
| Max. Negotiated Rate |
$6,274.79 |
| Rate for Payer: Aetna Commercial |
$6,274.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,680.33
|
| Rate for Payer: Aetna Managed Medicare |
$211.31
|
| Rate for Payer: Anthem Medicare Advantage |
$211.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$211.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$211.31
|
| 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 |
$6,274.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,302.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$211.31
|
| Rate for Payer: Health EOS Commercial |
$6,010.59
|
| Rate for Payer: HFN Commercial |
$6,274.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$872.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$872.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$211.31
|
| Rate for Payer: Multiplan Commercial |
$5,284.03
|
| Rate for Payer: NAPHCARE Commercial |
$316.96
|
| Rate for Payer: Preferred Network Access Commercial |
$6,274.79
|
| Rate for Payer: Quartz Beloit One Network |
$2,906.22
|
| Rate for Payer: Quartz Commercial |
$3,764.87
|
| Rate for Payer: Quartz Medicare Advantage |
$211.31
|
| Rate for Payer: The Alliance Commercial |
$802.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$211.31
|
| Rate for Payer: WEA Trust Commercial |
$3,632.77
|
| Rate for Payer: WPS Commercial |
$1,056.54
|
|
|
MRI Spine Lumbar w/ + w/o Contrast
|
Facility
|
IP
|
$6,235.00
|
|
|
Service Code
|
CPT 72158
|
| Hospital Charge Code |
631277
|
| Min. Negotiated Rate |
$3,177.36 |
| Max. Negotiated Rate |
$5,965.65 |
| Rate for Payer: Aetna Commercial |
$5,835.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,576.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,436.73
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$5,965.65
|
| Rate for Payer: Health EOS Commercial |
$5,771.12
|
| Rate for Payer: HFN Commercial |
$5,965.65
|
| Rate for Payer: Multiplan Commercial |
$5,187.52
|
| Rate for Payer: Preferred Network Access Commercial |
$5,965.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.36
|
| Rate for Payer: Quartz Commercial |
$3,890.64
|
| Rate for Payer: WEA Trust Commercial |
$3,566.42
|
| Rate for Payer: WPS Commercial |
$4,802.82
|
|
|
MRI Spine Lumbar w/ + w/o Contrast
|
Facility
|
OP
|
$6,235.00
|
|
|
Service Code
|
CPT 72158
|
| Hospital Charge Code |
631277
|
| Min. Negotiated Rate |
$367.15 |
| Max. Negotiated Rate |
$5,965.65 |
| Rate for Payer: Aetna Commercial |
$5,835.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,576.58
|
| Rate for Payer: Aetna Managed Medicare |
$367.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,214.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,242.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,112.51
|
| Rate for Payer: Anthem Medicare Advantage |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,436.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$367.15
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$5,965.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$367.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,628.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$367.15
|
| Rate for Payer: Health EOS Commercial |
$5,771.12
|
| Rate for Payer: HFN Commercial |
$5,965.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$367.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$367.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$367.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$367.15
|
| Rate for Payer: Multiplan Commercial |
$5,187.52
|
| Rate for Payer: NAPHCARE Commercial |
$550.73
|
| Rate for Payer: Preferred Network Access Commercial |
$5,965.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.36
|
| Rate for Payer: Quartz Commercial |
$4,214.86
|
| Rate for Payer: Quartz Medicare Advantage |
$367.15
|
| Rate for Payer: The Alliance Commercial |
$1,468.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$367.15
|
| Rate for Payer: WEA Trust Commercial |
$3,566.42
|
| Rate for Payer: Wellcare Medicare |
$367.15
|
| Rate for Payer: WPS Commercial |
$4,802.82
|
|
|
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 |
$3,236.47 |
| Max. Negotiated Rate |
$6,076.64 |
| Rate for Payer: Aetna Commercial |
$5,944.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,680.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,500.67
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cigna Commercial |
