|
X-ray Exam of Hand Min Three 7313026
|
Professional
|
Both
|
$106.00
|
|
|
Service Code
|
CPT 73130 26
|
| Hospital Charge Code |
3171548
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.44 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Aetna Commercial |
$100.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$100.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.60
|
| Rate for Payer: Health EOS Commercial |
$96.46
|
| Rate for Payer: HFN Commercial |
$100.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.44
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: Preferred Network Access Commercial |
$100.70
|
| Rate for Payer: Quartz Beloit One Network |
$46.64
|
| Rate for Payer: Quartz Commercial |
$60.42
|
| Rate for Payer: The Alliance Commercial |
$53.00
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
X-RAY Exam of Heel 7365026
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
CPT 73650 26
|
| Hospital Charge Code |
3206253
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$27.04 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.00
|
| Rate for Payer: Health EOS Commercial |
$81.90
|
| Rate for Payer: HFN Commercial |
$85.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.04
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$85.50
|
| Rate for Payer: Quartz Beloit One Network |
$39.60
|
| Rate for Payer: Quartz Commercial |
$51.30
|
| Rate for Payer: The Alliance Commercial |
$45.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
X-ray Exam of Knee, 3 View 73562
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
CPT 73562
|
| Hospital Charge Code |
3171475
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.32 |
| Max. Negotiated Rate |
$136.61 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.80
|
| Rate for Payer: Health EOS Commercial |
$70.98
|
| Rate for Payer: HFN Commercial |
$74.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$136.61
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$74.10
|
| Rate for Payer: Quartz Beloit One Network |
$34.32
|
| Rate for Payer: Quartz Commercial |
$44.46
|
| Rate for Payer: The Alliance Commercial |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
X-ray Exam of Knee, 3 View 7356226
|
Professional
|
Both
|
$111.00
|
|
|
Service Code
|
CPT 73562 26
|
| Hospital Charge Code |
3171480
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.81 |
| Max. Negotiated Rate |
$105.45 |
| Rate for Payer: Aetna Commercial |
$105.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$105.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.60
|
| Rate for Payer: Health EOS Commercial |
$101.01
|
| Rate for Payer: HFN Commercial |
$105.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.81
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$105.45
|
| Rate for Payer: Quartz Beloit One Network |
$48.84
|
| Rate for Payer: Quartz Commercial |
$63.27
|
| Rate for Payer: The Alliance Commercial |
$55.50
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
X-Ray Exam of Lower Spine 7211426
|
Professional
|
Both
|
$244.00
|
|
|
Service Code
|
CPT 72114 26
|
| Hospital Charge Code |
3451597
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.26 |
| Max. Negotiated Rate |
$231.80 |
| Rate for Payer: Aetna Commercial |
$231.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$231.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$122.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.40
|
| Rate for Payer: Health EOS Commercial |
$222.04
|
| Rate for Payer: HFN Commercial |
$231.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$51.26
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.80
|
| Rate for Payer: Quartz Beloit One Network |
$107.36
|
| Rate for Payer: Quartz Commercial |
$139.08
|
| Rate for Payer: The Alliance Commercial |
$122.00
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
X-ray Exam of Shoulder Complete 73030
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
CPT 73030
|
| Hospital Charge Code |
3171509
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$115.71 |
| Rate for Payer: Aetna Commercial |
$66.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.00
|
| Rate for Payer: Health EOS Commercial |
$63.70
|
| Rate for Payer: HFN Commercial |
$66.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$115.71
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: Preferred Network Access Commercial |
$66.50
|
| Rate for Payer: Quartz Beloit One Network |
$30.80
|
| Rate for Payer: Quartz Commercial |
$39.90
|
| Rate for Payer: The Alliance Commercial |
$35.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
X-ray Exam of Shoulder Min 7303026
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
CPT 73030 26
|
| Hospital Charge Code |
3171514
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.81 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.48
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.80
|
| Rate for Payer: Health EOS Commercial |
