|
XR Ankle Complete Right
|
Facility
IP
|
$577.00
|
|
|
Service Code
|
CPT 73610 RT,TC
|
| Hospital Charge Code |
1536821
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$282.73 |
| Max. Negotiated Rate |
$530.84 |
| Rate for Payer: Aetna Commercial |
$519.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$305.81
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$530.84
|
| Rate for Payer: Health EOS Commercial |
$513.53
|
| Rate for Payer: HFN Commercial |
$530.84
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: NAPHCARE Commercial |
$346.20
|
| Rate for Payer: Preferred Network Access Commercial |
$530.84
|
| Rate for Payer: Quartz Beloit One Network |
$282.73
|
| Rate for Payer: Quartz Commercial |
$346.20
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
XR Ankle Complete Right
|
Professional
|
$577.00
|
|
|
Service Code
|
CPT 73610 RT,TC
|
| Hospital Charge Code |
1536821
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$253.88 |
| Max. Negotiated Rate |
$548.15 |
| Rate for Payer: Aetna Commercial |
$548.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$496.22
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$548.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$288.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$346.20
|
| Rate for Payer: Health EOS Commercial |
$525.07
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: Preferred Network Access Commercial |
$548.15
|
| Rate for Payer: Quartz Beloit One Network |
$253.88
|
| Rate for Payer: Quartz Commercial |
$328.89
|
| Rate for Payer: The Alliance Commercial |
$288.50
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
XR Ankle Complete Right
|
Professional
|
$535.00
|
|
|
Service Code
|
CPT 73610
|
| Hospital Charge Code |
625726
|
| Min. Negotiated Rate |
$35.59 |
| Max. Negotiated Rate |
$508.25 |
| Rate for Payer: Aetna Commercial |
$508.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.10
|
| Rate for Payer: Aetna Managed Medicare |
$35.59
|
| Rate for Payer: Anthem Medicare Advantage |
$35.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.59
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$508.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$267.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.59
|
| Rate for Payer: Health EOS Commercial |
$486.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.59
|
| Rate for Payer: Multiplan Commercial |
$428.00
|
| Rate for Payer: Preferred Network Access Commercial |
$508.25
|
| Rate for Payer: Quartz Beloit One Network |
$235.40
|
| Rate for Payer: Quartz Commercial |
$304.95
|
| Rate for Payer: Quartz Medicare Advantage |
$35.59
|
| Rate for Payer: The Alliance Commercial |
$135.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.59
|
| Rate for Payer: WEA Trust Commercial |
$294.25
|
| Rate for Payer: WPS Commercial |
$177.95
|
|
|
XR Ankle Therapeutic Injection Lt
|
Facility
OP
|
$2,081.00
|
|
|
Service Code
|
CPT 20605 TC,LT
|
| Hospital Charge Code |
5268610
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$582.68 |
| Max. Negotiated Rate |
$8,324.00 |
| Rate for Payer: Aetna Commercial |
$1,872.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,789.66
|
| Rate for Payer: Aetna Managed Medicare |
$582.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,352.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,040.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$998.88
|
| 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: Dean Health DHI/DHP/ASO |
$1,164.53
|
| Rate for Payer: Health EOS Commercial |
$1,852.09
|
| Rate for Payer: HFN Commercial |
$1,914.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,560.75
|
| 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 |
$1,352.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,248.60
|
| Rate for Payer: The Alliance Commercial |
$8,324.00
|
| Rate for Payer: United Healthcare PPO |
$1,560.75
|
| Rate for Payer: WEA Trust Commercial |
$1,144.55
|
| Rate for Payer: WPS Commercial |
$1,541.40
|
|
|
XR Ankle Therapeutic Injection Lt
|
Professional
|
$2,081.00
|
|
|
Service Code
|
CPT 20605 TC,LT
|
| Hospital Charge Code |
5268610
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$915.64 |
| Max. Negotiated Rate |
$1,976.95 |
| Rate for Payer: Aetna Commercial |
$1,976.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,789.66
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,976.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,040.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,248.60
|
| Rate for Payer: Health EOS Commercial |
$1,893.71
|
| Rate for Payer: Multiplan Commercial |
$1,664.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,976.95
|
| Rate for Payer: Quartz Beloit One Network |
$915.64
|
| Rate for Payer: Quartz Commercial |
$1,186.17
|
| Rate for Payer: The Alliance Commercial |
$1,040.50
|
| Rate for Payer: WEA Trust Commercial |
$1,144.55
|
| Rate for Payer: WPS Commercial |
$1,541.40
|
|
|
XR Ankle Therapeutic Injection Lt
|
Facility
IP
|
$2,081.00
|
|
|
Service Code
|
CPT 20605 TC,LT
|
| Hospital Charge Code |
5268610
|
|
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: 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 Ankle Therapeutic Injection Rt
|
Facility
OP
|
$2,081.00
|
|
|
Service Code
|
CPT 20605 TC,RT
|
| Hospital Charge Code |
5268612
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$582.68 |
| Max. Negotiated Rate |
$8,324.00 |
| Rate for Payer: Aetna Commercial |
$1,872.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,789.66
|
| Rate for Payer: Aetna Managed Medicare |
$582.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,352.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,040.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$998.88
|
| 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: Dean Health DHI/DHP/ASO |
$1,164.53
|
| Rate for Payer: Health EOS Commercial |
$1,852.09
|