$6,076.64
|
| Rate for Payer: Health EOS Commercial |
$5,878.49
|
| Rate for Payer: HFN Commercial |
$6,076.64
|
| Rate for Payer: Multiplan Commercial |
$5,284.03
|
| Rate for Payer: Preferred Network Access Commercial |
$6,076.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,236.47
|
| Rate for Payer: Quartz Commercial |
$3,963.02
|
| Rate for Payer: WEA Trust Commercial |
$3,632.77
|
| Rate for Payer: WPS Commercial |
$4,892.18
|
|
|
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 |
$845.23 |
| Max. Negotiated Rate |
$6,076.64 |
| Rate for Payer: Aetna Commercial |
$5,944.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,680.33
|
| Rate for Payer: Aetna Managed Medicare |
$1,849.41
|
| 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 |
$3,500.67
|
| 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 |
$6,076.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,696.28
|
| Rate for Payer: Health EOS Commercial |
$5,878.49
|
| Rate for Payer: HFN Commercial |
$6,076.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,953.78
|
| Rate for Payer: Multiplan Commercial |
$5,284.03
|
| Rate for Payer: NAPHCARE Commercial |
$3,963.02
|
| Rate for Payer: Preferred Network Access Commercial |
$6,076.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,236.47
|
| Rate for Payer: Quartz Commercial |
$4,293.28
|
| Rate for Payer: Quartz Medicare Advantage |
$3,963.02
|
| Rate for Payer: The Alliance Commercial |
$845.23
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,632.77
|
| Rate for Payer: WPS Commercial |
$1,479.15
|
|
|
MRI Spine Thoracic w/ Contrast
|
Professional
|
Both
|
$6,080.00
|
|
|
Service Code
|
CPT 72147
|
| Hospital Charge Code |
631289
|
| Min. Negotiated Rate |
$270.05 |
| Max. Negotiated Rate |
$6,007.04 |
| Rate for Payer: Aetna Commercial |
$6,007.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.95
|
| Rate for Payer: Aetna Managed Medicare |
$270.05
|
| Rate for Payer: Anthem Medicare Advantage |
$270.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$270.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$270.05
|
| 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 |
$6,007.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,161.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$270.05
|
| Rate for Payer: Health EOS Commercial |
$5,754.11
|
| Rate for Payer: HFN Commercial |
$6,007.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,084.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,084.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$270.05
|
| Rate for Payer: Multiplan Commercial |
$5,058.56
|
| Rate for Payer: NAPHCARE Commercial |
$405.07
|
| Rate for Payer: Preferred Network Access Commercial |
$6,007.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,782.21
|
| Rate for Payer: Quartz Commercial |
$3,604.22
|
| Rate for Payer: Quartz Medicare Advantage |
$270.05
|
| Rate for Payer: The Alliance Commercial |
$1,026.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$270.05
|
| Rate for Payer: WEA Trust Commercial |
$3,477.76
|
| Rate for Payer: WPS Commercial |
$1,350.23
|
|
|
MRI Spine Thoracic w/ Contrast
|
Facility
|
OP
|
$6,080.00
|
|
|
Service Code
|
CPT 72147
|
| Hospital Charge Code |
631289
|
| Min. Negotiated Rate |
$367.15 |
| Max. Negotiated Rate |
$5,817.34 |
| Rate for Payer: Aetna Commercial |
$5,690.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.95
|
| Rate for Payer: Aetna Managed Medicare |
$367.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,110.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,161.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,035.14
|
| Rate for Payer: Anthem Medicare Advantage |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,351.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$367.15
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cigna Commercial |
$5,817.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$367.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,538.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$367.15
|
| Rate for Payer: Health EOS Commercial |
$5,627.65
|
| Rate for Payer: HFN Commercial |
$5,817.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$367.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$367.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$367.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$367.15
|
| Rate for Payer: Multiplan Commercial |
