|
XR Foot Complete Bilateral
|
Facility
OP
|
$1,032.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630552
|
| Min. Negotiated Rate |
$47.20 |
| Max. Negotiated Rate |
$949.44 |
| Rate for Payer: Aetna Commercial |
$928.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$887.52
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$670.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$516.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$495.36
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.96
|
| 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 |
$309.60
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cigna Commercial |
$949.44
|
| 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 |
$918.48
|
| Rate for Payer: HFN Commercial |
$949.44
|
| 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 |
$825.60
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$949.44
|
| Rate for Payer: Quartz Beloit One Network |
$505.68
|
| Rate for Payer: Quartz Commercial |
$670.80
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$47.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$567.60
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$764.40
|
|
|
XR Foot Complete Left
|
Facility
OP
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630548
|
| Min. Negotiated Rate |
$47.20 |
| Max. Negotiated Rate |
$474.72 |
| Rate for Payer: Aetna Commercial |
$464.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.76
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$258.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.68
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.48
|
| 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 |
$154.80
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$474.72
|
| 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 |
$459.24
|
| Rate for Payer: HFN Commercial |
$474.72
|
| 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 |
$412.80
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$474.72
|
| Rate for Payer: Quartz Beloit One Network |
$252.84
|
| Rate for Payer: Quartz Commercial |
$335.40
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$47.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$283.80
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$382.20
|
|
|
XR Foot Complete Left
|
Professional
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630548
|
| Min. Negotiated Rate |
$33.02 |
| Max. Negotiated Rate |
$490.20 |
| Rate for Payer: Aetna Commercial |
$490.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.76
|
| Rate for Payer: Aetna Managed Medicare |
$33.02
|
| Rate for Payer: Anthem Medicare Advantage |
$33.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.02
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$490.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$258.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.02
|
| Rate for Payer: Health EOS Commercial |
$469.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$115.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.02
|
| Rate for Payer: Multiplan Commercial |
$412.80
|
| Rate for Payer: Preferred Network Access Commercial |
$490.20
|
| Rate for Payer: Quartz Beloit One Network |
$227.04
|
| Rate for Payer: Quartz Commercial |
$294.12
|
| Rate for Payer: Quartz Medicare Advantage |
$33.02
|
| Rate for Payer: The Alliance Commercial |
$125.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.02
|
| Rate for Payer: WEA Trust Commercial |
$283.80
|
| Rate for Payer: WPS Commercial |
$165.10
|
|
|
XR Foot Complete Left
|
Facility
OP
|
$558.00
|
|
|
Service Code
|
CPT 73630 LT,TC
|
| Hospital Charge Code |
1537068
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$156.24 |
| Max. Negotiated Rate |
$2,232.00 |
| Rate for Payer: Aetna Commercial |
$502.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.88
|
| Rate for Payer: Aetna Managed Medicare |
$156.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$279.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$267.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.74
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$513.36
|
| Rate for Payer: Health EOS Commercial |
$496.62
|
| Rate for Payer: HFN Commercial |
$513.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$418.50
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: NAPHCARE Commercial |
$334.80
|
| Rate for Payer: Preferred Network Access Commercial |
$513.36
|
| Rate for Payer: Quartz Beloit One Network |
$273.42
|
| Rate for Payer: Quartz Commercial |
$362.70
|
| Rate for Payer: Quartz Medicare Advantage |
$334.80
|
| Rate for Payer: The Alliance Commercial |
$2,232.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
XR Foot Complete Left
|
Professional
|
$558.00
|
|
|
Service Code
|
CPT 73630 LT,TC
|
| Hospital Charge Code |
1537068
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$245.52 |
| Max. Negotiated Rate |
$530.10 |
| Rate for Payer: Aetna Commercial |
$530.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.88
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$530.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$279.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$334.80
