|
X-RAY Knee, 2 Views 7356026
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
CPT 73560 26
|
| Hospital Charge Code |
3236182
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.20 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Aetna Commercial |
$96.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$96.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.20
|
| Rate for Payer: Health EOS Commercial |
$92.82
|
| Rate for Payer: HFN Commercial |
$96.90
|
| 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 |
$81.60
|
| Rate for Payer: Preferred Network Access Commercial |
$96.90
|
| Rate for Payer: Quartz Beloit One Network |
$44.88
|
| Rate for Payer: Quartz Commercial |
$58.14
|
| Rate for Payer: The Alliance Commercial |
$51.00
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
X-RAY Knee 4 or More 73564
|
Professional
|
Both
|
$111.00
|
|
|
Service Code
|
CPT 73564
|
| Hospital Charge Code |
3236192
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.84 |
| Max. Negotiated Rate |
$155.46 |
| Rate for Payer: Aetna Commercial |
$105.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$105.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.60
|
| Rate for Payer: Health EOS Commercial |
$101.01
|
| Rate for Payer: HFN Commercial |
$105.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$155.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$155.46
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$105.45
|
| Rate for Payer: Quartz Beloit One Network |
$48.84
|
| Rate for Payer: Quartz Commercial |
$63.27
|
| Rate for Payer: The Alliance Commercial |
$55.50
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
X-RAY Knee 4 or More 7356426
|
Professional
|
Both
|
$148.00
|
|
|
Service Code
|
CPT 73564 26
|
| Hospital Charge Code |
3236193
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.91 |
| Max. Negotiated Rate |
$140.60 |
| Rate for Payer: Aetna Commercial |
$140.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.28
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$140.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.80
|
| Rate for Payer: Health EOS Commercial |
$134.68
|
| Rate for Payer: HFN Commercial |
$140.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$37.91
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: Preferred Network Access Commercial |
$140.60
|
| Rate for Payer: Quartz Beloit One Network |
$65.12
|
| Rate for Payer: Quartz Commercial |
$84.36
|
| Rate for Payer: The Alliance Commercial |
$74.00
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
X-RAY Knees Standing 73565
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
CPT 73565
|
| Hospital Charge Code |
3209604
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$137.63 |
| Rate for Payer: Aetna Commercial |
$33.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.10
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$33.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.00
|
| Rate for Payer: Health EOS Commercial |
$31.85
|
| Rate for Payer: HFN Commercial |
$33.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$137.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.63
|
| Rate for Payer: Multiplan Commercial |
$28.00
|
| Rate for Payer: Preferred Network Access Commercial |
$33.25
|
| Rate for Payer: Quartz Beloit One Network |
$15.40
|
| Rate for Payer: Quartz Commercial |
$19.95
|
| Rate for Payer: The Alliance Commercial |
$17.50
|
| Rate for Payer: WEA Trust Commercial |
$19.25
|
| Rate for Payer: WPS Commercial |
$25.92
|
|
|
X-RAY Knees Standing 7356526
|
Professional
|
Both
|
$61.00
|
|
|
Service Code
|
CPT 73565 26
|
| Hospital Charge Code |
3209609
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.84 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$57.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.60
|
| Rate for Payer: Health EOS Commercial |
$55.51
|
| Rate for Payer: HFN Commercial |
$57.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.37
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.95
|
| Rate for Payer: Quartz Beloit One Network |
$26.84
|
| Rate for Payer: Quartz Commercial |
$34.77
|
| Rate for Payer: The Alliance Commercial |
$30.50
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
X-RAY Lumbar 2-3 Views 7210026
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
CPT 72100 26
|
| Hospital Charge Code |
3236237
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.91 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.48
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.80
|
| Rate for Payer: Health EOS Commercial |
$107.38
|
| Rate for Payer: HFN Commercial |
$112.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$37.91
|
| Rate for Payer: Multiplan Commercial |
$94.40
|
| Rate for Payer: Preferred Network Access Commercial |
$112.10
|
| Rate for Payer: Quartz Beloit One Network |
$51.92
|
| Rate for Payer: Quartz Commercial |
$67.26
|
| Rate for Payer: The Alliance Commercial |
$59.00
|
| Rate for Payer: WEA Trust Commercial |
$64.90
|
| Rate for Payer: WPS Commercial |
$87.40
|
|
|
X-RAY Lumbar 4 Views 72110
|
Professional
|
Both
|
$108.00
|
|
|
Service Code
|
CPT 72110
|
| Hospital Charge Code |
