|
Xiaflex 0.9mg vial J0775
|
Facility
|
IP
|
$10,805.00
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
4356598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,294.45 |
| Max. Negotiated Rate |
$9,940.60 |
| Rate for Payer: Aetna Commercial |
$9,724.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,292.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,726.65
|
| Rate for Payer: Cash Price |
$3,241.50
|
| Rate for Payer: Cigna Commercial |
$9,940.60
|
| Rate for Payer: Health EOS Commercial |
$9,616.45
|
| Rate for Payer: HFN Commercial |
$9,940.60
|
| Rate for Payer: Multiplan Commercial |
$8,644.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,483.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,940.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,294.45
|
| Rate for Payer: Quartz Commercial |
$6,483.00
|
| Rate for Payer: WEA Trust Commercial |
$5,942.75
|
| Rate for Payer: WPS Commercial |
$8,003.26
|
|
|
Xiaflex 0.9mg vial J0775
|
Professional
|
Both
|
$10,805.00
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
4356598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.27 |
| Max. Negotiated Rate |
$10,264.75 |
| Rate for Payer: Aetna Commercial |
$10,264.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,292.30
|
| Rate for Payer: Cash Price |
$3,241.50
|
| Rate for Payer: Cash Price |
$3,241.50
|
| Rate for Payer: Cigna Commercial |
$10,264.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$66.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.97
|
| Rate for Payer: Health EOS Commercial |
$9,832.55
|
| Rate for Payer: HFN Commercial |
$10,264.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$79.48
|
| Rate for Payer: Multiplan Commercial |
$8,644.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,264.75
|
| Rate for Payer: Quartz Beloit One Network |
$4,754.20
|
| Rate for Payer: Quartz Commercial |
$6,158.85
|
| Rate for Payer: The Alliance Commercial |
$5,402.50
|
| Rate for Payer: United Healthcare Medicaid |
$66.27
|
| Rate for Payer: WEA Trust Commercial |
$5,942.75
|
| Rate for Payer: WPS Commercial |
$172.42
|
|
|
Xopenex 0.5 mg Charge
|
Professional
|
Both
|
$10.00
|
|
| Hospital Charge Code |
2958858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Aetna Commercial |
$9.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.60
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.00
|
| Rate for Payer: Health EOS Commercial |
$9.10
|
| Rate for Payer: HFN Commercial |
$9.50
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9.50
|
| Rate for Payer: Quartz Beloit One Network |
$4.40
|
| Rate for Payer: Quartz Commercial |
$5.70
|
| Rate for Payer: The Alliance Commercial |
$5.00
|
| Rate for Payer: WEA Trust Commercial |
$5.50
|
| Rate for Payer: WPS Commercial |
$7.41
|
|
|
Xopenex 0.5 mg Charge
|
Facility
|
OP
|
$10.00
|
|
| Hospital Charge Code |
2958858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$9.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.60
|
| Rate for Payer: Aetna Managed Medicare |
$2.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.30
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.60
|
| Rate for Payer: Health EOS Commercial |
$8.90
|
| Rate for Payer: HFN Commercial |
$9.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: NAPHCARE Commercial |
$6.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9.20
|
| Rate for Payer: Quartz Beloit One Network |
$4.90
|
| Rate for Payer: Quartz Commercial |
$6.50
|
| Rate for Payer: Quartz Medicare Advantage |
$6.00
|
| Rate for Payer: The Alliance Commercial |
$40.00
|
| Rate for Payer: WEA Trust Commercial |
$5.50
|
| Rate for Payer: WPS Commercial |
$7.41
|
|
|
Xopenex 0.5 mg Charge
|
Facility
|
IP
|
$10.00
|
|
| Hospital Charge Code |
2958858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$9.20 |
| Rate for Payer: Aetna Commercial |
$9.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.30
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: Health EOS Commercial |
$8.90
|
| Rate for Payer: HFN Commercial |
$9.20
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: NAPHCARE Commercial |
$6.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9.20
|
| Rate for Payer: Quartz Beloit One Network |
$4.90
|
| Rate for Payer: Quartz Commercial |
$6.00
|
| Rate for Payer: WEA Trust Commercial |
$5.50
|
| Rate for Payer: WPS Commercial |
$7.41
|
|
|
Xopenex - Additional Unit Dose Medicaiton
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
5516922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Aetna Managed Medicare |
$10.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.15
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$23.40
|
| Rate for Payer: Quartz Medicare Advantage |
