|
XR Ankle Complete Right
|
Facility
|
IP
|
$577.00
|
|
|
Service Code
|
CPT 73610 TC,RT
|
| Hospital Charge Code |
2980063
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$294.04 |
| Max. Negotiated Rate |
$552.07 |
| Rate for Payer: Aetna Commercial |
$540.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.04
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$552.07
|
| Rate for Payer: Health EOS Commercial |
$534.07
|
| Rate for Payer: HFN Commercial |
$552.07
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: Preferred Network Access Commercial |
$552.07
|
| Rate for Payer: Quartz Beloit One Network |
$294.04
|
| Rate for Payer: Quartz Commercial |
$360.05
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$444.46
|
|
|
XR Ankle Complete Right
|
Facility
|
OP
|
$577.00
|
|
|
Service Code
|
CPT 73610 TC,RT
|
| Hospital Charge Code |
2980063
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$168.02 |
| Max. Negotiated Rate |
$552.07 |
| Rate for Payer: Aetna Commercial |
$540.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Aetna Managed Medicare |
$168.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.04
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$552.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$335.81
|
| Rate for Payer: Health EOS Commercial |
$534.07
|
| Rate for Payer: HFN Commercial |
$552.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$450.06
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: NAPHCARE Commercial |
$360.05
|
| Rate for Payer: Preferred Network Access Commercial |
$552.07
|
| Rate for Payer: Quartz Beloit One Network |
$294.04
|
| Rate for Payer: Quartz Commercial |
$390.05
|
| Rate for Payer: Quartz Medicare Advantage |
$360.05
|
| Rate for Payer: The Alliance Commercial |
$300.04
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$444.46
|
|
|
XR Ankle Complete Right
|
Professional
|
Both
|
$577.00
|
|
|
Service Code
|
CPT 73610 RT,TC
|
| Hospital Charge Code |
1536821
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$128.71 |
| Max. Negotiated Rate |
$570.08 |
| Rate for Payer: Aetna Commercial |
$570.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$570.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$300.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$360.05
|
| Rate for Payer: Health EOS Commercial |
$546.07
|
| Rate for Payer: HFN Commercial |
$570.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$128.71
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: Preferred Network Access Commercial |
$570.08
|
| Rate for Payer: Quartz Beloit One Network |
$264.04
|
| Rate for Payer: Quartz Commercial |
$342.05
|
| Rate for Payer: The Alliance Commercial |
$300.04
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$444.46
|
|
|
XR Ankle Complete Right
|
Professional
|
Both
|
$577.00
|
|
|
Service Code
|
CPT 73610 TC,RT
|
| Hospital Charge Code |
2980063
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$128.71 |
| Max. Negotiated Rate |
$570.08 |
| Rate for Payer: Aetna Commercial |
$570.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$570.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$300.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$360.05
|
| Rate for Payer: Health EOS Commercial |
$546.07
|
| Rate for Payer: HFN Commercial |
$570.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$128.71
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: Preferred Network Access Commercial |
$570.08
|
| Rate for Payer: Quartz Beloit One Network |
$264.04
|
| Rate for Payer: Quartz Commercial |
$342.05
|
| Rate for Payer: The Alliance Commercial |
$300.04
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$444.46
|
|
|
XR Ankle Complete Right
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
CPT 73610
|
| Hospital Charge Code |
625726
|
| Min. Negotiated Rate |
$272.64 |
| Max. Negotiated Rate |
$511.89 |
| Rate for Payer: Aetna Commercial |
$500.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.89
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$511.89
|
| Rate for Payer: Health EOS Commercial |
$495.20
|
| Rate for Payer: HFN Commercial |
$511.89
|
| Rate for Payer: Multiplan Commercial |
$445.12
|
| Rate for Payer: Preferred Network Access Commercial |
$511.89
|
| Rate for Payer: Quartz Beloit One Network |
$272.64
|
| Rate for Payer: Quartz Commercial |
$333.84
|
| Rate for Payer: WEA Trust Commercial |
$306.02
|
| Rate for Payer: WPS Commercial |
$412.11
|
|
|
XR Ankle Therapeutic Injection Lt
|
Professional
|
Both
|
$2,081.00
|
|
|
Service Code
|
CPT 20605 TC,LT
|
| Hospital Charge Code |
5268610
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$51.54 |
| Max. Negotiated Rate |
$2,056.03 |
| Rate for Payer: Aetna Commercial |
$2,056.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,861.25
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$2,056.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,298.54