3236247
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.52 |
| Max. Negotiated Rate |
$171.98 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$102.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.80
|
| Rate for Payer: Health EOS Commercial |
$98.28
|
| Rate for Payer: HFN Commercial |
$102.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$171.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$171.98
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: Preferred Network Access Commercial |
$102.60
|
| Rate for Payer: Quartz Beloit One Network |
$47.52
|
| Rate for Payer: Quartz Commercial |
$61.56
|
| Rate for Payer: The Alliance Commercial |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
X-RAY Lumbar 4 Views 7211026
|
Professional
|
Both
|
$112.00
|
|
|
Service Code
|
CPT 72110 26
|
| Hospital Charge Code |
3236248
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.98 |
| Max. Negotiated Rate |
$106.40 |
| Rate for Payer: Aetna Commercial |
$106.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.32
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$106.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.20
|
| Rate for Payer: Health EOS Commercial |
$101.92
|
| Rate for Payer: HFN Commercial |
$106.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.98
|
| Rate for Payer: Multiplan Commercial |
$89.60
|
| Rate for Payer: Preferred Network Access Commercial |
$106.40
|
| Rate for Payer: Quartz Beloit One Network |
$49.28
|
| Rate for Payer: Quartz Commercial |
$63.84
|
| Rate for Payer: The Alliance Commercial |
$56.00
|
| Rate for Payer: WEA Trust Commercial |
$61.60
|
| Rate for Payer: WPS Commercial |
$82.96
|
|
|
X-Ray of Scapula 7301026
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
CPT 73010 26
|
| Hospital Charge Code |
3453522
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.57 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Aetna Commercial |
$104.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.60
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$104.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.00
|
| Rate for Payer: Health EOS Commercial |
$100.10
|
| Rate for Payer: HFN Commercial |
$104.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.57
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: Preferred Network Access Commercial |
$104.50
|
| Rate for Payer: Quartz Beloit One Network |
$48.40
|
| Rate for Payer: Quartz Commercial |
$62.70
|
| Rate for Payer: The Alliance Commercial |
$55.00
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
X-RAY of Tib/Fib 73590
|
Professional
|
Both
|
$69.00
|
|
|
Service Code
|
CPT 73590
|
| Hospital Charge Code |
3238224
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.36 |
| Max. Negotiated Rate |
$106.29 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.40
|
| Rate for Payer: Health EOS Commercial |
$62.79
|
| Rate for Payer: HFN Commercial |
$65.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$106.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$106.29
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$65.55
|
| Rate for Payer: Quartz Beloit One Network |
$30.36
|
| Rate for Payer: Quartz Commercial |
$39.33
|
| Rate for Payer: The Alliance Commercial |
$34.50
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
X-RAY of Tib/Fib 7359026
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
CPT 73590 26
|
| Hospital Charge Code |
3238225
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$27.04 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$95.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.00
|
| Rate for Payer: Health EOS Commercial |
$91.00
|
| Rate for Payer: HFN Commercial |
$95.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.04
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: Preferred Network Access Commercial |
$95.00
|
| Rate for Payer: Quartz Beloit One Network |
$44.00
|
| Rate for Payer: Quartz Commercial |
$57.00
|
| Rate for Payer: The Alliance Commercial |
$50.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
X-RAY of Wrist 2 Views 73100
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
CPT 73100
|
| Hospital Charge Code |
3238246
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$114.41 |
| Rate for Payer: Aetna Commercial |
$47.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$47.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.00
|
| Rate for Payer: Health EOS Commercial |
$45.50
|
| Rate for Payer: HFN Commercial |
$47.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$114.41
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: Preferred Network Access Commercial |
$47.50
|
| Rate for Payer: Quartz Beloit One Network |
$22.00
|
| Rate for Payer: Quartz Commercial |
$28.50
|
| Rate for Payer: The Alliance Commercial |
$25.00
|
| Rate for Payer: WEA Trust Commercial |
$27.50
|
| Rate for Payer: WPS Commercial |
$37.04
|
|
|
X-RAY of Wrist 2 Views 7310026
|
Professional
|
Both
|
$104.00
|
|
|
Service Code
|
CPT 73100 26
|
| Hospital Charge Code |
3238247
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.20 |
| Max. Negotiated Rate |
$98.80 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.40