$21.60
|
| Rate for Payer: The Alliance Commercial |
$144.00
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
Xopenex - Additional Unit Dose Medicaiton
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
5516922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$21.60
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
X-PLATE 8 HOLE BIOMET 73-2623
|
Facility
|
IP
|
$5,401.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4205986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,646.49 |
| Max. Negotiated Rate |
$4,968.92 |
| Rate for Payer: Aetna Commercial |
$4,860.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,644.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,862.53
|
| Rate for Payer: Cash Price |
$1,620.30
|
| Rate for Payer: Cigna Commercial |
$4,968.92
|
| Rate for Payer: Health EOS Commercial |
$4,806.89
|
| Rate for Payer: HFN Commercial |
$4,968.92
|
| Rate for Payer: Multiplan Commercial |
$4,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,240.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,968.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,646.49
|
| Rate for Payer: Quartz Commercial |
$3,240.60
|
| Rate for Payer: WEA Trust Commercial |
$2,970.55
|
| Rate for Payer: WPS Commercial |
$4,000.52
|
|
|
X-PLATE 8 HOLE BIOMET 73-2623
|
Facility
|
OP
|
$5,401.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4205986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,512.28 |
| Max. Negotiated Rate |
$21,604.00 |
| Rate for Payer: Aetna Commercial |
$4,860.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,644.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,512.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,510.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,700.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,592.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,862.53
|
| Rate for Payer: Cash Price |
$1,620.30
|
| Rate for Payer: Cigna Commercial |
$4,968.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,022.40
|
| Rate for Payer: Health EOS Commercial |
$4,806.89
|
| Rate for Payer: HFN Commercial |
$4,968.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,050.75
|
| Rate for Payer: Multiplan Commercial |
$4,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,240.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,968.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,646.49
|
| Rate for Payer: Quartz Commercial |
$3,510.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,240.60
|
| Rate for Payer: The Alliance Commercial |
$21,604.00
|
| Rate for Payer: WEA Trust Commercial |
$2,970.55
|
| Rate for Payer: WPS Commercial |
$4,000.52
|
|
|
XPOSE FOR ENDOPROSTH, FEMORL, EXT 3481222
|
Professional
|
Both
|
$2,712.00
|
|
|
Service Code
|
CPT 34812 22
|
| Hospital Charge Code |
6173443
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$248.18 |
| Max. Negotiated Rate |
$2,576.40 |
| Rate for Payer: Aetna Commercial |
$2,576.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,332.32
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Cigna Commercial |
$2,576.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$248.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,627.20
|
| Rate for Payer: Health EOS Commercial |
$2,467.92
|
| Rate for Payer: HFN Commercial |
$2,576.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$648.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$648.85
|
| Rate for Payer: Multiplan Commercial |
$2,169.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,576.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,193.28
|
| Rate for Payer: Quartz Commercial |
$1,545.84
|
| Rate for Payer: The Alliance Commercial |
$1,356.00
|
| Rate for Payer: United Healthcare Medicaid |
$248.18
|
| Rate for Payer: WEA Trust Commercial |
$1,491.60
|
| Rate for Payer: WPS Commercial |
$2,008.78
|
|
|
XPOSE FOR ENDOPROSTH, FEMORL, EXT & BILAT 34812-2250
|
Professional
|
Both
|
$5,425.00
|
|
|
Service Code
|
CPT 34812 22,50
|
| Hospital Charge Code |
6173442
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$248.18 |
| Max. Negotiated Rate |
$5,153.75 |
| Rate for Payer: Aetna Commercial |
$5,153.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,665.50
|
| Rate for Payer: Cash Price |
$1,627.50
|
| Rate for Payer: Cash Price |
$1,627.50
|
| Rate for Payer: Cash Price |
$1,627.50
|
| Rate for Payer: Cigna Commercial |
$5,153.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$248.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,255.00
|
| Rate for Payer: Health EOS Commercial |
$4,936.75
|
| Rate for Payer: HFN Commercial |
$5,153.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$648.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$648.85