$107.38
|
| Rate for Payer: HFN Commercial |
$112.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.81
|
| Rate for Payer: Multiplan Commercial |
$94.40
|
| Rate for Payer: Preferred Network Access Commercial |
$112.10
|
| Rate for Payer: Quartz Beloit One Network |
$51.92
|
| Rate for Payer: Quartz Commercial |
$67.26
|
| Rate for Payer: The Alliance Commercial |
$59.00
|
| Rate for Payer: WEA Trust Commercial |
$64.90
|
| Rate for Payer: WPS Commercial |
$87.40
|
|
|
X-Ray Exam of Sinuses Waters View Only 70210
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
CPT 70210
|
| Hospital Charge Code |
3811616
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.72 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Aetna Commercial |
$154.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$154.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.80
|
| Rate for Payer: Health EOS Commercial |
$148.33
|
| Rate for Payer: HFN Commercial |
$154.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.69
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: Preferred Network Access Commercial |
$154.85
|
| Rate for Payer: Quartz Beloit One Network |
$71.72
|
| Rate for Payer: Quartz Commercial |
$92.91
|
| Rate for Payer: The Alliance Commercial |
$81.50
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
X-RAY Exam of Sinuses Waters View Only 7021026
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
CPT 70210 26
|
| Hospital Charge Code |
3814462
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.44 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Aetna Commercial |
$154.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$154.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.80
|
| Rate for Payer: Health EOS Commercial |
$148.33
|
| Rate for Payer: HFN Commercial |
$154.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.44
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: Preferred Network Access Commercial |
$154.85
|
| Rate for Payer: Quartz Beloit One Network |
$71.72
|
| Rate for Payer: Quartz Commercial |
$92.91
|
| Rate for Payer: The Alliance Commercial |
$81.50
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
X-RAY Exam of Sternum 7112026
|
Professional
|
Both
|
$113.00
|
|
|
Service Code
|
CPT 71120 26
|
| Hospital Charge Code |
3238214
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.11 |
| Max. Negotiated Rate |
$107.35 |
| Rate for Payer: Aetna Commercial |
$107.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97.18
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cigna Commercial |
$107.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.80
|
| Rate for Payer: Health EOS Commercial |
$102.83
|
| Rate for Payer: HFN Commercial |
$107.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33.11
|
| Rate for Payer: Multiplan Commercial |
$90.40
|
| Rate for Payer: Preferred Network Access Commercial |
$107.35
|
| Rate for Payer: Quartz Beloit One Network |
$49.72
|
| Rate for Payer: Quartz Commercial |
$64.41
|
| Rate for Payer: The Alliance Commercial |
$56.50
|
| Rate for Payer: WEA Trust Commercial |
$62.15
|
| Rate for Payer: WPS Commercial |
$83.70
|
|
|
X-RAY Exam of Toe(S) 7366026
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
CPT 73660 26
|
| Hospital Charge Code |
3238236
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.17 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Aetna Commercial |
$79.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$79.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.40
|
| Rate for Payer: Health EOS Commercial |
$76.44
|
| Rate for Payer: HFN Commercial |
$79.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22.17
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Preferred Network Access Commercial |
$79.80
|
| Rate for Payer: Quartz Beloit One Network |
$36.96
|
| Rate for Payer: Quartz Commercial |
$47.88
|
| Rate for Payer: The Alliance Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
X-ray Exam of Wrist Complete 73110
|
Professional
|
Both
|
$59.00
|
|
|
Service Code
|
CPT 73110
|
| Hospital Charge Code |
3149484
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.96 |
| Max. Negotiated Rate |
$136.54 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$53.69
|
| Rate for Payer: HFN Commercial |
$56.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$136.54
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: Preferred Network Access Commercial |
$56.05
|
| Rate for Payer: Quartz Beloit One Network |
$25.96
|
| Rate for Payer: Quartz Commercial |
$33.63
|
| Rate for Payer: The Alliance Commercial |
$29.50
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
X-ray Exam of Wrist Complete 7311026
|
Professional
|
Both
|
$101.00
|
|
|
Service Code
|
CPT 73110 26
|
| Hospital Charge Code |
3149490
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.44 |
| Max. Negotiated Rate |
$95.95 |
| Rate for Payer: Aetna Commercial |
