|
XR Skull < 4 Views
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
CPT 70250 TC
|
| Hospital Charge Code |
1537313
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$278.32 |
| Max. Negotiated Rate |
$522.56 |
| Rate for Payer: Aetna Commercial |
$511.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.04
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$522.56
|
| Rate for Payer: Health EOS Commercial |
$505.52
|
| Rate for Payer: HFN Commercial |
$522.56
|
| Rate for Payer: Multiplan Commercial |
$454.40
|
| Rate for Payer: NAPHCARE Commercial |
$340.80
|
| Rate for Payer: Preferred Network Access Commercial |
$522.56
|
| Rate for Payer: Quartz Beloit One Network |
$278.32
|
| Rate for Payer: Quartz Commercial |
$340.80
|
| Rate for Payer: WEA Trust Commercial |
$312.40
|
| Rate for Payer: WPS Commercial |
$420.72
|
|
|
XR Skull < 4 Views
|
Professional
|
Both
|
$568.00
|
|
|
Service Code
|
CPT 70250 TC
|
| Hospital Charge Code |
1537313
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.73 |
| Max. Negotiated Rate |
$539.60 |
| Rate for Payer: Aetna Commercial |
$539.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.48
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$539.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$284.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$340.80
|
| Rate for Payer: Health EOS Commercial |
$516.88
|
| Rate for Payer: HFN Commercial |
$539.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.73
|
| Rate for Payer: Multiplan Commercial |
$454.40
|
| Rate for Payer: Preferred Network Access Commercial |
$539.60
|
| Rate for Payer: Quartz Beloit One Network |
$249.92
|
| Rate for Payer: Quartz Commercial |
$323.76
|
| Rate for Payer: The Alliance Commercial |
$284.00
|
| Rate for Payer: WEA Trust Commercial |
$312.40
|
| Rate for Payer: WPS Commercial |
$420.72
|
|
|
XR Skull < 4 Views
|
Professional
|
Both
|
$568.00
|
|
|
Service Code
|
CPT 70250 TC
|
| Hospital Charge Code |
5510675
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.73 |
| Max. Negotiated Rate |
$539.60 |
| Rate for Payer: Aetna Commercial |
$539.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.48
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$539.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$284.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$340.80
|
| Rate for Payer: Health EOS Commercial |
$516.88
|
| Rate for Payer: HFN Commercial |
$539.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.73
|
| Rate for Payer: Multiplan Commercial |
$454.40
|
| Rate for Payer: Preferred Network Access Commercial |
$539.60
|
| Rate for Payer: Quartz Beloit One Network |
$249.92
|
| Rate for Payer: Quartz Commercial |
$323.76
|
| Rate for Payer: The Alliance Commercial |
$284.00
|
| Rate for Payer: WEA Trust Commercial |
$312.40
|
| Rate for Payer: WPS Commercial |
$420.72
|
|
|
XR Skull < 4 Views
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
CPT 70250 TC
|
| Hospital Charge Code |
5510675
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$278.32 |
| Max. Negotiated Rate |
$522.56 |
| Rate for Payer: Aetna Commercial |
$511.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.04
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$522.56
|
| Rate for Payer: Health EOS Commercial |
$505.52
|
| Rate for Payer: HFN Commercial |
$522.56
|
| Rate for Payer: Multiplan Commercial |
$454.40
|
| Rate for Payer: NAPHCARE Commercial |
$340.80
|
| Rate for Payer: Preferred Network Access Commercial |
$522.56
|
| Rate for Payer: Quartz Beloit One Network |
$278.32
|
| Rate for Payer: Quartz Commercial |
$340.80
|
| Rate for Payer: WEA Trust Commercial |
$312.40
|
| Rate for Payer: WPS Commercial |
$420.72
|
|
|
XR Skull < 4 Views
|
Facility
|
IP
|
$586.00
|
|
|
Service Code
|
CPT 70250
|
| Hospital Charge Code |
630096
|
| Min. Negotiated Rate |
$287.14 |
| Max. Negotiated Rate |
$539.12 |
| Rate for Payer: Aetna Commercial |
$527.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$503.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$310.58
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$539.12
|
| Rate for Payer: Health EOS Commercial |
$521.54
|
| Rate for Payer: HFN Commercial |
$539.12
|
| Rate for Payer: Multiplan Commercial |
$468.80
|
| Rate for Payer: NAPHCARE Commercial |
$351.60
|
| Rate for Payer: Preferred Network Access Commercial |