$5,058.56
|
| Rate for Payer: NAPHCARE Commercial |
$550.73
|
| Rate for Payer: Preferred Network Access Commercial |
$5,817.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,098.37
|
| Rate for Payer: Quartz Commercial |
$4,110.08
|
| Rate for Payer: Quartz Medicare Advantage |
$367.15
|
| Rate for Payer: The Alliance Commercial |
$1,468.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$367.15
|
| Rate for Payer: WEA Trust Commercial |
$3,477.76
|
| Rate for Payer: Wellcare Medicare |
$367.15
|
| Rate for Payer: WPS Commercial |
$4,683.42
|
|
|
MRI Spine Thoracic w/ Contrast
|
Facility
|
IP
|
$6,080.00
|
|
|
Service Code
|
CPT 72147
|
| Hospital Charge Code |
631289
|
| Min. Negotiated Rate |
$3,098.37 |
| Max. Negotiated Rate |
$5,817.34 |
| Rate for Payer: Aetna Commercial |
$5,690.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,351.30
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cigna Commercial |
$5,817.34
|
| Rate for Payer: Health EOS Commercial |
$5,627.65
|
| Rate for Payer: HFN Commercial |
$5,817.34
|
| Rate for Payer: Multiplan Commercial |
$5,058.56
|
| Rate for Payer: Preferred Network Access Commercial |
$5,817.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,098.37
|
| Rate for Payer: Quartz Commercial |
$3,793.92
|
| Rate for Payer: WEA Trust Commercial |
$3,477.76
|
| Rate for Payer: WPS Commercial |
$4,683.42
|
|
|
MRI Spine Thoracic w/ Contrast
|
Facility
|
IP
|
$6,194.00
|
|
|
Service Code
|
CPT 72147 TC
|
| Hospital Charge Code |
1611319
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,156.46 |
| Max. Negotiated Rate |
$5,926.42 |
| Rate for Payer: Aetna Commercial |
$5,797.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,539.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,414.13
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,926.42
|
| Rate for Payer: Health EOS Commercial |
$5,733.17
|
| Rate for Payer: HFN Commercial |
$5,926.42
|
| Rate for Payer: Multiplan Commercial |
$5,153.41
|
| Rate for Payer: Preferred Network Access Commercial |
$5,926.42
|
| Rate for Payer: Quartz Beloit One Network |
$3,156.46
|
| Rate for Payer: Quartz Commercial |
$3,865.06
|
| Rate for Payer: WEA Trust Commercial |
$3,542.97
|
| Rate for Payer: WPS Commercial |
$4,771.24
|
|
|
MRI Spine Thoracic w/ Contrast
|
Professional
|
Both
|
$6,194.00
|
|
|
Service Code
|
CPT 72147 TC
|
| Hospital Charge Code |
1611319
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$187.68 |
| Max. Negotiated Rate |
$6,119.67 |
| Rate for Payer: Aetna Commercial |
$6,119.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,539.91
|
| Rate for Payer: Aetna Managed Medicare |
$187.68
|
| Rate for Payer: Anthem Medicare Advantage |
$187.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$187.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$187.68
|
| 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 |
$6,119.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,220.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$187.68
|
| Rate for Payer: Health EOS Commercial |
$5,862.00
|
| Rate for Payer: HFN Commercial |
$6,119.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$774.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$774.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$187.68
|
| Rate for Payer: Multiplan Commercial |
$5,153.41
|
| Rate for Payer: NAPHCARE Commercial |
$281.52
|
| Rate for Payer: Preferred Network Access Commercial |
$6,119.67
|
| Rate for Payer: Quartz Beloit One Network |
$2,834.37
|
| Rate for Payer: Quartz Commercial |
$3,671.80
|
| Rate for Payer: Quartz Medicare Advantage |
$187.68
|
| Rate for Payer: The Alliance Commercial |
$713.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$187.68
|
| Rate for Payer: WEA Trust Commercial |
$3,542.97
|
| Rate for Payer: WPS Commercial |
$938.39
|
|
|
MRI Spine Thoracic w/ Contrast
|
Facility
|
OP
|
$6,194.00
|
|
|
Service Code
|
CPT 72147 TC
|
| Hospital Charge Code |
1611319
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$750.71 |
| Max. Negotiated Rate |
$5,926.42 |
| Rate for Payer: Aetna Commercial |
$5,797.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,539.91
|
| Rate for Payer: Aetna Managed Medicare |
$1,803.69
|
| 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 |
$3,414.13
|
| 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 |
$5,926.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,604.91
|
