|
XR Ankle Therapeutic Injection Rt
|
Facility
|
IP
|
$2,081.00
|
|
|
Service Code
|
CPT 20605 TC,RT
|
| Hospital Charge Code |
5268612
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$1,019.69 |
| Max. Negotiated Rate |
$1,914.52 |
| Rate for Payer: Aetna Commercial |
$1,872.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,789.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,102.93
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,914.52
|
| Rate for Payer: Health EOS Commercial |
$1,852.09
|
| Rate for Payer: HFN Commercial |
$1,914.52
|
| Rate for Payer: Multiplan Commercial |
$1,664.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,248.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,914.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,019.69
|
| Rate for Payer: Quartz Commercial |
$1,248.60
|
| Rate for Payer: WEA Trust Commercial |
$1,144.55
|
| Rate for Payer: WPS Commercial |
$1,541.40
|
|
|
XR Arthrogram Ankle Left
|
Facility
|
IP
|
$1,705.00
|
|
|
Service Code
|
CPT 77002 TC,LT
|
| Hospital Charge Code |
3072701
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$835.45 |
| Max. Negotiated Rate |
$1,568.60 |
| Rate for Payer: Aetna Commercial |
$1,534.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.65
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,568.60
|
| Rate for Payer: Health EOS Commercial |
$1,517.45
|
| Rate for Payer: HFN Commercial |
$1,568.60
|
| Rate for Payer: Multiplan Commercial |
$1,364.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,568.60
|
| Rate for Payer: Quartz Beloit One Network |
$835.45
|
| Rate for Payer: Quartz Commercial |
$1,023.00
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
XR Arthrogram Ankle Left
|
Facility
|
OP
|
$1,705.00
|
|
|
Service Code
|
CPT 77002 TC,LT
|
| Hospital Charge Code |
3072701
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$6,820.00 |
| Rate for Payer: Aetna Commercial |
$1,534.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.30
|
| Rate for Payer: Aetna Managed Medicare |
$477.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,108.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$852.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$818.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.65
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,568.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$954.12
|
| Rate for Payer: Health EOS Commercial |
$1,517.45
|
| Rate for Payer: HFN Commercial |
$1,568.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,278.75
|
| Rate for Payer: Multiplan Commercial |
$1,364.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,568.60
|
| Rate for Payer: Quartz Beloit One Network |
$835.45
|
| Rate for Payer: Quartz Commercial |
$1,108.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,023.00
|
| Rate for Payer: The Alliance Commercial |
$6,820.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
XR Arthrogram Ankle Left
|
Professional
|
Both
|
$1,705.00
|
|
|
Service Code
|
CPT 77002 TC,LT
|
| Hospital Charge Code |
3072701
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$395.54 |
| Max. Negotiated Rate |
$1,619.75 |
| Rate for Payer: Aetna Commercial |
$1,619.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.30
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,619.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$852.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,023.00
|
| Rate for Payer: Health EOS Commercial |
$1,551.55
|
| Rate for Payer: HFN Commercial |
$1,619.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$395.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$395.54
|
| Rate for Payer: Multiplan Commercial |
$1,364.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,619.75
|
| Rate for Payer: Quartz Beloit One Network |
$750.20
|
| Rate for Payer: Quartz Commercial |
$971.85
|
| Rate for Payer: The Alliance Commercial |
$852.50
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
XR Arthrogram Ankle Right
|
Facility
|
OP
|
$1,705.00
|
|
|
Service Code
|
CPT 73615 TC,RT
|
| Hospital Charge Code |
3072702
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$1,568.60 |
| Rate for Payer: Aetna Commercial |
$1,534.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.30
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,425.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,140.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,083.34
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.65
|
| 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 |
$511.50
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,568.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$954.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$1,517.45
|
| Rate for Payer: HFN Commercial |
$1,568.60
|
| 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 |
$1,364.00
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,568.60
|
| Rate for Payer: Quartz Beloit One Network |
$835.45
|
| Rate for Payer: Quartz Commercial |
$1,108.25
|
| 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 |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
XR Arthrogram Ankle Right
|
Professional
|
Both
|
$1,705.00
|
|
|
Service Code
|
CPT 73615 TC,RT
|
| Hospital Charge Code |
3072702
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$465.50 |
| Max. Negotiated Rate |
$1,619.75 |
| Rate for Payer: Aetna Commercial |
$1,619.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.30
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,619.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$852.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,023.00
|
| Rate for Payer: Health EOS Commercial |
$1,551.55
|
| Rate for Payer: HFN Commercial |