|
| Rate for Payer: Health EOS Commercial |
$507.78
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$530.10
|
| Rate for Payer: Quartz Beloit One Network |
$245.52
|
| Rate for Payer: Quartz Commercial |
$318.06
|
| Rate for Payer: The Alliance Commercial |
$279.00
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
XR Foot Complete Left
|
Facility
IP
|
$558.00
|
|
|
Service Code
|
CPT 73630 LT,TC
|
| Hospital Charge Code |
1537068
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$273.42 |
| Max. Negotiated Rate |
$513.36 |
| Rate for Payer: Aetna Commercial |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.74
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$513.36
|
| Rate for Payer: Health EOS Commercial |
$496.62
|
| Rate for Payer: HFN Commercial |
$513.36
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: NAPHCARE Commercial |
$334.80
|
| Rate for Payer: Preferred Network Access Commercial |
$513.36
|
| Rate for Payer: Quartz Beloit One Network |
$273.42
|
| Rate for Payer: Quartz Commercial |
$334.80
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
XR Foot Complete Left
|
Facility
IP
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630548
|
| Min. Negotiated Rate |
$252.84 |
| Max. Negotiated Rate |
$474.72 |
| Rate for Payer: Aetna Commercial |
$464.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.48
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$474.72
|
| Rate for Payer: Health EOS Commercial |
$459.24
|
| Rate for Payer: HFN Commercial |
$474.72
|
| Rate for Payer: Multiplan Commercial |
$412.80
|
| Rate for Payer: NAPHCARE Commercial |
$309.60
|
| Rate for Payer: Preferred Network Access Commercial |
$474.72
|
| Rate for Payer: Quartz Beloit One Network |
$252.84
|
| Rate for Payer: Quartz Commercial |
$309.60
|
| Rate for Payer: WEA Trust Commercial |
$283.80
|
| Rate for Payer: WPS Commercial |
$382.20
|
|
|
XR Foot Complete Right
|
Professional
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630533
|
| Min. Negotiated Rate |
$33.02 |
| Max. Negotiated Rate |
$490.20 |
| Rate for Payer: Aetna Commercial |
$490.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.76
|
| Rate for Payer: Aetna Managed Medicare |
$33.02
|
| Rate for Payer: Anthem Medicare Advantage |
$33.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.02
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$490.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$258.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.02
|
| Rate for Payer: Health EOS Commercial |
$469.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$115.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.02
|
| Rate for Payer: Multiplan Commercial |
$412.80
|
| Rate for Payer: Preferred Network Access Commercial |
$490.20
|
| Rate for Payer: Quartz Beloit One Network |
$227.04
|
| Rate for Payer: Quartz Commercial |
$294.12
|
| Rate for Payer: Quartz Medicare Advantage |
$33.02
|
| Rate for Payer: The Alliance Commercial |
$125.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.02
|
| Rate for Payer: WEA Trust Commercial |
$283.80
|
| Rate for Payer: WPS Commercial |
$165.10
|
|
|
XR Foot Complete Right
|
Facility
IP
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630533
|
| Min. Negotiated Rate |
$252.84 |
| Max. Negotiated Rate |
$474.72 |
| Rate for Payer: Aetna Commercial |
$464.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.48
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$474.72
|
| Rate for Payer: Health EOS Commercial |
$459.24
|
| Rate for Payer: HFN Commercial |
$474.72
|
| Rate for Payer: Multiplan Commercial |
$412.80
|
| Rate for Payer: NAPHCARE Commercial |
$309.60
|
| Rate for Payer: Preferred Network Access Commercial |
$474.72
|
| Rate for Payer: Quartz Beloit One Network |
$252.84
|
| Rate for Payer: Quartz Commercial |
$309.60
|
| Rate for Payer: WEA Trust Commercial |
$283.80
|
| Rate for Payer: WPS Commercial |
$382.20
|
|
|
XR Foot Complete Right
|
Professional
|
$558.00
|
|
|
Service Code
|
CPT 73630 TC,RT
|
| Hospital Charge Code |
2980067
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$245.52 |
| Max. Negotiated Rate |
$530.10 |
| Rate for Payer: Aetna Commercial |
$530.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.88
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$530.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$279.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$334.80
|
| Rate for Payer: Health EOS Commercial |
$507.78
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$530.10
|
| Rate for Payer: Quartz Beloit One Network |
$245.52
|
| Rate for Payer: Quartz Commercial |
$318.06
|
| Rate for Payer: The Alliance Commercial |
$279.00
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
XR Foot Complete Right
|
Facility
OP
|
$558.00
|
|
|
Service Code
|
CPT 73630 RT,TC
|
| Hospital Charge Code |
1537070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$156.24 |
| Max. Negotiated Rate |
$2,232.00 |
| Rate for Payer: Aetna Commercial |
$502.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.88
|
| Rate for Payer: Aetna Managed Medicare |