|
| Rate for Payer: Health EOS Commercial |
$1,969.46
|
| Rate for Payer: HFN Commercial |
$2,056.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$129.16
|
| Rate for Payer: Multiplan Commercial |
$1,731.39
|
| Rate for Payer: Preferred Network Access Commercial |
$2,056.03
|
| Rate for Payer: Quartz Beloit One Network |
$952.27
|
| Rate for Payer: Quartz Commercial |
$1,233.62
|
| Rate for Payer: The Alliance Commercial |
$1,082.12
|
| Rate for Payer: United Healthcare Medicaid |
$51.54
|
| Rate for Payer: WEA Trust Commercial |
$1,190.33
|
| Rate for Payer: WPS Commercial |
$1,602.99
|
|
|
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 |
$605.99 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$1,947.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,861.25
|
| Rate for Payer: Aetna Managed Medicare |
$605.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,406.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,082.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,038.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,147.05
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,991.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$1,926.17
|
| Rate for Payer: HFN Commercial |
$1,991.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,623.18
|
| Rate for Payer: Multiplan Commercial |
$1,731.39
|
| Rate for Payer: NAPHCARE Commercial |
$1,298.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,991.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,060.48
|
| Rate for Payer: Quartz Commercial |
$1,406.76
|
| Rate for Payer: Quartz Medicare Advantage |
$1,298.54
|
| Rate for Payer: The Alliance Commercial |
$1,082.12
|
| Rate for Payer: United Healthcare PPO |
$1,623.18
|
| Rate for Payer: WEA Trust Commercial |
$1,190.33
|
| Rate for Payer: WPS Commercial |
$1,602.99
|
|
|
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 |
$1,060.48 |
| Max. Negotiated Rate |
$1,991.10 |
| Rate for Payer: Aetna Commercial |
$1,947.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,861.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,147.05
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,991.10
|
| Rate for Payer: Health EOS Commercial |
$1,926.17
|
| Rate for Payer: HFN Commercial |
$1,991.10
|
| Rate for Payer: Multiplan Commercial |
$1,731.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,991.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,060.48
|
| Rate for Payer: Quartz Commercial |
$1,298.54
|
| Rate for Payer: WEA Trust Commercial |
$1,190.33
|
| Rate for Payer: WPS Commercial |
$1,602.99
|
|
|
XR Ankle Therapeutic Injection Rt
|
Professional
|
Both
|
$2,081.00
|
|
|
Service Code
|
CPT 20605 TC,RT
|
| Hospital Charge Code |
5268612
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$51.54 |
| Max. Negotiated Rate |
$2,056.03 |
| Rate for Payer: Aetna Commercial |
$2,056.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,861.25
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$2,056.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,298.54
|
| Rate for Payer: Health EOS Commercial |
$1,969.46
|
| Rate for Payer: HFN Commercial |
$2,056.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$129.16
|
| Rate for Payer: Multiplan Commercial |
$1,731.39
|
| Rate for Payer: Preferred Network Access Commercial |
$2,056.03
|
| Rate for Payer: Quartz Beloit One Network |
$952.27
|
| Rate for Payer: Quartz Commercial |
$1,233.62
|
| Rate for Payer: The Alliance Commercial |
$1,082.12
|
| Rate for Payer: United Healthcare Medicaid |
$51.54
|
| Rate for Payer: WEA Trust Commercial |
$1,190.33
|
| Rate for Payer: WPS Commercial |
$1,602.99
|
|
|
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 |
$605.99 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$1,947.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,861.25
|
| Rate for Payer: Aetna Managed Medicare |
$605.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,406.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,082.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,038.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,147.05
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,991.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$1,926.17
|
| Rate for Payer: HFN Commercial |
$1,991.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,623.18
|
| Rate for Payer: Multiplan Commercial |
$1,731.39
|
| Rate for Payer: NAPHCARE Commercial |
$1,298.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,991.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,060.48
|
| Rate for Payer: Quartz Commercial |
$1,406.76
|
| Rate for Payer: Quartz Medicare Advantage |
$1,298.54
|
| Rate for Payer: The Alliance Commercial |
$1,082.12
|
| Rate for Payer: United Healthcare PPO |
$1,623.18
|
| Rate for Payer: WEA Trust Commercial |
$1,190.33
|
| Rate for Payer: WPS Commercial |
$1,602.99
|
|
|
