|
XR Bone Survey Infant
|
Facility
IP
|
$696.00
|
|
|
Service Code
|
CPT 77076 TC
|
| Hospital Charge Code |
1536897
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$341.04 |
| Max. Negotiated Rate |
$640.32 |
| Rate for Payer: Aetna Commercial |
$626.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$368.88
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cigna Commercial |
$640.32
|
| Rate for Payer: Health EOS Commercial |
$619.44
|
| Rate for Payer: HFN Commercial |
$640.32
|
| Rate for Payer: Multiplan Commercial |
$556.80
|
| Rate for Payer: NAPHCARE Commercial |
$417.60
|
| Rate for Payer: Preferred Network Access Commercial |
$640.32
|
| Rate for Payer: Quartz Beloit One Network |
$341.04
|
| Rate for Payer: Quartz Commercial |
$417.60
|
| Rate for Payer: WEA Trust Commercial |
$382.80
|
| Rate for Payer: WPS Commercial |
$515.53
|
|
|
XR Bone Survey Infant
|
Facility
OP
|
$696.00
|
|
|
Service Code
|
CPT 77076 TC
|
| Hospital Charge Code |
1536897
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$194.88 |
| Max. Negotiated Rate |
$2,784.00 |
| Rate for Payer: Aetna Commercial |
$626.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$598.56
|
| Rate for Payer: Aetna Managed Medicare |
$194.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$452.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$348.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$334.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$368.88
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cigna Commercial |
$640.32
|
| Rate for Payer: Health EOS Commercial |
$619.44
|
| Rate for Payer: HFN Commercial |
$640.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$522.00
|
| Rate for Payer: Multiplan Commercial |
$556.80
|
| Rate for Payer: NAPHCARE Commercial |
$417.60
|
| Rate for Payer: Preferred Network Access Commercial |
$640.32
|
| Rate for Payer: Quartz Beloit One Network |
$341.04
|
| Rate for Payer: Quartz Commercial |
$452.40
|
| Rate for Payer: Quartz Medicare Advantage |
$417.60
|
| Rate for Payer: The Alliance Commercial |
$2,784.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$382.80
|
| Rate for Payer: WPS Commercial |
$515.53
|
|
|
XR Bone Survey Infant
|
Facility
OP
|
$669.00
|
|
|
Service Code
|
CPT 77076
|
| Hospital Charge Code |
627660
|
| Min. Negotiated Rate |
$15.80 |
| Max. Negotiated Rate |
$615.48 |
| Rate for Payer: Aetna Commercial |
$602.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.34
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$434.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$334.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$321.12
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$615.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$595.41
|
| Rate for Payer: HFN Commercial |
$615.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$615.48
|
| Rate for Payer: Quartz Beloit One Network |
$327.81
|
| Rate for Payer: Quartz Commercial |
$434.85
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$15.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
|
XR Bone Survey Limited (Mets)
|
Facility
IP
|
$1,070.00
|
|
|
Service Code
|
CPT 77074
|
| Hospital Charge Code |
627662
|
| Min. Negotiated Rate |
$524.30 |
| Max. Negotiated Rate |
$984.40 |
| Rate for Payer: Aetna Commercial |
$963.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$567.10
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$984.40
|
| Rate for Payer: Health EOS Commercial |
$952.30
|
| Rate for Payer: HFN Commercial |
$984.40
|
| Rate for Payer: Multiplan Commercial |
$856.00
|
| Rate for Payer: NAPHCARE Commercial |
$642.00
|
| Rate for Payer: Preferred Network Access Commercial |
$984.40
|
| Rate for Payer: Quartz Beloit One Network |
$524.30
|
| Rate for Payer: Quartz Commercial |
$642.00
|
| Rate for Payer: WEA Trust Commercial |
$588.50
|
| Rate for Payer: WPS Commercial |
$792.55
|
|
|
XR Bone Survey Limited (Mets)
|
Facility
IP
|
$1,155.00
|
|
|
Service Code
|
CPT 77074 TC
|
| Hospital Charge Code |
1536899
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$565.95 |
| Max. Negotiated Rate |
$1,062.60 |
| Rate for Payer: Aetna Commercial |
$1,039.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$612.15
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cigna Commercial |
$1,062.60
|
| Rate for Payer: Health EOS Commercial |
$1,027.95
|