$156.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$279.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$267.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.74
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$513.36
|
| Rate for Payer: Health EOS Commercial |
$496.62
|
| Rate for Payer: HFN Commercial |
$513.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$418.50
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: NAPHCARE Commercial |
$334.80
|
| Rate for Payer: Preferred Network Access Commercial |
$513.36
|
| Rate for Payer: Quartz Beloit One Network |
$273.42
|
| Rate for Payer: Quartz Commercial |
$362.70
|
| Rate for Payer: Quartz Medicare Advantage |
$334.80
|
| Rate for Payer: The Alliance Commercial |
$2,232.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
XR Foot Complete Right
|
Facility
OP
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630533
|
| Min. Negotiated Rate |
$47.20 |
| Max. Negotiated Rate |
$474.72 |
| Rate for Payer: Aetna Commercial |
$464.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.76
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$258.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.68
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.48
|
| 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 |
$154.80
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$474.72
|
| 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 |
$459.24
|
| Rate for Payer: HFN Commercial |
$474.72
|
| 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 |
$412.80
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$474.72
|
| Rate for Payer: Quartz Beloit One Network |
$252.84
|
| Rate for Payer: Quartz Commercial |
$335.40
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$47.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$283.80
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$382.20
|
|
|
XR Foot Complete Right
|
Professional
|
$558.00
|
|
|
Service Code
|
CPT 73630 RT,TC
|
| Hospital Charge Code |
1537070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$245.52 |
| Max. Negotiated Rate |
$530.10 |
| Rate for Payer: Aetna Commercial |
$530.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.88
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$530.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$279.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$334.80
|
| Rate for Payer: Health EOS Commercial |
$507.78
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$530.10
|
| Rate for Payer: Quartz Beloit One Network |
$245.52
|
| Rate for Payer: Quartz Commercial |
$318.06
|
| Rate for Payer: The Alliance Commercial |
$279.00
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
XR Foot Complete Right
|
Facility
IP
|
$558.00
|
|
|
Service Code
|
CPT 73630 RT,TC
|
| Hospital Charge Code |
1537070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$273.42 |
| Max. Negotiated Rate |
$513.36 |
| Rate for Payer: Aetna Commercial |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.74
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$513.36
|
| Rate for Payer: Health EOS Commercial |
$496.62
|
| Rate for Payer: HFN Commercial |
$513.36
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: NAPHCARE Commercial |
$334.80
|
| Rate for Payer: Preferred Network Access Commercial |
$513.36
|
| Rate for Payer: Quartz Beloit One Network |
$273.42
|
| Rate for Payer: Quartz Commercial |
$334.80
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
XR Foot Complete Right
|
Facility
IP
|
$558.00
|
|
|
Service Code
|
CPT 73630 TC,RT
|
| Hospital Charge Code |
2980067
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$273.42 |
| Max. Negotiated Rate |
$513.36 |
| Rate for Payer: Aetna Commercial |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.74
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$513.36
|
| Rate for Payer: Health EOS Commercial |
$496.62
|
| Rate for Payer: HFN Commercial |
$513.36
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: NAPHCARE Commercial |
$334.80
|
| Rate for Payer: Preferred Network Access Commercial |
$513.36
|
| Rate for Payer: Quartz Beloit One Network |
$273.42
|
| Rate for Payer: Quartz Commercial |
$334.80
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
XR Foot Complete Right
|
Facility
OP
|
$558.00
|
|
|
Service Code
|
CPT 73630 TC,RT
|
| Hospital Charge Code |
2980067
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$156.24 |
| Max. Negotiated Rate |
$2,232.00 |
| Rate for Payer: Aetna Commercial |
$502.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.88
|
| Rate for Payer: Aetna Managed Medicare |
$156.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$279.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$267.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.74
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$513.36
|
| Rate for Payer: Health EOS Commercial |
$496.62
|
| Rate for Payer: HFN Commercial |
$513.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$418.50
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: NAPHCARE Commercial |
$334.80
|
| Rate for Payer: Preferred Network Access Commercial |
$513.36
|
| Rate for Payer: Quartz Beloit One Network |