|
| Rate for Payer: Multiplan Commercial |
$4,340.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,153.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,387.00
|
| Rate for Payer: Quartz Commercial |
$3,092.25
|
| Rate for Payer: The Alliance Commercial |
$2,712.50
|
| Rate for Payer: United Healthcare Medicaid |
$248.18
|
| Rate for Payer: WEA Trust Commercial |
$2,983.75
|
| Rate for Payer: WPS Commercial |
$4,018.30
|
|
|
XR Abdomen 1 View
|
Professional
|
Both
|
$531.00
|
|
|
Service Code
|
CPT 74018 TC
|
| Hospital Charge Code |
5724247
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$504.45 |
| Rate for Payer: Aetna Commercial |
$504.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$456.66
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$504.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$265.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$318.60
|
| Rate for Payer: Health EOS Commercial |
$483.21
|
| Rate for Payer: HFN Commercial |
$504.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$70.00
|
| Rate for Payer: Multiplan Commercial |
$424.80
|
| Rate for Payer: Preferred Network Access Commercial |
$504.45
|
| Rate for Payer: Quartz Beloit One Network |
$233.64
|
| Rate for Payer: Quartz Commercial |
$302.67
|
| Rate for Payer: The Alliance Commercial |
$265.50
|
| Rate for Payer: WEA Trust Commercial |
$292.05
|
| Rate for Payer: WPS Commercial |
$393.31
|
|
|
XR Abdomen 1 View
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
CPT 74018 TC
|
| Hospital Charge Code |
5724247
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$260.19 |
| Max. Negotiated Rate |
$488.52 |
| Rate for Payer: Aetna Commercial |
$477.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$456.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.43
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$488.52
|
| Rate for Payer: Health EOS Commercial |
$472.59
|
| Rate for Payer: HFN Commercial |
$488.52
|
| Rate for Payer: Multiplan Commercial |
$424.80
|
| Rate for Payer: NAPHCARE Commercial |
$318.60
|
| Rate for Payer: Preferred Network Access Commercial |
$488.52
|
| Rate for Payer: Quartz Beloit One Network |
$260.19
|
| Rate for Payer: Quartz Commercial |
$318.60
|
| Rate for Payer: WEA Trust Commercial |
$292.05
|
| Rate for Payer: WPS Commercial |
$393.31
|
|
|
XR Abdomen 1 View
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
CPT 74018 TC
|
| Hospital Charge Code |
5724247
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$488.52 |
| Rate for Payer: Aetna Commercial |
$477.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$456.66
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.99
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$488.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$297.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$472.59
|
| Rate for Payer: HFN Commercial |
$488.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$424.80
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$488.52
|
| Rate for Payer: Quartz Beloit One Network |
$260.19
|
| Rate for Payer: Quartz Commercial |
$345.15
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$292.05
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$393.31
|
|
|
XR Abdomen 2 Views
|
Facility
|
OP
|
$530.00
|
|
|
Service Code
|
CPT 74019 TC
|
| Hospital Charge Code |
5963652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$487.60 |
| Rate for Payer: Aetna Commercial |
$477.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$455.80
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$407.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$326.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$309.71
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$280.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cigna Commercial |
$487.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$296.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$471.70
|
| Rate for Payer: HFN Commercial |
$487.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$424.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$487.60
|
| Rate for Payer: Quartz Beloit One Network |
$259.70
|
| Rate for Payer: Quartz Commercial |
$344.50
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$291.50
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$392.57
|
|
|
XR Abdomen 2 Views
|
Professional
|
Both
|
$530.00
|
|
|
Service Code
|
CPT 74019 TC
|
| Hospital Charge Code |
5963652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$86.20 |
| Max. Negotiated Rate |
$503.50 |
| Rate for Payer: Aetna Commercial |
$503.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$455.80