| Rate for Payer: Health EOS Commercial |
$5,733.17
|
| Rate for Payer: HFN Commercial |
$5,926.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,831.32
|
| Rate for Payer: Multiplan Commercial |
$5,153.41
|
| Rate for Payer: NAPHCARE Commercial |
$3,865.06
|
| Rate for Payer: Preferred Network Access Commercial |
$5,926.42
|
| Rate for Payer: Quartz Beloit One Network |
$3,156.46
|
| Rate for Payer: Quartz Commercial |
$4,187.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,865.06
|
| Rate for Payer: The Alliance Commercial |
$750.71
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,542.97
|
| Rate for Payer: WPS Commercial |
$1,313.75
|
|
|
MRI Spine Thoracic w/o Contrast
|
Professional
|
Both
|
$5,410.00
|
|
|
Service Code
|
CPT 72146 TC
|
| Hospital Charge Code |
1611321
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$121.35 |
| Max. Negotiated Rate |
$5,345.08 |
| Rate for Payer: Aetna Commercial |
$5,345.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,838.70
|
| Rate for Payer: Aetna Managed Medicare |
$121.35
|
| Rate for Payer: Anthem Medicare Advantage |
$121.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$121.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$121.35
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cigna Commercial |
$5,345.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,813.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.35
|
| Rate for Payer: Health EOS Commercial |
$5,120.02
|
| Rate for Payer: HFN Commercial |
$5,345.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$493.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$493.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$121.35
|
| Rate for Payer: Multiplan Commercial |
$4,501.12
|
| Rate for Payer: NAPHCARE Commercial |
$182.02
|
| Rate for Payer: Preferred Network Access Commercial |
$5,345.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,475.62
|
| Rate for Payer: Quartz Commercial |
$3,207.05
|
| Rate for Payer: Quartz Medicare Advantage |
$121.35
|
| Rate for Payer: The Alliance Commercial |
$461.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$121.35
|
| Rate for Payer: WEA Trust Commercial |
$3,094.52
|
| Rate for Payer: WPS Commercial |
$606.74
|
|
|
MRI Spine Thoracic w/o Contrast
|
Facility
|
OP
|
$5,410.00
|
|
|
Service Code
|
CPT 72146 TC
|
| Hospital Charge Code |
3072643
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$485.39 |
| Max. Negotiated Rate |
$5,176.29 |
| Rate for Payer: Aetna Commercial |
$5,063.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,838.70
|
| Rate for Payer: Aetna Managed Medicare |
$1,575.39
|
| 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 |
$2,981.99
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cigna Commercial |
$5,176.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,148.62
|
| Rate for Payer: Health EOS Commercial |
$5,007.50
|
| Rate for Payer: HFN Commercial |
$5,176.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,219.80
|
| Rate for Payer: Multiplan Commercial |
$4,501.12
|
| Rate for Payer: NAPHCARE Commercial |
$3,375.84
|
| Rate for Payer: Preferred Network Access Commercial |
$5,176.29
|
| Rate for Payer: Quartz Beloit One Network |
$2,756.94
|
| Rate for Payer: Quartz Commercial |
$3,657.16
|
| Rate for Payer: Quartz Medicare Advantage |
$3,375.84
|
| Rate for Payer: The Alliance Commercial |
$485.39
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,094.52
|
| Rate for Payer: WPS Commercial |
$849.43
|
|
|
MRI Spine Thoracic w/o Contrast
|
Facility
|
IP
|
$4,627.00
|
|
|
Service Code
|
CPT 72146
|
| Hospital Charge Code |
631295
|
| Min. Negotiated Rate |
$2,357.92 |
| Max. Negotiated Rate |
$4,427.11 |
| Rate for Payer: Aetna Commercial |
$4,330.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,138.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,550.40
|
| Rate for Payer: Cash Price |
$1,388.10
|
| Rate for Payer: Cigna Commercial |
$4,427.11
|
| Rate for Payer: Health EOS Commercial |
$4,282.75
|
| Rate for Payer: HFN Commercial |
$4,427.11
|
| Rate for Payer: Multiplan Commercial |
$3,849.66
|
| Rate for Payer: Preferred Network Access Commercial |
$4,427.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,357.92
|
| Rate for Payer: Quartz Commercial |
$2,887.25
|
| Rate for Payer: WEA Trust Commercial |
$2,646.64
|
| Rate for Payer: WPS Commercial |
$3,564.18
|
|
|
MRI Spine Thoracic w/o Contrast
|
Facility
|
OP
|