$95.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.86
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.60
|
| Rate for Payer: Health EOS Commercial |
$91.91
|
| Rate for Payer: HFN Commercial |
$95.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.44
|
| Rate for Payer: Multiplan Commercial |
$80.80
|
| Rate for Payer: Preferred Network Access Commercial |
$95.95
|
| Rate for Payer: Quartz Beloit One Network |
$44.44
|
| Rate for Payer: Quartz Commercial |
$57.57
|
| Rate for Payer: The Alliance Commercial |
$50.50
|
| Rate for Payer: WEA Trust Commercial |
$55.55
|
| Rate for Payer: WPS Commercial |
$74.81
|
|
|
X-RAY Femur 73552
|
Professional
|
Both
|
$80.00
|
|
|
Service Code
|
CPT 73552
|
| Hospital Charge Code |
4605772
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.20 |
| Max. Negotiated Rate |
$119.21 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.00
|
| Rate for Payer: Health EOS Commercial |
$72.80
|
| Rate for Payer: HFN Commercial |
$76.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$119.21
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: Preferred Network Access Commercial |
$76.00
|
| Rate for Payer: Quartz Beloit One Network |
$35.20
|
| Rate for Payer: Quartz Commercial |
$45.60
|
| Rate for Payer: The Alliance Commercial |
$40.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
X-RAY Femur 7355226
|
Professional
|
Both
|
$80.00
|
|
|
Service Code
|
CPT 73552 26
|
| Hospital Charge Code |
4605773
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.64 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.00
|
| Rate for Payer: Health EOS Commercial |
$72.80
|
| Rate for Payer: HFN Commercial |
$76.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.64
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: Preferred Network Access Commercial |
$76.00
|
| Rate for Payer: Quartz Beloit One Network |
$35.20
|
| Rate for Payer: Quartz Commercial |
$45.60
|
| Rate for Payer: The Alliance Commercial |
$40.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
X-RAY Finger(S) 73140
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
CPT 73140
|
| Hospital Charge Code |
3209515
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$125.81 |
| Rate for Payer: Aetna Commercial |
$38.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.00
|
| Rate for Payer: Health EOS Commercial |
$36.40
|
| Rate for Payer: HFN Commercial |
$38.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$125.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$125.81
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: Preferred Network Access Commercial |
$38.00
|
| Rate for Payer: Quartz Beloit One Network |
$17.60
|
| Rate for Payer: Quartz Commercial |
$22.80
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
X-RAY Finger(S) 7314026
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
CPT 73140 26
|
| Hospital Charge Code |
3209520
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.33 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Aetna Commercial |
$96.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$96.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.20
|
| Rate for Payer: Health EOS Commercial |
$92.82
|
| Rate for Payer: HFN Commercial |
$96.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.33
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: Preferred Network Access Commercial |
$96.90
|
| Rate for Payer: Quartz Beloit One Network |
$44.88
|
| Rate for Payer: Quartz Commercial |
$58.14
|
| Rate for Payer: The Alliance Commercial |
$51.00
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
X-RAY Foot 2 View 73620
|
Professional
|
Both
|
$48.00
|
|
|
Service Code
|
CPT 73620
|
| Hospital Charge Code |
3209527
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$21.12 |
| Max. Negotiated Rate |
$95.84 |
| Rate for Payer: Aetna Commercial |
$45.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.80
|
| Rate for Payer: Health EOS Commercial |
$43.68
|
| Rate for Payer: HFN Commercial |
$45.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$95.84
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.60
|
| Rate for Payer: Quartz Beloit One Network |
$21.12
|
| Rate for Payer: Quartz Commercial |
$27.36
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
X-RAY Foot 2 View 7362026
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
CPT 73620 26
|
| Hospital Charge Code |
3209532
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$71.25 |
| Rate for Payer: Aetna Commercial |
$71.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$71.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.00
|
| Rate for Payer: Health EOS Commercial |
$68.25
|
| Rate for Payer: HFN Commercial |
$71.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.87
|
| Rate for Payer: Multiplan Commercial |
$60.00
|
| Rate for Payer: Preferred Network Access Commercial |
$71.25
|
| Rate for Payer: Quartz Beloit One Network |
$33.00
|