$539.12
|
| Rate for Payer: Quartz Beloit One Network |
$287.14
|
| Rate for Payer: Quartz Commercial |
$351.60
|
| Rate for Payer: WEA Trust Commercial |
$322.30
|
| Rate for Payer: WPS Commercial |
$434.05
|
|
|
XR Skull Complete
|
Facility
|
OP
|
$687.00
|
|
|
Service Code
|
CPT 70260
|
| Hospital Charge Code |
630092
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$632.04 |
| Rate for Payer: Aetna Commercial |
$618.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$590.82
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$446.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$343.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$329.76
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$364.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cigna Commercial |
$632.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$384.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$611.43
|
| Rate for Payer: HFN Commercial |
$632.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$549.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$632.04
|
| Rate for Payer: Quartz Beloit One Network |
$336.63
|
| Rate for Payer: Quartz Commercial |
$446.55
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$377.85
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$508.86
|
|
|
XR Skull Complete
|
Professional
|
Both
|
$687.00
|
|
|
Service Code
|
CPT 70260
|
| Hospital Charge Code |
630092
|
| Min. Negotiated Rate |
$152.39 |
| Max. Negotiated Rate |
$652.65 |
| Rate for Payer: Aetna Commercial |
$652.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$590.82
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cigna Commercial |
$652.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$343.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$412.20
|
| Rate for Payer: Health EOS Commercial |
$625.17
|
| Rate for Payer: HFN Commercial |
$652.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$152.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$152.39
|
| Rate for Payer: Multiplan Commercial |
$549.60
|
| Rate for Payer: Preferred Network Access Commercial |
$652.65
|
| Rate for Payer: Quartz Beloit One Network |
$302.28
|
| Rate for Payer: Quartz Commercial |
$391.59
|
| Rate for Payer: The Alliance Commercial |
$343.50
|
| Rate for Payer: WEA Trust Commercial |
$377.85
|
| Rate for Payer: WPS Commercial |
$508.86
|
|
|
XR Skull Complete
|
Facility
|
OP
|
$743.00
|
|
|
Service Code
|
CPT 70260 TC
|
| Hospital Charge Code |
1537315
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$683.56 |
| Rate for Payer: Aetna Commercial |
$668.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$638.98
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$407.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$326.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$309.71
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$393.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$222.90
|
| Rate for Payer: Cash Price |
$222.90
|
| Rate for Payer: Cash Price |
$222.90
|
| Rate for Payer: Cigna Commercial |
$683.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$415.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$661.27
|
| Rate for Payer: HFN Commercial |
$683.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$594.40
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$683.56
|
| Rate for Payer: Quartz Beloit One Network |
$364.07
|
| Rate for Payer: Quartz Commercial |
$482.95
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$408.65
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$550.34
|
|
|
XR Skull Complete
|
Facility
|
IP
|
$743.00
|
|
|
Service Code
|
CPT 70260 TC
|
| Hospital Charge Code |
1537315
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$364.07 |
| Max. Negotiated Rate |
$683.56 |
| Rate for Payer: Aetna Commercial |
$668.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$638.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$393.79
|
| Rate for Payer: Cash Price |
$222.90
|
| Rate for Payer: Cigna Commercial |
$683.56
|
| Rate for Payer: Health EOS Commercial |
$661.27
|
| Rate for Payer: HFN Commercial |
$683.56
|
| Rate for Payer: Multiplan Commercial |
$594.40
|
| Rate for Payer: NAPHCARE Commercial |
$445.80
|
| Rate for Payer: Preferred Network Access Commercial |
$683.56
|
| Rate for Payer: Quartz Beloit One Network |