$1,619.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$465.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$465.50
|
| Rate for Payer: Multiplan Commercial |
$1,364.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,619.75
|
| Rate for Payer: Quartz Beloit One Network |
$750.20
|
| Rate for Payer: Quartz Commercial |
$971.85
|
| Rate for Payer: The Alliance Commercial |
$852.50
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
XR Arthrogram Ankle Right
|
Facility
|
IP
|
$1,705.00
|
|
|
Service Code
|
CPT 73615 TC,RT
|
| Hospital Charge Code |
3072702
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$835.45 |
| Max. Negotiated Rate |
$1,568.60 |
| Rate for Payer: Aetna Commercial |
$1,534.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.65
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,568.60
|
| Rate for Payer: Health EOS Commercial |
$1,517.45
|
| Rate for Payer: HFN Commercial |
$1,568.60
|
| Rate for Payer: Multiplan Commercial |
$1,364.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,568.60
|
| Rate for Payer: Quartz Beloit One Network |
$835.45
|
| Rate for Payer: Quartz Commercial |
$1,023.00
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
XR Arthrogram Hip Left
|
Facility
|
IP
|
$1,133.00
|
|
|
Service Code
|
CPT 77002 TC,LT
|
| Hospital Charge Code |
3072703
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$555.17 |
| Max. Negotiated Rate |
$1,042.36 |
| Rate for Payer: Aetna Commercial |
$1,019.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$600.49
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,042.36
|
| Rate for Payer: Health EOS Commercial |
$1,008.37
|
| Rate for Payer: HFN Commercial |
$1,042.36
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: NAPHCARE Commercial |
$679.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,042.36
|
| Rate for Payer: Quartz Beloit One Network |
$555.17
|
| Rate for Payer: Quartz Commercial |
$679.80
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
XR Arthrogram Hip Left
|
Facility
|
OP
|
$1,133.00
|
|
|
Service Code
|
CPT 77002 TC,LT
|
| Hospital Charge Code |
3072703
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$4,532.00 |
| Rate for Payer: Aetna Commercial |
$1,019.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Aetna Managed Medicare |
$317.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$736.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$543.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$600.49
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,042.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$634.03
|
| Rate for Payer: Health EOS Commercial |
$1,008.37
|
| Rate for Payer: HFN Commercial |
$1,042.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$849.75
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: NAPHCARE Commercial |
$679.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,042.36
|
| Rate for Payer: Quartz Beloit One Network |
$555.17
|
| Rate for Payer: Quartz Commercial |
$736.45
|
| Rate for Payer: Quartz Medicare Advantage |
$679.80
|
| Rate for Payer: The Alliance Commercial |
$4,532.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
XR Arthrogram Hip Left
|
Professional
|
Both
|
$1,133.00
|
|
|
Service Code
|
CPT 77002 TC,LT
|
| Hospital Charge Code |
3072703
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$395.54 |
| Max. Negotiated Rate |
$1,076.35 |
| Rate for Payer: Aetna Commercial |
$1,076.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,076.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$566.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$679.80
|
| Rate for Payer: Health EOS Commercial |
$1,031.03
|
| Rate for Payer: HFN Commercial |
$1,076.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$395.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$395.54
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,076.35
|
| Rate for Payer: Quartz Beloit One Network |
$498.52
|
| Rate for Payer: Quartz Commercial |
$645.81
|
| Rate for Payer: The Alliance Commercial |
$566.50
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
XR Arthrogram Hip Right
|
Facility
|
IP
|
$1,133.00
|
|
|
Service Code
|
CPT 77002 TC,RT
|
| Hospital Charge Code |
3072704
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$555.17 |
| Max. Negotiated Rate |
$1,042.36 |
| Rate for Payer: Aetna Commercial |
$1,019.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$600.49
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,042.36
|
| Rate for Payer: Health EOS Commercial |
$1,008.37
|
| Rate for Payer: HFN Commercial |
$1,042.36
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: NAPHCARE Commercial |
$679.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,042.36
|
| Rate for Payer: Quartz Beloit One Network |
$555.17
|
| Rate for Payer: Quartz Commercial |
$679.80
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
XR Arthrogram Hip Right
|
Professional
|
Both
|
$1,133.00
|
|
|
Service Code
|
CPT 77002 TC,RT
|
| Hospital Charge Code |
3072704
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$395.54 |
| Max. Negotiated Rate |
$1,076.35 |
| Rate for Payer: Aetna Commercial |
$1,076.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,076.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$566.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$679.80
|
| Rate for Payer: Health EOS Commercial |
$1,031.03
|
| Rate for Payer: HFN Commercial |
$1,076.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$395.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$395.54
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,076.35
|
| Rate for Payer: Quartz Beloit One Network |
$498.52
|
| Rate for Payer: Quartz Commercial |
$645.81
|
| Rate for Payer: The Alliance Commercial |
$566.50