| Rate for Payer: HFN Commercial |
$1,914.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,560.75
|
| 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 |
$1,352.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,248.60
|
| Rate for Payer: The Alliance Commercial |
$8,324.00
|
| Rate for Payer: United Healthcare PPO |
$1,560.75
|
| Rate for Payer: WEA Trust Commercial |
$1,144.55
|
| Rate for Payer: WPS Commercial |
$1,541.40
|
|
|
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: 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 Ankle Therapeutic Injection Rt
|
Professional
|
$2,081.00
|
|
|
Service Code
|
CPT 20605 TC,RT
|
| Hospital Charge Code |
5268612
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$915.64 |
| Max. Negotiated Rate |
$1,976.95 |
| Rate for Payer: Aetna Commercial |
$1,976.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,789.66
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,976.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,040.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,248.60
|
| Rate for Payer: Health EOS Commercial |
$1,893.71
|
| Rate for Payer: Multiplan Commercial |
$1,664.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,976.95
|
| Rate for Payer: Quartz Beloit One Network |
$915.64
|
| Rate for Payer: Quartz Commercial |
$1,186.17
|
| Rate for Payer: The Alliance Commercial |
$1,040.50
|
| Rate for Payer: WEA Trust Commercial |
$1,144.55
|
| Rate for Payer: WPS Commercial |
$1,541.40
|
|
|
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: 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: 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
|
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: 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
|
Professional
|
$1,705.00
|
|
|
Service Code
|
CPT 77002 TC,LT
|
| Hospital Charge Code |
3072701
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$750.20 |
| 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: 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: 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: 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 Right
|
Professional
|
$1,705.00
|
|
|
Service Code
|
CPT 73615 TC,RT
|
| Hospital Charge Code |
3072702
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$750.20 |
| 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: 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: 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 |
$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: 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: 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 Hip Left
|
Professional
|
$1,133.00
|
|
|
Service Code
|
CPT 77002 TC,LT
|
| Hospital Charge Code |
3072703
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$498.52 |
| 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: 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: 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 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: 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: 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: 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 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: 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
|
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: 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: 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 Right
|
Professional
|
$1,133.00
|
|
|
Service Code
|
CPT 77002 TC,RT
|
| Hospital Charge Code |
3072704
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$498.52 |
| 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: 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: 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 Knee Left
|
Professional
|
$1,763.00
|
|
|
Service Code
|
CPT 73580 TC,LT
|
| Hospital Charge Code |
3072705
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$775.72 |
| 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: 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: 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 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: 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 |
$7,052.00 |
| Rate for Payer: Aetna Commercial |
$1,586.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Aetna Managed Medicare |
$493.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,145.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$881.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$846.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.39
|
| 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: Health EOS Commercial |
$1,569.07
|
| Rate for Payer: HFN Commercial |
$1,621.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,322.25
|
| 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 |
$1,145.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,057.80
|
| Rate for Payer: The Alliance Commercial |
$7,052.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| 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 |
$7,052.00 |
| Rate for Payer: Aetna Commercial |
$1,586.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Aetna Managed Medicare |
$493.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,145.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$881.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$846.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.39
|
| 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: Health EOS Commercial |
$1,569.07
|
| Rate for Payer: HFN Commercial |
$1,621.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,322.25
|
| 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 |
$1,145.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,057.80
|
| Rate for Payer: The Alliance Commercial |
$7,052.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