|
| Rate for Payer: Health EOS Commercial |
$94.64
|
| Rate for Payer: HFN Commercial |
$98.80
|
| 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 |
$83.20
|
| Rate for Payer: Preferred Network Access Commercial |
$98.80
|
| Rate for Payer: Quartz Beloit One Network |
$45.76
|
| Rate for Payer: Quartz Commercial |
$59.28
|
| Rate for Payer: The Alliance Commercial |
$52.00
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
X-RAY Pelvis 1 or 2 Views 72170
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
3209615
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.52 |
| Max. Negotiated Rate |
$93.62 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Health EOS Commercial |
$75.53
|
| Rate for Payer: HFN Commercial |
$78.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$93.62
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: Preferred Network Access Commercial |
$78.85
|
| Rate for Payer: Quartz Beloit One Network |
$36.52
|
| Rate for Payer: Quartz Commercial |
$47.31
|
| Rate for Payer: The Alliance Commercial |
$41.50
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
X-RAY Pelvis 1 or 2 Views 7217026
|
Professional
|
Both
|
$162.00
|
|
|
Service Code
|
CPT 72170 26
|
| Hospital Charge Code |
3209620
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.44 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$153.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.20
|
| Rate for Payer: Health EOS Commercial |
$147.42
|
| Rate for Payer: HFN Commercial |
$153.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.44
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: Preferred Network Access Commercial |
$153.90
|
| Rate for Payer: Quartz Beloit One Network |
$71.28
|
| Rate for Payer: Quartz Commercial |
$92.34
|
| Rate for Payer: The Alliance Commercial |
$81.00
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
X-RAY Pelvis Complete Minimum 3 Views 72190
|
Professional
|
Both
|
$269.00
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
4568644
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$118.36 |
| Max. Negotiated Rate |
$255.55 |
| Rate for Payer: Aetna Commercial |
$255.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$231.34
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$255.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$134.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.40
|
| Rate for Payer: Health EOS Commercial |
$244.79
|
| Rate for Payer: HFN Commercial |
$255.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$141.76
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: Preferred Network Access Commercial |
$255.55
|
| Rate for Payer: Quartz Beloit One Network |
$118.36
|
| Rate for Payer: Quartz Commercial |
$153.33
|
| Rate for Payer: The Alliance Commercial |
$134.50
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
X-RAY Pelvis Complete Minimum 3 Views 7219026
|
Professional
|
Both
|
$269.00
|
|
|
Service Code
|
CPT 72190 26
|
| Hospital Charge Code |
4616760
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.75 |
| Max. Negotiated Rate |
$255.55 |
| Rate for Payer: Aetna Commercial |
$255.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$231.34
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$255.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$134.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.40
|
| Rate for Payer: Health EOS Commercial |
$244.79
|
| Rate for Payer: HFN Commercial |
$255.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.75
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: Preferred Network Access Commercial |
$255.55
|
| Rate for Payer: Quartz Beloit One Network |
$118.36
|
| Rate for Payer: Quartz Commercial |
$153.33
|
| Rate for Payer: The Alliance Commercial |
$134.50
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
X-RAY Sacrum & Coccyx 2 View 72220
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
CPT 72220
|
| Hospital Charge Code |
3209626
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.96 |
| Max. Negotiated Rate |
$108.69 |
| 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 |
$108.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.69
|
| 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 Sacrum & Coccyx 2 View 7222026
|
Professional
|
Both
|
$159.00
|
|
|
Service Code
|
CPT 72220 26
|
| Hospital Charge Code |
3209631
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.44 |
| Max. Negotiated Rate |
$151.05 |
| Rate for Payer: Aetna Commercial |
$151.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$151.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$79.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.40
|
| Rate for Payer: Health EOS Commercial |
$144.69
|
| Rate for Payer: HFN Commercial |
$151.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.44
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: Preferred Network Access Commercial |
$151.05
|
| Rate for Payer: Quartz Beloit One Network |
$69.96
|
| Rate for Payer: Quartz Commercial |
$90.63
|
| Rate for Payer: The Alliance Commercial |
$79.50
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
X-RAY Shoulder 1 View 7302026
|
Professional
|
Both