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cigna Commercial |
$503.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$265.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$318.00
|
| Rate for Payer: Health EOS Commercial |
$482.30
|
| Rate for Payer: HFN Commercial |
$503.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$86.20
|
| Rate for Payer: Multiplan Commercial |
$424.00
|
| Rate for Payer: Preferred Network Access Commercial |
$503.50
|
| Rate for Payer: Quartz Beloit One Network |
$233.20
|
| Rate for Payer: Quartz Commercial |
$302.10
|
| Rate for Payer: The Alliance Commercial |
$265.00
|
| Rate for Payer: WEA Trust Commercial |
$291.50
|
| Rate for Payer: WPS Commercial |
$392.57
|
|
|
XR Abdomen 2 Views
|
Facility
|
IP
|
$530.00
|
|
|
Service Code
|
CPT 74019 TC
|
| Hospital Charge Code |
5963652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$259.70 |
| Max. Negotiated Rate |
$487.60 |
| Rate for Payer: Aetna Commercial |
$477.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$455.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$280.90
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cigna Commercial |
$487.60
|
| Rate for Payer: Health EOS Commercial |
$471.70
|
| Rate for Payer: HFN Commercial |
$487.60
|
| Rate for Payer: Multiplan Commercial |
$424.00
|
| Rate for Payer: NAPHCARE Commercial |
$318.00
|
| Rate for Payer: Preferred Network Access Commercial |
$487.60
|
| Rate for Payer: Quartz Beloit One Network |
$259.70
|
| Rate for Payer: Quartz Commercial |
$318.00
|
| Rate for Payer: WEA Trust Commercial |
$291.50
|
| Rate for Payer: WPS Commercial |
$392.57
|
|
|
XR Abdomen AP
|
Professional
|
Both
|
$409.00
|
|
|
Service Code
|
CPT 74000
|
| Hospital Charge Code |
625614
|
| Min. Negotiated Rate |
$179.96 |
| Max. Negotiated Rate |
$388.55 |
| Rate for Payer: Aetna Commercial |
$388.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.74
|
| Rate for Payer: Cash Price |
$122.70
|
| Rate for Payer: Cigna Commercial |
$388.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$204.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$245.40
|
| Rate for Payer: Health EOS Commercial |
$372.19
|
| Rate for Payer: HFN Commercial |
$388.55
|
| Rate for Payer: Multiplan Commercial |
$327.20
|
| Rate for Payer: Preferred Network Access Commercial |
$388.55
|
| Rate for Payer: Quartz Beloit One Network |
$179.96
|
| Rate for Payer: Quartz Commercial |
$233.13
|
| Rate for Payer: The Alliance Commercial |
$204.50
|
| Rate for Payer: WEA Trust Commercial |
$224.95
|
| Rate for Payer: WPS Commercial |
$302.95
|
|
|
XR Abdomen AP
|
Professional
|
Both
|
$531.00
|
|
|
Service Code
|
CPT 74018 TC
|
| Hospital Charge Code |
1536803
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$504.45 |
| Rate for Payer: Aetna Commercial |
$504.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$456.66
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$504.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$265.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$318.60
|
| Rate for Payer: Health EOS Commercial |
$483.21
|
| Rate for Payer: HFN Commercial |
$504.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$70.00
|
| Rate for Payer: Multiplan Commercial |
$424.80
|
| Rate for Payer: Preferred Network Access Commercial |
$504.45
|
| Rate for Payer: Quartz Beloit One Network |
$233.64
|
| Rate for Payer: Quartz Commercial |
$302.67
|
| Rate for Payer: The Alliance Commercial |
$265.50
|
| Rate for Payer: WEA Trust Commercial |
$292.05
|
| Rate for Payer: WPS Commercial |
$393.31
|
|
|
XR Abdomen AP
|
Facility
|
IP
|
$409.00
|
|
|
Service Code
|
CPT 74000
|
| Hospital Charge Code |
625614
|
| Min. Negotiated Rate |
$200.41 |
| Max. Negotiated Rate |
$376.28 |
| Rate for Payer: Aetna Commercial |
$368.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.77
|
| Rate for Payer: Cash Price |
$122.70
|
| Rate for Payer: Cigna Commercial |
$376.28
|
| Rate for Payer: Health EOS Commercial |
$364.01
|
| Rate for Payer: HFN Commercial |
$376.28
|
| Rate for Payer: Multiplan Commercial |
$327.20
|
| Rate for Payer: NAPHCARE Commercial |
$245.40
|
| Rate for Payer: Preferred Network Access Commercial |
$376.28
|
| Rate for Payer: Quartz Beloit One Network |
$200.41
|
| Rate for Payer: Quartz Commercial |
$245.40
|
| Rate for Payer: WEA Trust Commercial |
$224.95
|
| Rate for Payer: WPS Commercial |
$302.95
|
|
|
XR Abdomen AP
|
Facility
|
OP
|
$409.00
|
|
|
Service Code
|
CPT 74000
|
| Hospital Charge Code |
625614
|
| Min. Negotiated Rate |
$114.52 |
| Max. Negotiated Rate |
$1,636.00 |
| Rate for Payer: Aetna Commercial |
$368.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.74
|
| Rate for Payer: Aetna Managed Medicare |