$273.42
|
| Rate for Payer: Quartz Commercial |
$362.70
|
| Rate for Payer: Quartz Medicare Advantage |
$334.80
|
| Rate for Payer: The Alliance Commercial |
$2,232.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
XR Forearm 2 Views Bilateral
|
Professional
|
$1,013.00
|
|
|
Service Code
|
CPT 73090
|
| Hospital Charge Code |
630527
|
| Min. Negotiated Rate |
$28.17 |
| Max. Negotiated Rate |
$962.35 |
| Rate for Payer: Aetna Commercial |
$962.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$871.18
|
| Rate for Payer: Aetna Managed Medicare |
$28.17
|
| Rate for Payer: Anthem Medicare Advantage |
$28.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.17
|
| Rate for Payer: Cash Price |
$303.90
|
| Rate for Payer: Cash Price |
$303.90
|
| Rate for Payer: Cigna Commercial |
$962.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$506.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.17
|
| Rate for Payer: Health EOS Commercial |
$921.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$98.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$98.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.17
|
| Rate for Payer: Multiplan Commercial |
$810.40
|
| Rate for Payer: Preferred Network Access Commercial |
$962.35
|
| Rate for Payer: Quartz Beloit One Network |
$445.72
|
| Rate for Payer: Quartz Commercial |
$577.41
|
| Rate for Payer: Quartz Medicare Advantage |
$28.17
|
| Rate for Payer: The Alliance Commercial |
$107.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.17
|
| Rate for Payer: WEA Trust Commercial |
$557.15
|
| Rate for Payer: WPS Commercial |
$140.85
|
|
|
XR Forearm 2 Views Bilateral
|
Facility
OP
|
$1,013.00
|
|
|
Service Code
|
CPT 73090
|
| Hospital Charge Code |
630527
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$2,182.48 |
| Rate for Payer: Aetna Commercial |
$911.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$871.18
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$658.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$506.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$486.24
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$536.89
|
| 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 |
$303.90
|
| Rate for Payer: Cash Price |
$303.90
|
| Rate for Payer: Cigna Commercial |
$931.96
|
| 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 |
$901.57
|
| Rate for Payer: HFN Commercial |
$931.96
|
| 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 |
$810.40
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$931.96
|
| Rate for Payer: Quartz Beloit One Network |
$496.37
|
| Rate for Payer: Quartz Commercial |
$658.45
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$2,182.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$557.15
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$750.33
|
|
|
XR Forearm 2 Views Bilateral
|
Facility
OP
|
$526.00
|
|
|
Service Code
|
CPT 73090 LT,TC
|
| Hospital Charge Code |
1537072
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$147.28 |
| Max. Negotiated Rate |
$2,104.00 |
| Rate for Payer: Aetna Commercial |
$473.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$452.36
|
| Rate for Payer: Aetna Managed Medicare |
$147.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$341.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$263.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$252.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$278.78
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cigna Commercial |
$483.92
|
| Rate for Payer: Health EOS Commercial |
$468.14
|
| Rate for Payer: HFN Commercial |
$483.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$394.50
|
| Rate for Payer: Multiplan Commercial |
$420.80
|
| Rate for Payer: NAPHCARE Commercial |
$315.60
|
| Rate for Payer: Preferred Network Access Commercial |
$483.92
|
| Rate for Payer: Quartz Beloit One Network |
$257.74
|
| Rate for Payer: Quartz Commercial |
$341.90
|
| Rate for Payer: Quartz Medicare Advantage |
$315.60
|
| Rate for Payer: The Alliance Commercial |
$2,104.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$289.30
|
| Rate for Payer: WPS Commercial |
$389.61
|
|
|
XR Forearm 2 Views Bilateral
|
Professional
|
$526.00
|
|
|
Service Code
|
CPT 73090 LT,TC
|
| Hospital Charge Code |
1537072
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$231.44 |
| Max. Negotiated Rate |
$499.70 |
| Rate for Payer: Aetna Commercial |
$499.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$452.36
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cigna Commercial |
$499.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$263.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$315.60
|
| Rate for Payer: Health EOS Commercial |
$478.66
|
| Rate for Payer: Multiplan Commercial |
$420.80
|
| Rate for Payer: Preferred Network Access Commercial |
$499.70
|
| Rate for Payer: Quartz Beloit One Network |
$231.44
|
| Rate for Payer: Quartz Commercial |
$299.82
|
| Rate for Payer: The Alliance Commercial |
$263.00
|
| Rate for Payer: WEA Trust Commercial |
$289.30
|
| Rate for Payer: WPS Commercial |
$389.61
|
|
|
XR Forearm 2 Views Bilateral
|
Facility
IP
|
$1,013.00