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 |
$1,060.48 |
| Max. Negotiated Rate |
$1,991.10 |
| Rate for Payer: Aetna Commercial |
$1,947.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,861.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,147.05
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,991.10
|
| Rate for Payer: Health EOS Commercial |
$1,926.17
|
| Rate for Payer: HFN Commercial |
$1,991.10
|
| Rate for Payer: Multiplan Commercial |
$1,731.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,991.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,060.48
|
| Rate for Payer: Quartz Commercial |
$1,298.54
|
| Rate for Payer: WEA Trust Commercial |
$1,190.33
|
| Rate for Payer: WPS Commercial |
$1,602.99
|
|
|
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 |
$868.87 |
| Max. Negotiated Rate |
$1,631.34 |
| Rate for Payer: Aetna Commercial |
$1,595.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.80
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,631.34
|
| Rate for Payer: Health EOS Commercial |
$1,578.15
|
| Rate for Payer: HFN Commercial |
$1,631.34
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,631.34
|
| Rate for Payer: Quartz Beloit One Network |
$868.87
|
| Rate for Payer: Quartz Commercial |
$1,063.92
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
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 |
$313.04 |
| Max. Negotiated Rate |
$1,631.34 |
| Rate for Payer: Aetna Commercial |
$1,595.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| Rate for Payer: Aetna Managed Medicare |
$496.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,152.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$886.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$851.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.80
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,631.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$992.31
|
| Rate for Payer: Health EOS Commercial |
$1,578.15
|
| Rate for Payer: HFN Commercial |
$1,631.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,329.90
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: NAPHCARE Commercial |
$1,063.92
|
| Rate for Payer: Preferred Network Access Commercial |
$1,631.34
|
| Rate for Payer: Quartz Beloit One Network |
$868.87
|
| Rate for Payer: Quartz Commercial |
$1,152.58
|
| Rate for Payer: Quartz Medicare Advantage |
$1,063.92
|
| Rate for Payer: The Alliance Commercial |
$886.60
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
XR Arthrogram Ankle Left
|
Professional
|
Both
|
$1,705.00
|
|
|
Service Code
|
CPT 77002 TC,LT
|
| Hospital Charge Code |
3072701
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$411.36 |
| Max. Negotiated Rate |
$1,684.54 |
| Rate for Payer: Aetna Commercial |
$1,684.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| 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 |
$1,684.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$886.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,063.92
|
| Rate for Payer: Health EOS Commercial |
$1,613.61
|
| Rate for Payer: HFN Commercial |
$1,684.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$411.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$411.36
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,684.54
|
| Rate for Payer: Quartz Beloit One Network |
$780.21
|
| Rate for Payer: Quartz Commercial |
$1,010.72
|
| Rate for Payer: The Alliance Commercial |
$886.60
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
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 |
$868.87 |
| Max. Negotiated Rate |
$1,631.34 |
| Rate for Payer: Aetna Commercial |
$1,595.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.80
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,631.34
|
| Rate for Payer: Health EOS Commercial |
$1,578.15
|
| Rate for Payer: HFN Commercial |
$1,631.34
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,631.34
|
| Rate for Payer: Quartz Beloit One Network |
$868.87
|
| Rate for Payer: Quartz Commercial |
$1,063.92
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
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 |
$313.04 |
| Max. Negotiated Rate |
$1,631.34 |
| Rate for Payer: Aetna Commercial |
$1,595.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| Rate for Payer: Aetna Managed Medicare |
$496.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,185.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,126.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.80
|
| 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 |
$1,631.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$992.31
|
| Rate for Payer: Health EOS Commercial |
$1,578.15
|
| Rate for Payer: HFN Commercial |
$1,631.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,329.90
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: NAPHCARE Commercial |
$1,063.92
|
| Rate for Payer: Preferred Network Access Commercial |