$114.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$265.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$204.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$196.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.77
|
| Rate for Payer: Cash Price |
$122.70
|
| Rate for Payer: Cigna Commercial |
$376.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$228.88
|
| Rate for Payer: Health EOS Commercial |
$364.01
|
| Rate for Payer: HFN Commercial |
$376.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$306.75
|
| Rate for Payer: Multiplan Commercial |
$327.20
|
| Rate for Payer: NAPHCARE Commercial |
$245.40
|
| Rate for Payer: Preferred Network Access Commercial |
$376.28
|
| Rate for Payer: Quartz Beloit One Network |
$200.41
|
| Rate for Payer: Quartz Commercial |
$265.85
|
| Rate for Payer: Quartz Medicare Advantage |
$245.40
|
| Rate for Payer: The Alliance Commercial |
$1,636.00
|
| Rate for Payer: WEA Trust Commercial |
$224.95
|
| Rate for Payer: WPS Commercial |
$302.95
|
|
|
XR Abdomen AP
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
CPT 74018 TC
|
| Hospital Charge Code |
1536803
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$260.19 |
| Max. Negotiated Rate |
$488.52 |
| Rate for Payer: Aetna Commercial |
$477.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$456.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.43
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$488.52
|
| Rate for Payer: Health EOS Commercial |
$472.59
|
| Rate for Payer: HFN Commercial |
$488.52
|
| Rate for Payer: Multiplan Commercial |
$424.80
|
| Rate for Payer: NAPHCARE Commercial |
$318.60
|
| Rate for Payer: Preferred Network Access Commercial |
$488.52
|
| Rate for Payer: Quartz Beloit One Network |
$260.19
|
| Rate for Payer: Quartz Commercial |
$318.60
|
| Rate for Payer: WEA Trust Commercial |
$292.05
|
| Rate for Payer: WPS Commercial |
$393.31
|
|
|
XR Abdomen AP
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
CPT 74018 TC
|
| Hospital Charge Code |
1536803
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$488.52 |
| Rate for Payer: Aetna Commercial |
$477.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$456.66
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.99
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$488.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$297.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$472.59
|
| Rate for Payer: HFN Commercial |
$488.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$424.80
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$488.52
|
| Rate for Payer: Quartz Beloit One Network |
$260.19
|
| Rate for Payer: Quartz Commercial |
$345.15
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$292.05
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$393.31
|
|
|
XR Abdomen AP Obliques Cone Views
|
Facility
|
IP
|
$510.00
|
|
|
Service Code
|
CPT 74010
|
| Hospital Charge Code |
625616
|
| Min. Negotiated Rate |
$249.90 |
| Max. Negotiated Rate |
$469.20 |
| Rate for Payer: Aetna Commercial |
$459.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$438.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$270.30
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cigna Commercial |
$469.20
|
| Rate for Payer: Health EOS Commercial |
$453.90
|
| Rate for Payer: HFN Commercial |
$469.20
|
| Rate for Payer: Multiplan Commercial |
$408.00
|
| Rate for Payer: NAPHCARE Commercial |
$306.00
|
| Rate for Payer: Preferred Network Access Commercial |
$469.20
|
| Rate for Payer: Quartz Beloit One Network |
$249.90
|
| Rate for Payer: Quartz Commercial |
$306.00
|
| Rate for Payer: WEA Trust Commercial |
$280.50
|
| Rate for Payer: WPS Commercial |
$377.76
|
|
|
XR Abdomen AP Obliques Cone Views
|
Professional
|
Both
|
$510.00
|
|
|
Service Code
|
CPT 74010
|
| Hospital Charge Code |
625616
|
| Min. Negotiated Rate |
$224.40 |
| Max. Negotiated Rate |
$484.50 |
| Rate for Payer: Aetna Commercial |
$484.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$438.60
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cigna Commercial |
$484.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$255.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.00
|
| Rate for Payer: Health EOS Commercial |
$464.10
|
| Rate for Payer: HFN Commercial |
$484.50
|
| Rate for Payer: Multiplan Commercial |
$408.00
|
| Rate for Payer: Preferred Network Access Commercial |
$484.50
|
| Rate for Payer: Quartz Beloit One Network |
$224.40
|
| Rate for Payer: Quartz Commercial |
$290.70
|
| Rate for Payer: The Alliance Commercial |
$255.00
|
| Rate for Payer: WEA Trust Commercial |
$280.50
|
| Rate for Payer: WPS Commercial |
$377.76
|
|