$364.07
|
| Rate for Payer: Quartz Commercial |
$445.80
|
| Rate for Payer: WEA Trust Commercial |
$408.65
|
| Rate for Payer: WPS Commercial |
$550.34
|
|
|
XR Skull Complete
|
Professional
|
Both
|
$743.00
|
|
|
Service Code
|
CPT 70260 TC
|
| Hospital Charge Code |
1537315
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$104.77 |
| Max. Negotiated Rate |
$705.85 |
| Rate for Payer: Aetna Commercial |
$705.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$638.98
|
| Rate for Payer: Cash Price |
$222.90
|
| Rate for Payer: Cash Price |
$222.90
|
| Rate for Payer: Cash Price |
$222.90
|
| Rate for Payer: Cigna Commercial |
$705.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$371.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$445.80
|
| Rate for Payer: Health EOS Commercial |
$676.13
|
| Rate for Payer: HFN Commercial |
$705.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$104.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$104.77
|
| Rate for Payer: Multiplan Commercial |
$594.40
|
| Rate for Payer: Preferred Network Access Commercial |
$705.85
|
| Rate for Payer: Quartz Beloit One Network |
$326.92
|
| Rate for Payer: Quartz Commercial |
$423.51
|
| Rate for Payer: The Alliance Commercial |
$371.50
|
| Rate for Payer: WEA Trust Commercial |
$408.65
|
| Rate for Payer: WPS Commercial |
$550.34
|
|
|
XR Skull Complete
|
Facility
|
IP
|
$687.00
|
|
|
Service Code
|
CPT 70260
|
| Hospital Charge Code |
630092
|
| Min. Negotiated Rate |
$336.63 |
| Max. Negotiated Rate |
$632.04 |
| Rate for Payer: Aetna Commercial |
$618.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$590.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$364.11
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cigna Commercial |
$632.04
|
| Rate for Payer: Health EOS Commercial |
$611.43
|
| Rate for Payer: HFN Commercial |
$632.04
|
| Rate for Payer: Multiplan Commercial |
$549.60
|
| Rate for Payer: NAPHCARE Commercial |
$412.20
|
| Rate for Payer: Preferred Network Access Commercial |
$632.04
|
| Rate for Payer: Quartz Beloit One Network |
$336.63
|
| Rate for Payer: Quartz Commercial |
$412.20
|
| Rate for Payer: WEA Trust Commercial |
$377.85
|
| Rate for Payer: WPS Commercial |
$508.86
|
|
|
XR Small Bowel
|
Facility
|
IP
|
$912.00
|
|
|
Service Code
|
CPT 74248
|
| Hospital Charge Code |
5609775
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$446.88 |
| Max. Negotiated Rate |
$839.04 |
| Rate for Payer: Aetna Commercial |
$820.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$784.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$483.36
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cigna Commercial |
$839.04
|
| Rate for Payer: Health EOS Commercial |
$811.68
|
| Rate for Payer: HFN Commercial |
$839.04
|
| Rate for Payer: Multiplan Commercial |
$729.60
|
| Rate for Payer: NAPHCARE Commercial |
$547.20
|
| Rate for Payer: Preferred Network Access Commercial |
$839.04
|
| Rate for Payer: Quartz Beloit One Network |
$446.88
|
| Rate for Payer: Quartz Commercial |
$547.20
|
| Rate for Payer: WEA Trust Commercial |
$501.60
|
| Rate for Payer: WPS Commercial |
$675.52
|
|
|
XR Small Bowel
|
Professional
|
Both
|
$912.00
|
|
|
Service Code
|
CPT 74248
|
| Hospital Charge Code |
5609775
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$290.73 |
| Max. Negotiated Rate |
$866.40 |
| Rate for Payer: Aetna Commercial |
$866.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$784.32
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cigna Commercial |
$866.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$456.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$547.20
|
| Rate for Payer: Health EOS Commercial |
$829.92
|
| Rate for Payer: HFN Commercial |
$866.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$290.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$290.73
|
| Rate for Payer: Multiplan Commercial |
$729.60
|
| Rate for Payer: Preferred Network Access Commercial |
$866.40
|
| Rate for Payer: Quartz Beloit One Network |
$401.28
|
| Rate for Payer: Quartz Commercial |
$519.84
|
| Rate for Payer: The Alliance Commercial |
$456.00
|
| Rate for Payer: WEA Trust Commercial |
$501.60
|
| Rate for Payer: WPS Commercial |
$675.52
|
|
|
XR Small Bowel
|
Facility
|
OP
|
$912.00
|
|
|
Service Code
|
CPT 74248
|
| Hospital Charge Code |
5609775