|
|
|
Service Code
|
CPT 73090
|
| Hospital Charge Code |
630527
|
| Min. Negotiated Rate |
$496.37 |
| Max. Negotiated Rate |
$931.96 |
| Rate for Payer: Aetna Commercial |
$911.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$536.89
|
| Rate for Payer: Cash Price |
$303.90
|
| Rate for Payer: Cigna Commercial |
$931.96
|
| Rate for Payer: Health EOS Commercial |
$901.57
|
| Rate for Payer: HFN Commercial |
$931.96
|
| Rate for Payer: Multiplan Commercial |
$810.40
|
| Rate for Payer: NAPHCARE Commercial |
$607.80
|
| Rate for Payer: Preferred Network Access Commercial |
$931.96
|
| Rate for Payer: Quartz Beloit One Network |
$496.37
|
| Rate for Payer: Quartz Commercial |
$607.80
|
| Rate for Payer: WEA Trust Commercial |
$557.15
|
| Rate for Payer: WPS Commercial |
$750.33
|
|
|
XR Forearm 2 Views Bilateral
|
Facility
IP
|
$526.00
|
|
|
Service Code
|
CPT 73090 LT,TC
|
| Hospital Charge Code |
1537072
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$257.74 |
| Max. Negotiated Rate |
$483.92 |
| Rate for Payer: Aetna Commercial |
$473.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$278.78
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cigna Commercial |
$483.92
|
| Rate for Payer: Health EOS Commercial |
$468.14
|
| Rate for Payer: HFN Commercial |
$483.92
|
| Rate for Payer: Multiplan Commercial |
$420.80
|
| Rate for Payer: NAPHCARE Commercial |
$315.60
|
| Rate for Payer: Preferred Network Access Commercial |
$483.92
|
| Rate for Payer: Quartz Beloit One Network |
$257.74
|
| Rate for Payer: Quartz Commercial |
$315.60
|
| Rate for Payer: WEA Trust Commercial |
$289.30
|
| Rate for Payer: WPS Commercial |
$389.61
|
|
|
XR Forearm 2 Views Left
|
Professional
|
$506.00
|
|
|
Service Code
|
CPT 73090
|
| Hospital Charge Code |
630523
|
| Min. Negotiated Rate |
$28.17 |
| Max. Negotiated Rate |
$480.70 |
| Rate for Payer: Aetna Commercial |
$480.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$435.16
|
| Rate for Payer: Aetna Managed Medicare |
$28.17
|
| Rate for Payer: Anthem Medicare Advantage |
$28.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.17
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cigna Commercial |
$480.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$253.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.17
|
| Rate for Payer: Health EOS Commercial |
$460.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$98.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$98.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.17
|
| Rate for Payer: Multiplan Commercial |
$404.80
|
| Rate for Payer: Preferred Network Access Commercial |
$480.70
|
| Rate for Payer: Quartz Beloit One Network |
$222.64
|
| Rate for Payer: Quartz Commercial |
$288.42
|
| Rate for Payer: Quartz Medicare Advantage |
$28.17
|
| Rate for Payer: The Alliance Commercial |
$107.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.17
|
| Rate for Payer: WEA Trust Commercial |
$278.30
|
| Rate for Payer: WPS Commercial |
$140.85
|
|
|
XR Forearm 2 Views Left
|
Facility
IP
|
$506.00
|
|
|
Service Code
|
CPT 73090
|
| Hospital Charge Code |
630523
|
| Min. Negotiated Rate |
$247.94 |
| Max. Negotiated Rate |
$465.52 |
| Rate for Payer: Aetna Commercial |
$455.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$268.18
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cigna Commercial |
$465.52
|
| Rate for Payer: Health EOS Commercial |
$450.34
|
| Rate for Payer: HFN Commercial |
$465.52
|
| Rate for Payer: Multiplan Commercial |
$404.80
|
| Rate for Payer: NAPHCARE Commercial |
$303.60
|
| Rate for Payer: Preferred Network Access Commercial |
$465.52
|
| Rate for Payer: Quartz Beloit One Network |
$247.94
|
| Rate for Payer: Quartz Commercial |
$303.60
|
| Rate for Payer: WEA Trust Commercial |
$278.30
|
| Rate for Payer: WPS Commercial |
$374.79
|
|
|
XR Forearm 2 Views Left
|
Facility
OP
|
$546.00
|
|
|
Service Code
|
CPT 73090 LT,TC
|
| Hospital Charge Code |
1537074
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$152.88 |
| Max. Negotiated Rate |
$2,184.00 |
| Rate for Payer: Aetna Commercial |
$491.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$469.56
|
| Rate for Payer: Aetna Managed Medicare |
$152.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$354.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$273.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$262.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.38
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cigna Commercial |
$502.32
|
| Rate for Payer: Health EOS Commercial |
$485.94
|
| Rate for Payer: HFN Commercial |
$502.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$409.50
|
| Rate for Payer: Multiplan Commercial |
$436.80
|
| Rate for Payer: NAPHCARE Commercial |
$327.60
|
| Rate for Payer: Preferred Network Access Commercial |
$502.32
|
| Rate for Payer: Quartz Beloit One Network |
$267.54
|
| Rate for Payer: Quartz Commercial |
$354.90
|
| Rate for Payer: Quartz Medicare Advantage |
$327.60
|
| Rate for Payer: The Alliance Commercial |
$2,184.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$300.30
|
| Rate for Payer: WPS Commercial |
$404.42
|
|