| Rate for Payer: HFN Commercial |
$1,062.60
|
| Rate for Payer: Multiplan Commercial |
$924.00
|
| Rate for Payer: NAPHCARE Commercial |
$693.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,062.60
|
| Rate for Payer: Quartz Beloit One Network |
$565.95
|
| Rate for Payer: Quartz Commercial |
$693.00
|
| Rate for Payer: WEA Trust Commercial |
$635.25
|
| Rate for Payer: WPS Commercial |
$855.51
|
|
|
XR Bone Survey Limited (Mets)
|
Facility
OP
|
$1,070.00
|
|
|
Service Code
|
CPT 77074
|
| Hospital Charge Code |
627662
|
| Min. Negotiated Rate |
$60.56 |
| Max. Negotiated Rate |
$984.40 |
| Rate for Payer: Aetna Commercial |
$963.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$920.20
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$695.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$535.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$513.60
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$567.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$984.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$952.30
|
| Rate for Payer: HFN Commercial |
$984.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$856.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$984.40
|
| Rate for Payer: Quartz Beloit One Network |
$524.30
|
| Rate for Payer: Quartz Commercial |
$695.50
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$60.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$588.50
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$792.55
|
|
|
XR Bone Survey Limited (Mets)
|
Professional
|
$1,070.00
|
|
|
Service Code
|
CPT 77074
|
| Hospital Charge Code |
627662
|
| Min. Negotiated Rate |
$62.87 |
| Max. Negotiated Rate |
$1,016.50 |
| Rate for Payer: Aetna Commercial |
$1,016.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$920.20
|
| Rate for Payer: Aetna Managed Medicare |
$62.87
|
| Rate for Payer: Anthem Medicare Advantage |
$62.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.87
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$1,016.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$535.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.87
|
| Rate for Payer: Health EOS Commercial |
$973.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$221.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$221.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.87
|
| Rate for Payer: Multiplan Commercial |
$856.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,016.50
|
| Rate for Payer: Quartz Beloit One Network |
$470.80
|
| Rate for Payer: Quartz Commercial |
$609.90
|
| Rate for Payer: Quartz Medicare Advantage |
$62.87
|
| Rate for Payer: The Alliance Commercial |
$238.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.87
|
| Rate for Payer: WEA Trust Commercial |
$588.50
|
| Rate for Payer: WPS Commercial |
$314.35
|
|
|
XR Bone Survey Limited (Mets)
|
Facility
OP
|
$1,155.00
|
|
|
Service Code
|
CPT 77074 TC
|
| Hospital Charge Code |
1536899
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$1,039.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$993.30
|
| Rate for Payer: Aetna Managed Medicare |
$323.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$750.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$577.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$554.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$612.15
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cigna Commercial |
$1,062.60
|
| Rate for Payer: Health EOS Commercial |
$1,027.95
|
| Rate for Payer: HFN Commercial |
$1,062.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$866.25
|
| Rate for Payer: Multiplan Commercial |
$924.00
|
| Rate for Payer: NAPHCARE Commercial |
$693.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,062.60
|
| Rate for Payer: Quartz Beloit One Network |
$565.95
|
| Rate for Payer: Quartz Commercial |
$750.75
|
| Rate for Payer: Quartz Medicare Advantage |
$693.00
|
| Rate for Payer: The Alliance Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$635.25
|
| Rate for Payer: WPS Commercial |
$855.51
|
|
|
XR Bone Survey Limited (Mets)
|
Professional
|
$1,155.00
|
|
|
Service Code
|
CPT 77074 TC
|
| Hospital Charge Code |
1536899
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$42.60 |
| Max. Negotiated Rate |
$1,097.25 |
| Rate for Payer: Aetna Commercial |
$1,097.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$993.30