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
XR Arthrogram Hip Right
|
Facility
|
OP
|
$1,133.00
|
|
|
Service Code
|
CPT 77002 TC,RT
|
| Hospital Charge Code |
3072704
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$4,532.00 |
| Rate for Payer: Aetna Commercial |
$1,019.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Aetna Managed Medicare |
$317.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$736.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$543.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$600.49
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,042.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$634.03
|
| Rate for Payer: Health EOS Commercial |
$1,008.37
|
| Rate for Payer: HFN Commercial |
$1,042.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$849.75
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: NAPHCARE Commercial |
$679.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,042.36
|
| Rate for Payer: Quartz Beloit One Network |
$555.17
|
| Rate for Payer: Quartz Commercial |
$736.45
|
| Rate for Payer: Quartz Medicare Advantage |
$679.80
|
| Rate for Payer: The Alliance Commercial |
$4,532.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
XR Arthrogram Knee Left
|
Facility
|
IP
|
$1,763.00
|
|
|
Service Code
|
CPT 73580 TC,LT
|
| Hospital Charge Code |
3072705
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$863.87 |
| Max. Negotiated Rate |
$1,621.96 |
| Rate for Payer: Aetna Commercial |
$1,586.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.39
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,621.96
|
| Rate for Payer: Health EOS Commercial |
$1,569.07
|
| Rate for Payer: HFN Commercial |
$1,621.96
|
| Rate for Payer: Multiplan Commercial |
$1,410.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,057.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,621.96
|
| Rate for Payer: Quartz Beloit One Network |
$863.87
|
| Rate for Payer: Quartz Commercial |
$1,057.80
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
XR Arthrogram Knee Left
|
Facility
|
OP
|
$1,763.00
|
|
|
Service Code
|
CPT 73580 TC,LT
|
| Hospital Charge Code |
3072705
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$1,621.96 |
| Rate for Payer: Aetna Commercial |
$1,586.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,425.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,140.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,083.34
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.39
|
| 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 |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,621.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$986.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$1,569.07
|
| Rate for Payer: HFN Commercial |
$1,621.96
|
| 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 |
$1,410.40
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,621.96
|
| Rate for Payer: Quartz Beloit One Network |
$863.87
|
| Rate for Payer: Quartz Commercial |
$1,145.95
|
| 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 |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
XR Arthrogram Knee Left
|
Professional
|
Both
|
$1,763.00
|
|
|
Service Code
|
CPT 73580 TC,LT
|
| Hospital Charge Code |
3072705
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$495.68 |
| Max. Negotiated Rate |
$1,674.85 |
| Rate for Payer: Aetna Commercial |
$1,674.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,674.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$881.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,057.80
|
| Rate for Payer: Health EOS Commercial |
$1,604.33
|
| Rate for Payer: HFN Commercial |
$1,674.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$495.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$495.68
|
| Rate for Payer: Multiplan Commercial |
$1,410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,674.85
|
| Rate for Payer: Quartz Beloit One Network |
$775.72
|
| Rate for Payer: Quartz Commercial |
$1,004.91
|
| Rate for Payer: The Alliance Commercial |
$881.50
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
XR Arthrogram Knee Right
|
Facility
|
IP
|
$1,763.00
|
|
|
Service Code
|
CPT 73580 TC,RT
|
| Hospital Charge Code |
3072706
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$863.87 |
| Max. Negotiated Rate |
$1,621.96 |
| Rate for Payer: Aetna Commercial |
$1,586.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.39
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,621.96
|
| Rate for Payer: Health EOS Commercial |
$1,569.07
|
| Rate for Payer: HFN Commercial |
$1,621.96
|
| Rate for Payer: Multiplan Commercial |
$1,410.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,057.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,621.96
|
| Rate for Payer: Quartz Beloit One Network |
$863.87
|
| Rate for Payer: Quartz Commercial |
$1,057.80
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
XR Arthrogram Knee Right
|
Professional
|
Both
|
$1,763.00
|
|
|
Service Code
|
CPT 73580 TC,RT
|
| Hospital Charge Code |
3072706
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$495.68 |
| Max. Negotiated Rate |
$1,674.85 |
| Rate for Payer: Aetna Commercial |
$1,674.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,674.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$881.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,057.80
|
| Rate for Payer: Health EOS Commercial |
$1,604.33
|
| Rate for Payer: HFN Commercial |
$1,674.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$495.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$495.68
|
| Rate for Payer: Multiplan Commercial |
$1,410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,674.85
|
| Rate for Payer: Quartz Beloit One Network |