$5,410.00
|
|
|
Service Code
|
CPT 72146 TC
|
| Hospital Charge Code |
1611321
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$485.39 |
| Max. Negotiated Rate |
$5,176.29 |
| Rate for Payer: Aetna Commercial |
$5,063.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,838.70
|
| Rate for Payer: Aetna Managed Medicare |
$1,575.39
|
| 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 |
$2,981.99
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cigna Commercial |
$5,176.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,148.62
|
| Rate for Payer: Health EOS Commercial |
$5,007.50
|
| Rate for Payer: HFN Commercial |
$5,176.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,219.80
|
| Rate for Payer: Multiplan Commercial |
$4,501.12
|
| Rate for Payer: NAPHCARE Commercial |
$3,375.84
|
| Rate for Payer: Preferred Network Access Commercial |
$5,176.29
|
| Rate for Payer: Quartz Beloit One Network |
$2,756.94
|
| Rate for Payer: Quartz Commercial |
$3,657.16
|
| Rate for Payer: Quartz Medicare Advantage |
$3,375.84
|
| Rate for Payer: The Alliance Commercial |
$485.39
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,094.52
|
| Rate for Payer: WPS Commercial |
$849.43
|
|
|
MRI Spine Thoracic w/o Contrast
|
Professional
|
Both
|
$4,627.00
|
|
|
Service Code
|
CPT 72146
|
| Hospital Charge Code |
631295
|
| Min. Negotiated Rate |
$189.53 |
| Max. Negotiated Rate |
$4,571.48 |
| Rate for Payer: Aetna Commercial |
$4,571.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,138.39
|
| Rate for Payer: Aetna Managed Medicare |
$189.53
|
| Rate for Payer: Anthem Medicare Advantage |
$189.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$189.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$189.53
|
| Rate for Payer: Cash Price |
$1,388.10
|
| Rate for Payer: Cash Price |
$1,388.10
|
| Rate for Payer: Cash Price |
$1,388.10
|
| Rate for Payer: Cigna Commercial |
$4,571.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,406.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.53
|
| Rate for Payer: Health EOS Commercial |
$4,378.99
|
| Rate for Payer: HFN Commercial |
$4,571.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$750.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$750.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$189.53
|
| Rate for Payer: Multiplan Commercial |
$3,849.66
|
| Rate for Payer: NAPHCARE Commercial |
$284.29
|
| Rate for Payer: Preferred Network Access Commercial |
$4,571.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,117.32
|
| Rate for Payer: Quartz Commercial |
$2,742.89
|
| Rate for Payer: Quartz Medicare Advantage |
$189.53
|
| Rate for Payer: The Alliance Commercial |
$720.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$189.53
|
| Rate for Payer: WEA Trust Commercial |
$2,646.64
|
| Rate for Payer: WPS Commercial |
$947.65
|
|
|
MRI Spine Thoracic w/o Contrast
|
Professional
|
Both
|
$5,410.00
|
|
|
Service Code
|
CPT 72146 TC
|
| Hospital Charge Code |
3072643
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$121.35 |
| Max. Negotiated Rate |
$5,345.08 |
| Rate for Payer: Aetna Commercial |
$5,345.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,838.70
|
| Rate for Payer: Aetna Managed Medicare |
$121.35
|
| Rate for Payer: Anthem Medicare Advantage |
$121.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$121.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$121.35
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cigna Commercial |
$5,345.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,813.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.35
|
| Rate for Payer: Health EOS Commercial |
$5,120.02
|
| Rate for Payer: HFN Commercial |
$5,345.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$493.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$493.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$121.35
|
| Rate for Payer: Multiplan Commercial |
$4,501.12
|
| Rate for Payer: NAPHCARE Commercial |
$182.02
|
| Rate for Payer: Preferred Network Access Commercial |
$5,345.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,475.62
|
| Rate for Payer: Quartz Commercial |
$3,207.05
|
| Rate for Payer: Quartz Medicare Advantage |
$121.35
|
| Rate for Payer: The Alliance Commercial |
$461.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$121.35
|
| Rate for Payer: WEA Trust Commercial |
$3,094.52
|
| Rate for Payer: WPS Commercial |
$606.74
|
|