|
| Rate for Payer: Aetna Managed Medicare |
$42.60
|
| Rate for Payer: Anthem Medicare Advantage |
$42.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$42.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$42.60
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cigna Commercial |
$1,097.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$577.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.60
|
| Rate for Payer: Health EOS Commercial |
$1,051.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$147.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$42.60
|
| Rate for Payer: Multiplan Commercial |
$924.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,097.25
|
| Rate for Payer: Quartz Beloit One Network |
$508.20
|
| Rate for Payer: Quartz Commercial |
$658.35
|
| Rate for Payer: Quartz Medicare Advantage |
$42.60
|
| Rate for Payer: The Alliance Commercial |
$161.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42.60
|
| Rate for Payer: WEA Trust Commercial |
$635.25
|
| Rate for Payer: WPS Commercial |
$213.00
|
|
|
XR Calcaneous Bilateral
|
Facility
IP
|
$868.00
|
|
|
Service Code
|
CPT 73650
|
| Hospital Charge Code |
629616
|
| Min. Negotiated Rate |
$425.32 |
| Max. Negotiated Rate |
$798.56 |
| Rate for Payer: Aetna Commercial |
$781.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$460.04
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cigna Commercial |
$798.56
|
| Rate for Payer: Health EOS Commercial |
$772.52
|
| Rate for Payer: HFN Commercial |
$798.56
|
| Rate for Payer: Multiplan Commercial |
$694.40
|
| Rate for Payer: NAPHCARE Commercial |
$520.80
|
| Rate for Payer: Preferred Network Access Commercial |
$798.56
|
| Rate for Payer: Quartz Beloit One Network |
$425.32
|
| Rate for Payer: Quartz Commercial |
$520.80
|
| Rate for Payer: WEA Trust Commercial |
$477.40
|
| Rate for Payer: WPS Commercial |
$642.93
|
|
|
XR Calcaneous Bilateral
|
Facility
IP
|
$316.00
|
|
|
Service Code
|
CPT 73650 LT,TC
|
| Hospital Charge Code |
1536907
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$154.84 |
| Max. Negotiated Rate |
$290.72 |
| Rate for Payer: Aetna Commercial |
$284.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$167.48
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$290.72
|
| Rate for Payer: Health EOS Commercial |
$281.24
|
| Rate for Payer: HFN Commercial |
$290.72
|
| Rate for Payer: Multiplan Commercial |
$252.80
|
| Rate for Payer: NAPHCARE Commercial |
$189.60
|
| Rate for Payer: Preferred Network Access Commercial |
$290.72
|
| Rate for Payer: Quartz Beloit One Network |
$154.84
|
| Rate for Payer: Quartz Commercial |
$189.60
|
| Rate for Payer: WEA Trust Commercial |
$173.80
|
| Rate for Payer: WPS Commercial |
$234.06
|
|
|
XR Calcaneous Bilateral
|
Professional
|
$316.00
|
|
|
Service Code
|
CPT 73650 LT,TC
|
| Hospital Charge Code |
1536907
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$139.04 |
| Max. Negotiated Rate |
$300.20 |
| Rate for Payer: Aetna Commercial |
$300.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$271.76
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$300.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$158.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.60
|
| Rate for Payer: Health EOS Commercial |
$287.56
|
| Rate for Payer: Multiplan Commercial |
$252.80
|
| Rate for Payer: Preferred Network Access Commercial |
$300.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.04
|
| Rate for Payer: Quartz Commercial |
$180.12
|
| Rate for Payer: The Alliance Commercial |
$158.00
|
| Rate for Payer: WEA Trust Commercial |
$173.80
|
| Rate for Payer: WPS Commercial |
$234.06
|
|
|
XR Calcaneous Bilateral
|
Facility
OP
|
$868.00
|
|
|
Service Code
|
CPT 73650
|
| Hospital Charge Code |
629616
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$798.56 |
| Rate for Payer: Aetna Commercial |
$781.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$746.48
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$564.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$434.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$416.64
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$460.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cigna Commercial |
$798.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$772.52
|
| Rate for Payer: HFN Commercial |