$775.72
|
| Rate for Payer: Quartz Commercial |
$1,004.91
|
| Rate for Payer: The Alliance Commercial |
$881.50
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
XR Arthrogram Knee Right
|
Facility
|
OP
|
$1,763.00
|
|
|
Service Code
|
CPT 73580 TC,RT
|
| Hospital Charge Code |
3072706
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$1,621.96 |
| Rate for Payer: Aetna Commercial |
$1,586.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,425.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,140.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,083.34
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.39
|
| 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 |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,621.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$986.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$1,569.07
|
| Rate for Payer: HFN Commercial |
$1,621.96
|
| 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 |
$1,410.40
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,621.96
|
| Rate for Payer: Quartz Beloit One Network |
$863.87
|
| Rate for Payer: Quartz Commercial |
$1,145.95
|
| 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 |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
X-ray Ankle 2 Views 73600
|
Professional
|
Both
|
$51.00
|
|
|
Service Code
|
CPT 73600
|
| Hospital Charge Code |
3206235
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$109.78 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.60
|
| Rate for Payer: Health EOS Commercial |
$46.41
|
| Rate for Payer: HFN Commercial |
$48.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$109.78
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.45
|
| Rate for Payer: Quartz Beloit One Network |
$22.44
|
| Rate for Payer: Quartz Commercial |
$29.07
|
| Rate for Payer: The Alliance Commercial |
$25.50
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
X-ray Ankle 2 Views 7360026
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
CPT 73600 26
|
| Hospital Charge Code |
3206241
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.20 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Aetna Commercial |
$79.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$79.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.40
|
| Rate for Payer: Health EOS Commercial |
$76.44
|
| Rate for Payer: HFN Commercial |
$79.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.20
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Preferred Network Access Commercial |
$79.80
|
| Rate for Payer: Quartz Beloit One Network |
$36.96
|
| Rate for Payer: Quartz Commercial |
$47.88
|
| Rate for Payer: The Alliance Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
X-Ray Aorta, Leg Arteries 7563026
|
Professional
|
Both
|
$880.00
|
|
|
Service Code
|
CPT 75630 26
|
| Hospital Charge Code |
3549522
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$320.14 |
| Max. Negotiated Rate |
$836.00 |
| Rate for Payer: Aetna Commercial |
$836.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$756.80
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cigna Commercial |
$836.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$440.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$528.00
|
| Rate for Payer: Health EOS Commercial |
$800.80
|
| Rate for Payer: HFN Commercial |
$836.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$320.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$320.14
|
| Rate for Payer: Multiplan Commercial |
$704.00
|
| Rate for Payer: Preferred Network Access Commercial |
$836.00
|
| Rate for Payer: Quartz Beloit One Network |
$387.20
|
| Rate for Payer: Quartz Commercial |
$501.60
|
| Rate for Payer: The Alliance Commercial |
$440.00
|
| Rate for Payer: WEA Trust Commercial |
$484.00
|
| Rate for Payer: WPS Commercial |
$651.82
|
|
|
XRAY Chest 2 Views 71046
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 71046
|
| Hospital Charge Code |
5340631
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.00
|
| Rate for Payer: Health EOS Commercial |
$109.20
|
| Rate for Payer: HFN Commercial |
$114.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$113.70
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$114.00
|
| Rate for Payer: Quartz Beloit One Network |
$52.80
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
XRAY Chest 2 Views 7104626
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 71046 26
|
| Hospital Charge Code |
5340632
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.00
|
| Rate for Payer: Health EOS Commercial |
$109.20
|
| Rate for Payer: HFN Commercial |
$114.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$36.75
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$114.00
|
| Rate for Payer: Quartz Beloit One Network |
$52.80
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
X-RAY C-Spine 2-3 Views 72040
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
CPT 72040
|
| Hospital Charge Code |
3236203
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$90.20 |
| Max. Negotiated Rate |
$194.75 |
| Rate for Payer: Aetna Commercial |
$194.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$194.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$102.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.00
|
| Rate for Payer: Health EOS Commercial |
$186.55
|
| Rate for Payer: HFN Commercial |
$194.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$133.40
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: Preferred Network Access Commercial |
$194.75
|
| Rate for Payer: Quartz Beloit One Network |
$90.20
|
| Rate for Payer: Quartz Commercial |
$116.85
|
| Rate for Payer: The Alliance Commercial |
$102.50
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