$1,631.34
|
| Rate for Payer: Quartz Beloit One Network |
$868.87
|
| Rate for Payer: Quartz Commercial |
$1,152.58
|
| Rate for Payer: Quartz Medicare Advantage |
$1,063.92
|
| Rate for Payer: The Alliance Commercial |
$886.60
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
XR Arthrogram Ankle Right
|
Professional
|
Both
|
$1,705.00
|
|
|
Service Code
|
CPT 73615 TC,RT
|
| Hospital Charge Code |
3072702
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$484.12 |
| Max. Negotiated Rate |
$1,684.54 |
| Rate for Payer: Aetna Commercial |
$1,684.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| 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 |
$1,684.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$886.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,063.92
|
| Rate for Payer: Health EOS Commercial |
$1,613.61
|
| Rate for Payer: HFN Commercial |
$1,684.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$484.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$484.12
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,684.54
|
| Rate for Payer: Quartz Beloit One Network |
$780.21
|
| Rate for Payer: Quartz Commercial |
$1,010.72
|
| Rate for Payer: The Alliance Commercial |
$886.60
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
XR Arthrogram Hip Left
|
Professional
|
Both
|
$1,133.00
|
|
|
Service Code
|
CPT 77002 TC,LT
|
| Hospital Charge Code |
3072703
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$411.36 |
| Max. Negotiated Rate |
$1,119.40 |
| Rate for Payer: Aetna Commercial |
$1,119.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,013.36
|
| 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 |
$1,119.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$589.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$706.99
|
| Rate for Payer: Health EOS Commercial |
$1,072.27
|
| Rate for Payer: HFN Commercial |
$1,119.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$411.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$411.36
|
| Rate for Payer: Multiplan Commercial |
$942.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,119.40
|
| Rate for Payer: Quartz Beloit One Network |
$518.46
|
| Rate for Payer: Quartz Commercial |
$671.64
|
| Rate for Payer: The Alliance Commercial |
$589.16
|
| Rate for Payer: WEA Trust Commercial |
$648.08
|
| Rate for Payer: WPS Commercial |
$872.75
|
|
|
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 |
$577.38 |
| Max. Negotiated Rate |
$1,084.05 |
| Rate for Payer: Aetna Commercial |
$1,060.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,013.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$624.51
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,084.05
|
| Rate for Payer: Health EOS Commercial |
$1,048.70
|
| Rate for Payer: HFN Commercial |
$1,084.05
|
| Rate for Payer: Multiplan Commercial |
$942.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,084.05
|
| Rate for Payer: Quartz Beloit One Network |
$577.38
|
| Rate for Payer: Quartz Commercial |
$706.99
|
| Rate for Payer: WEA Trust Commercial |
$648.08
|
| Rate for Payer: WPS Commercial |
$872.75
|
|
|
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 |
$313.04 |
| Max. Negotiated Rate |
$1,084.05 |
| Rate for Payer: Aetna Commercial |
$1,060.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,013.36
|
| Rate for Payer: Aetna Managed Medicare |
$329.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$765.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$589.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$565.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$624.51
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,084.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$659.41
|
| Rate for Payer: Health EOS Commercial |
$1,048.70
|
| Rate for Payer: HFN Commercial |
$1,084.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$883.74
|
| Rate for Payer: Multiplan Commercial |
$942.66
|
| Rate for Payer: NAPHCARE Commercial |
$706.99
|
| Rate for Payer: Preferred Network Access Commercial |
$1,084.05
|
| Rate for Payer: Quartz Beloit One Network |
$577.38
|
| Rate for Payer: Quartz Commercial |
$765.91
|
| Rate for Payer: Quartz Medicare Advantage |
$706.99
|
| Rate for Payer: The Alliance Commercial |
$589.16
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$648.08
|
| Rate for Payer: WPS Commercial |
$872.75
|
|
|
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 |
$313.04 |
| Max. Negotiated Rate |
$1,084.05 |
| Rate for Payer: Aetna Commercial |
$1,060.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,013.36
|
| Rate for Payer: Aetna Managed Medicare |
$329.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$765.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$589.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$565.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$624.51