$798.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$694.40
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$798.56
|
| Rate for Payer: Quartz Beloit One Network |
$425.32
|
| Rate for Payer: Quartz Commercial |
$564.20
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$766.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$477.40
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$642.93
|
|
|
XR Calcaneous Bilateral
|
Professional
|
$868.00
|
|
|
Service Code
|
CPT 73650
|
| Hospital Charge Code |
629616
|
| Min. Negotiated Rate |
$27.53 |
| Max. Negotiated Rate |
$824.60 |
| Rate for Payer: Aetna Commercial |
$824.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$746.48
|
| Rate for Payer: Aetna Managed Medicare |
$27.53
|
| Rate for Payer: Anthem Medicare Advantage |
$27.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.53
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cigna Commercial |
$824.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$434.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.53
|
| Rate for Payer: Health EOS Commercial |
$789.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$97.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.53
|
| Rate for Payer: Multiplan Commercial |
$694.40
|
| Rate for Payer: Preferred Network Access Commercial |
$824.60
|
| Rate for Payer: Quartz Beloit One Network |
$381.92
|
| Rate for Payer: Quartz Commercial |
$494.76
|
| Rate for Payer: Quartz Medicare Advantage |
$27.53
|
| Rate for Payer: The Alliance Commercial |
$104.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.53
|
| Rate for Payer: WEA Trust Commercial |
$477.40
|
| Rate for Payer: WPS Commercial |
$137.65
|
|
|
XR Calcaneous Bilateral
|
Facility
OP
|
$316.00
|
|
|
Service Code
|
CPT 73650 LT,TC
|
| Hospital Charge Code |
1536907
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$88.48 |
| Max. Negotiated Rate |
$1,264.00 |
| Rate for Payer: Aetna Commercial |
$284.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$271.76
|
| Rate for Payer: Aetna Managed Medicare |
$88.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$205.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$158.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$151.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$167.48
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$290.72
|
| Rate for Payer: Health EOS Commercial |
$281.24
|
| Rate for Payer: HFN Commercial |
$290.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.00
|
| Rate for Payer: Multiplan Commercial |
$252.80
|
| Rate for Payer: NAPHCARE Commercial |
$189.60
|
| Rate for Payer: Preferred Network Access Commercial |
$290.72
|
| Rate for Payer: Quartz Beloit One Network |
$154.84
|
| Rate for Payer: Quartz Commercial |
$205.40
|
| Rate for Payer: Quartz Medicare Advantage |
$189.60
|
| Rate for Payer: The Alliance Commercial |
$1,264.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$173.80
|
| Rate for Payer: WPS Commercial |
$234.06
|
|
|
XR Calcaneous Left
|
Facility
OP
|
$316.00
|
|
|
Service Code
|
CPT 73650 LT,TC
|
| Hospital Charge Code |
1536909
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$88.48 |
| Max. Negotiated Rate |
$1,264.00 |
| Rate for Payer: Aetna Commercial |
$284.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$271.76
|
| Rate for Payer: Aetna Managed Medicare |
$88.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$205.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$158.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$151.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$167.48
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$290.72
|
| Rate for Payer: Health EOS Commercial |
$281.24
|
| Rate for Payer: HFN Commercial |
$290.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.00
|
| Rate for Payer: Multiplan Commercial |
$252.80
|
| Rate for Payer: NAPHCARE Commercial |
$189.60
|
| Rate for Payer: Preferred Network Access Commercial |
$290.72
|
| Rate for Payer: Quartz Beloit One Network |
$154.84
|
| Rate for Payer: Quartz Commercial |
$205.40
|
| Rate for Payer: Quartz Medicare Advantage |
$189.60
|
| Rate for Payer: The Alliance Commercial |
$1,264.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$173.80
|
| Rate for Payer: WPS Commercial |
$234.06
|
|
|
XR Calcaneous Left
|
Facility
IP
|
$316.00
|
|
|
Service Code
|
CPT 73650 LT,TC
|
| Hospital Charge Code |