| Rate for Payer: Quartz Commercial |
$42.75
|
| Rate for Payer: The Alliance Commercial |
$37.50
|
| Rate for Payer: WEA Trust Commercial |
$41.25
|
| Rate for Payer: WPS Commercial |
$55.55
|
|
|
X-RAY Forearm 2 View Complete 73090
|
Professional
|
Both
|
$56.00
|
|
|
Service Code
|
CPT 73090
|
| Hospital Charge Code |
3209540
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$98.17 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.60
|
| Rate for Payer: Health EOS Commercial |
$50.96
|
| Rate for Payer: HFN Commercial |
$53.20
|
| 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: Multiplan Commercial |
$44.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.20
|
| Rate for Payer: Quartz Beloit One Network |
$24.64
|
| Rate for Payer: Quartz Commercial |
$31.92
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
X-RAY Forearm 2 View Complete 7309026
|
Professional
|
Both
|
$97.00
|
|
|
Service Code
|
CPT 73090 26
|
| Hospital Charge Code |
3209545
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$27.04 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Aetna Commercial |
$92.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.42
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$92.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$48.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Health EOS Commercial |
$88.27
|
| Rate for Payer: HFN Commercial |
$92.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.04
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.15
|
| Rate for Payer: Quartz Beloit One Network |
$42.68
|
| Rate for Payer: Quartz Commercial |
$55.29
|
| Rate for Payer: The Alliance Commercial |
$48.50
|
| Rate for Payer: WEA Trust Commercial |
$53.35
|
| Rate for Payer: WPS Commercial |
$71.85
|
|
|
X-RAY Hand 2 Views 73120
|
Professional
|
Both
|
$42.00
|
|
|
Service Code
|
CPT 73120
|
| Hospital Charge Code |
3209551
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$18.48 |
| Max. Negotiated Rate |
$105.12 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36.12
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$39.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.20
|
| Rate for Payer: Health EOS Commercial |
$38.22
|
| Rate for Payer: HFN Commercial |
$39.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$105.12
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$39.90
|
| Rate for Payer: Quartz Beloit One Network |
$18.48
|
| Rate for Payer: Quartz Commercial |
$23.94
|
| Rate for Payer: The Alliance Commercial |
$21.00
|
| Rate for Payer: WEA Trust Commercial |
$23.10
|
| Rate for Payer: WPS Commercial |
$31.11
|
|
|
X-RAY Hand 2 Views 7312026
|
Professional
|
Both
|
$69.00
|
|
|
Service Code
|
CPT 73120 26
|
| Hospital Charge Code |
3209556
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.20 |
| Max. Negotiated Rate |
$65.55 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.40
|
| Rate for Payer: Health EOS Commercial |
$62.79
|
| Rate for Payer: HFN Commercial |
$65.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.20
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$65.55
|
| Rate for Payer: Quartz Beloit One Network |
$30.36
|
| Rate for Payer: Quartz Commercial |
$39.33
|
| Rate for Payer: The Alliance Commercial |
$34.50
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
X-RAY Hip 2 Views 73502
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
CPT 73502
|
| Hospital Charge Code |
4605766
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$157.79 |
| Rate for Payer: Aetna Commercial |
$63.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$63.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.20
|
| Rate for Payer: Health EOS Commercial |
$60.97
|
| Rate for Payer: HFN Commercial |
$63.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$157.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$157.79
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: Preferred Network Access Commercial |
$63.65
|
| Rate for Payer: Quartz Beloit One Network |
$29.48
|
| Rate for Payer: Quartz Commercial |
$38.19
|
| Rate for Payer: The Alliance Commercial |
$33.50
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
X-RAY Hip 2 Views 7350226
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
CPT 73502 26
|
| Hospital Charge Code |
4605767
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Aetna Commercial |
$63.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$63.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.20
|
| Rate for Payer: Health EOS Commercial |
$60.97
|
| Rate for Payer: HFN Commercial |
$63.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$37.91
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: Preferred Network Access Commercial |
$63.65
|
| Rate for Payer: Quartz Beloit One Network |
$29.48
|
| Rate for Payer: Quartz Commercial |
$38.19
|
| Rate for Payer: The Alliance Commercial |
$33.50
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