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,084.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$659.41
|
| Rate for Payer: Health EOS Commercial |
$1,048.70
|
| Rate for Payer: HFN Commercial |
$1,084.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$883.74
|
| Rate for Payer: Multiplan Commercial |
$942.66
|
| Rate for Payer: NAPHCARE Commercial |
$706.99
|
| Rate for Payer: Preferred Network Access Commercial |
$1,084.05
|
| Rate for Payer: Quartz Beloit One Network |
$577.38
|
| Rate for Payer: Quartz Commercial |
$765.91
|
| Rate for Payer: Quartz Medicare Advantage |
$706.99
|
| Rate for Payer: The Alliance Commercial |
$589.16
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$648.08
|
| Rate for Payer: WPS Commercial |
$872.75
|
|
|
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 |
$577.38 |
| Max. Negotiated Rate |
$1,084.05 |
| Rate for Payer: Aetna Commercial |
$1,060.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,013.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$624.51
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,084.05
|
| Rate for Payer: Health EOS Commercial |
$1,048.70
|
| Rate for Payer: HFN Commercial |
$1,084.05
|
| Rate for Payer: Multiplan Commercial |
$942.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,084.05
|
| Rate for Payer: Quartz Beloit One Network |
$577.38
|
| Rate for Payer: Quartz Commercial |
$706.99
|
| Rate for Payer: WEA Trust Commercial |
$648.08
|
| Rate for Payer: WPS Commercial |
$872.75
|
|
|
XR Arthrogram Hip Right
|
Professional
|
Both
|
$1,133.00
|
|
|
Service Code
|
CPT 77002 TC,RT
|
| Hospital Charge Code |
3072704
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$411.36 |
| Max. Negotiated Rate |
$1,119.40 |
| Rate for Payer: Aetna Commercial |
$1,119.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,013.36
|
| 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 |
$1,119.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$589.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$706.99
|
| Rate for Payer: Health EOS Commercial |
$1,072.27
|
| Rate for Payer: HFN Commercial |
$1,119.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$411.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$411.36
|
| Rate for Payer: Multiplan Commercial |
$942.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,119.40
|
| Rate for Payer: Quartz Beloit One Network |
$518.46
|
| Rate for Payer: Quartz Commercial |
$671.64
|
| Rate for Payer: The Alliance Commercial |
$589.16
|
| Rate for Payer: WEA Trust Commercial |
$648.08
|
| Rate for Payer: WPS Commercial |
$872.75
|
|
|
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 |
$313.04 |
| Max. Negotiated Rate |
$1,686.84 |
| Rate for Payer: Aetna Commercial |
$1,650.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,576.83
|
| Rate for Payer: Aetna Managed Medicare |
$513.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,185.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,126.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$971.77
|
| 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 |
$1,686.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,026.07
|
| Rate for Payer: Health EOS Commercial |
$1,631.83
|
| Rate for Payer: HFN Commercial |
$1,686.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,375.14
|
| Rate for Payer: Multiplan Commercial |
$1,466.82
|
| Rate for Payer: NAPHCARE Commercial |
$1,100.11
|
| Rate for Payer: Preferred Network Access Commercial |
$1,686.84
|
| Rate for Payer: Quartz Beloit One Network |
$898.42
|
| Rate for Payer: Quartz Commercial |
$1,191.79
|
| Rate for Payer: Quartz Medicare Advantage |
$1,100.11
|
| Rate for Payer: The Alliance Commercial |
$916.76
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$1,008.44
|
| Rate for Payer: WPS Commercial |
$1,358.04
|
|
|
XR Arthrogram Knee Left
|
Professional
|
Both
|
$1,763.00
|
|
|
Service Code
|
CPT 73580 TC,LT
|
| Hospital Charge Code |
3072705
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$515.51 |
| Max. Negotiated Rate |
$1,741.84 |
| Rate for Payer: Aetna Commercial |
$1,741.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,576.83
|
| 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 |
$1,741.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$916.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,100.11
|
| Rate for Payer: Health EOS Commercial |
$1,668.50
|
| Rate for Payer: HFN Commercial |
$1,741.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$515.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$515.51
|
| Rate for Payer: Multiplan Commercial |
$1,466.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,741.84
|
| Rate for Payer: Quartz Beloit One Network |
$806.75
|
| Rate for Payer: Quartz Commercial |
$1,045.11
|
| Rate for Payer: The Alliance Commercial |
$916.76
|
| Rate for Payer: WEA Trust Commercial |
$1,008.44
|
| Rate for Payer: WPS Commercial |
$1,358.04
|
|