1536909
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$154.84 |
| Max. Negotiated Rate |
$290.72 |
| Rate for Payer: Aetna Commercial |
$284.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$167.48
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$290.72
|
| Rate for Payer: Health EOS Commercial |
$281.24
|
| Rate for Payer: HFN Commercial |
$290.72
|
| Rate for Payer: Multiplan Commercial |
$252.80
|
| Rate for Payer: NAPHCARE Commercial |
$189.60
|
| Rate for Payer: Preferred Network Access Commercial |
$290.72
|
| Rate for Payer: Quartz Beloit One Network |
$154.84
|
| Rate for Payer: Quartz Commercial |
$189.60
|
| Rate for Payer: WEA Trust Commercial |
$173.80
|
| Rate for Payer: WPS Commercial |
$234.06
|
|
|
XR Calcaneous Left
|
Facility
IP
|
$434.00
|
|
|
Service Code
|
CPT 73650
|
| Hospital Charge Code |
629618
|
| Min. Negotiated Rate |
$212.66 |
| Max. Negotiated Rate |
$399.28 |
| Rate for Payer: Aetna Commercial |
$390.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.02
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$399.28
|
| Rate for Payer: Health EOS Commercial |
$386.26
|
| Rate for Payer: HFN Commercial |
$399.28
|
| Rate for Payer: Multiplan Commercial |
$347.20
|
| Rate for Payer: NAPHCARE Commercial |
$260.40
|
| Rate for Payer: Preferred Network Access Commercial |
$399.28
|
| Rate for Payer: Quartz Beloit One Network |
$212.66
|
| Rate for Payer: Quartz Commercial |
$260.40
|
| Rate for Payer: WEA Trust Commercial |
$238.70
|
| Rate for Payer: WPS Commercial |
$321.46
|
|
|
XR Calcaneous Left
|
Facility
OP
|
$434.00
|
|
|
Service Code
|
CPT 73650
|
| Hospital Charge Code |
629618
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$766.08 |
| Rate for Payer: Aetna Commercial |
$390.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.24
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$282.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$217.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$208.32
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$399.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$386.26
|
| Rate for Payer: HFN Commercial |
$399.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$347.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$399.28
|
| Rate for Payer: Quartz Beloit One Network |
$212.66
|
| Rate for Payer: Quartz Commercial |
$282.10
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$766.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$238.70
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$321.46
|
|
|
XR Calcaneous Left
|
Professional
|
$434.00
|
|
|
Service Code
|
CPT 73650
|
| Hospital Charge Code |
629618
|
| Min. Negotiated Rate |
$27.53 |
| Max. Negotiated Rate |
$412.30 |
| Rate for Payer: Aetna Commercial |
$412.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.24
|
| Rate for Payer: Aetna Managed Medicare |
$27.53
|
| Rate for Payer: Anthem Medicare Advantage |
$27.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.53
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$412.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$217.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.53
|
| Rate for Payer: Health EOS Commercial |
$394.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$97.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.53
|
| Rate for Payer: Multiplan Commercial |
$347.20
|
| Rate for Payer: Preferred Network Access Commercial |
$412.30
|
| Rate for Payer: Quartz Beloit One Network |
$190.96
|
| Rate for Payer: Quartz Commercial |
$247.38
|
| Rate for Payer: Quartz Medicare Advantage |
$27.53
|
| Rate for Payer: The Alliance Commercial |
$104.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.53
|
| Rate for Payer: WEA Trust Commercial |
$238.70
|
| Rate for Payer: WPS Commercial |
$137.65
|
|
|
XR Calcaneous Left
|
Professional
|
$316.00
|
|
|
Service Code
|
CPT 73650 LT,TC
|
| Hospital Charge Code |
1536909
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$139.04 |
| Max. Negotiated Rate |
$300.20 |
| Rate for Payer: Aetna Commercial |
$300.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$271.76
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$300.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$158.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.60
|
| Rate for Payer: Health EOS Commercial |
$287.56
|