|
$59.00
|
|
|
Service Code
|
CPT 73020 26
|
| Hospital Charge Code |
3209642
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.80 |
| Max. Negotiated Rate |
$56.05 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$53.69
|
| Rate for Payer: HFN Commercial |
$56.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.80
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: Preferred Network Access Commercial |
$56.05
|
| Rate for Payer: Quartz Beloit One Network |
$25.96
|
| Rate for Payer: Quartz Commercial |
$33.63
|
| Rate for Payer: The Alliance Commercial |
$29.50
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
X-Ray Spine Scoliosis Study Standing 72081
|
Professional
|
Both
|
$470.00
|
|
|
Service Code
|
CPT 72081
|
| Hospital Charge Code |
5294616
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$142.97 |
| Max. Negotiated Rate |
$446.50 |
| Rate for Payer: Aetna Commercial |
$446.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.20
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$446.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$235.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$282.00
|
| Rate for Payer: Health EOS Commercial |
$427.70
|
| Rate for Payer: HFN Commercial |
$446.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$142.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$142.97
|
| Rate for Payer: Multiplan Commercial |
$376.00
|
| Rate for Payer: Preferred Network Access Commercial |
$446.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.80
|
| Rate for Payer: Quartz Commercial |
$267.90
|
| Rate for Payer: The Alliance Commercial |
$235.00
|
| Rate for Payer: WEA Trust Commercial |
$258.50
|
| Rate for Payer: WPS Commercial |
$348.13
|
|
|
X-Ray Spine Scoliosis Study Standing 7208126
|
Professional
|
Both
|
$123.00
|
|
|
Service Code
|
CPT 72081 26
|
| Hospital Charge Code |
5294617
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.98 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Aetna Commercial |
$116.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$116.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$73.80
|
| Rate for Payer: Health EOS Commercial |
$111.93
|
| Rate for Payer: HFN Commercial |
$116.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.98
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$116.85
|
| Rate for Payer: Quartz Beloit One Network |
$54.12
|
| Rate for Payer: Quartz Commercial |
$70.11
|
| Rate for Payer: The Alliance Commercial |
$61.50
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
XRAY Sternoclavicular Joint(s) 71130
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
CPT 71130
|
| Hospital Charge Code |
4616757
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.52 |
| Max. Negotiated Rate |
$140.39 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Health EOS Commercial |
$75.53
|
| Rate for Payer: HFN Commercial |
$78.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$140.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.39
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: Preferred Network Access Commercial |
$78.85
|
| Rate for Payer: Quartz Beloit One Network |
$36.52
|
| Rate for Payer: Quartz Commercial |
$47.31
|
| Rate for Payer: The Alliance Commercial |
$41.50
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
XRAY sternoclavicular Joint(s) 7113026
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
CPT 71130 26
|
| Hospital Charge Code |
4616758
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.52 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Health EOS Commercial |
$75.53
|
| Rate for Payer: HFN Commercial |
$78.85
|
| 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 |
$66.40
|
| Rate for Payer: Preferred Network Access Commercial |
$78.85
|
| Rate for Payer: Quartz Beloit One Network |
$36.52
|
| Rate for Payer: Quartz Commercial |
$47.31
|
| Rate for Payer: The Alliance Commercial |
$41.50
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
X-RAYS, TRANSCATH THERAPY 7589426
|
Professional
|
Both
|
$796.00
|
|
|
Service Code
|
CPT 75894 26
|
| Hospital Charge Code |
3015295
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$229.70 |
| Max. Negotiated Rate |
$756.20 |
| Rate for Payer: Aetna Commercial |
$756.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$684.56
|
| Rate for Payer: Cash Price |
$238.80
|
| Rate for Payer: Cash Price |
$238.80
|
| Rate for Payer: Cash Price |
$238.80
|
| Rate for Payer: Cigna Commercial |
$756.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$398.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$477.60
|
| Rate for Payer: Health EOS Commercial |
$724.36
|
| Rate for Payer: HFN Commercial |
$756.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$229.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$229.70
|
| Rate for Payer: Multiplan Commercial |
$636.80
|
| Rate for Payer: Preferred Network Access Commercial |
$756.20
|
| Rate for Payer: Quartz Beloit One Network |
$350.24
|
| Rate for Payer: Quartz Commercial |
$453.72
|
| Rate for Payer: The Alliance Commercial |
$398.00
|
| Rate for Payer: WEA Trust Commercial |
$437.80
|
| Rate for Payer: WPS Commercial |
$589.60
|
|