| Rate for Payer: Multiplan Commercial |
$252.80
|
| Rate for Payer: Preferred Network Access Commercial |
$300.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.04
|
| Rate for Payer: Quartz Commercial |
$180.12
|
| Rate for Payer: The Alliance Commercial |
$158.00
|
| Rate for Payer: WEA Trust Commercial |
$173.80
|
| Rate for Payer: WPS Commercial |
$234.06
|
|
|
XR Calcaneous Right
|
Professional
|
$316.00
|
|
|
Service Code
|
CPT 73650 RT,TC
|
| Hospital Charge Code |
1536911
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$139.04 |
| Max. Negotiated Rate |
$300.20 |
| Rate for Payer: Aetna Commercial |
$300.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$271.76
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$300.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$158.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.60
|
| Rate for Payer: Health EOS Commercial |
$287.56
|
| Rate for Payer: Multiplan Commercial |
$252.80
|
| Rate for Payer: Preferred Network Access Commercial |
$300.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.04
|
| Rate for Payer: Quartz Commercial |
$180.12
|
| Rate for Payer: The Alliance Commercial |
$158.00
|
| Rate for Payer: WEA Trust Commercial |
$173.80
|
| Rate for Payer: WPS Commercial |
$234.06
|
|
|
XR Calcaneous Right
|
Facility
OP
|
$434.00
|
|
|
Service Code
|
CPT 73650
|
| Hospital Charge Code |
629620
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$766.08 |
| Rate for Payer: The Alliance Commercial |
$766.08
|
| Rate for Payer: Aetna Commercial |
$390.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.24
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$282.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$217.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$208.32
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$399.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$386.26
|
| Rate for Payer: HFN Commercial |
$399.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$347.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$399.28
|
| Rate for Payer: Quartz Beloit One Network |
$212.66
|
| Rate for Payer: Quartz Commercial |
$282.10
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$238.70
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$321.46
|
|
|
XR Calcaneous Right
|
Facility
IP
|
$316.00
|
|
|
Service Code
|
CPT 73650 TC,RT
|
| Hospital Charge Code |
2980068
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$154.84 |
| Max. Negotiated Rate |
$290.72 |
| Rate for Payer: Aetna Commercial |
$284.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$167.48
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$290.72
|
| Rate for Payer: Health EOS Commercial |
$281.24
|
| Rate for Payer: HFN Commercial |
$290.72
|
| Rate for Payer: Multiplan Commercial |
$252.80
|
| Rate for Payer: NAPHCARE Commercial |
$189.60
|
| Rate for Payer: Preferred Network Access Commercial |
$290.72
|
| Rate for Payer: Quartz Beloit One Network |
$154.84
|
| Rate for Payer: Quartz Commercial |
$189.60
|
| Rate for Payer: WEA Trust Commercial |
$173.80
|
| Rate for Payer: WPS Commercial |
$234.06
|
|
|
XR Calcaneous Right
|
Professional
|
$434.00
|
|
|
Service Code
|
CPT 73650
|
| Hospital Charge Code |
629620
|
| Min. Negotiated Rate |
$27.53 |
| Max. Negotiated Rate |
$412.30 |
| Rate for Payer: Aetna Commercial |
$412.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.24
|
| Rate for Payer: Aetna Managed Medicare |
$27.53
|
| Rate for Payer: Anthem Medicare Advantage |
$27.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.53
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$412.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$217.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.53
|
| Rate for Payer: Health EOS Commercial |
$394.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$97.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.53
|
| Rate for Payer: Multiplan Commercial |
$347.20
|
| Rate for Payer: Preferred Network Access Commercial |
$412.30
|
| Rate for Payer: Quartz Beloit One Network |
$190.96
|
| Rate for Payer: Quartz Commercial |
$247.38
|
| Rate for Payer: Quartz Medicare Advantage |
$27.53
|
| Rate for Payer: The Alliance Commercial |
$104.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.53
|
| Rate for Payer: WEA Trust Commercial |
$238.70
|
| Rate for Payer: WPS Commercial |
$137.65
|
|