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$255.36 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$820.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$784.32
|
| Rate for Payer: Aetna Managed Medicare |
$255.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$592.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$456.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$437.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$483.36
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cigna Commercial |
$839.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$510.36
|
| Rate for Payer: Health EOS Commercial |
$811.68
|
| Rate for Payer: HFN Commercial |
$839.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$684.00
|
| Rate for Payer: Multiplan Commercial |
$729.60
|
| Rate for Payer: NAPHCARE Commercial |
$547.20
|
| Rate for Payer: Preferred Network Access Commercial |
$839.04
|
| Rate for Payer: Quartz Beloit One Network |
$446.88
|
| Rate for Payer: Quartz Commercial |
$592.80
|
| Rate for Payer: Quartz Medicare Advantage |
$547.20
|
| Rate for Payer: The Alliance Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$501.60
|
| Rate for Payer: WPS Commercial |
$675.52
|
|
|
XR Small Bowel w/ Serial Films
|
Facility
|
OP
|
$985.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
1537319
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$906.20 |
| Rate for Payer: Aetna Commercial |
$886.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$847.10
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$681.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$544.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$517.56
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$522.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cigna Commercial |
$906.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$551.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$876.65
|
| Rate for Payer: HFN Commercial |
$906.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$788.00
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$906.20
|
| Rate for Payer: Quartz Beloit One Network |
$482.65
|
| Rate for Payer: Quartz Commercial |
$640.25
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$726.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$541.75
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$729.59
|
|
|
XR Small Bowel w/ Serial Films
|
Facility
|
IP
|
$985.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
1537319
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$482.65 |
| Max. Negotiated Rate |
$906.20 |
| Rate for Payer: Aetna Commercial |
$886.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$847.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$522.05
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cigna Commercial |
$906.20
|
| Rate for Payer: Health EOS Commercial |
$876.65
|
| Rate for Payer: HFN Commercial |
$906.20
|
| Rate for Payer: Multiplan Commercial |
$788.00
|
| Rate for Payer: NAPHCARE Commercial |
$591.00
|
| Rate for Payer: Preferred Network Access Commercial |
$906.20
|
| Rate for Payer: Quartz Beloit One Network |
$482.65
|
| Rate for Payer: Quartz Commercial |
$591.00
|
| Rate for Payer: WEA Trust Commercial |
$541.75
|
| Rate for Payer: WPS Commercial |
$729.59
|
|
|
XR Small Bowel w/ Serial Films
|
Professional
|
Both
|
$985.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
1537319
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$428.79 |
| Max. Negotiated Rate |
$935.75 |
| Rate for Payer: Aetna Commercial |
$935.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$847.10
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cigna Commercial |
$935.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$492.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$591.00
|
| Rate for Payer: Health EOS Commercial |
$896.35
|
| Rate for Payer: HFN Commercial |
$935.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$428.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$428.79
|
| Rate for Payer: Multiplan Commercial |
$788.00
|
| Rate for Payer: Preferred Network Access Commercial |
$935.75
|
| Rate for Payer: Quartz Beloit One Network |
$433.40
|
| Rate for Payer: Quartz Commercial |
$561.45
|
| Rate for Payer: The Alliance Commercial |
$492.50
|
| Rate for Payer: WEA Trust Commercial |
$541.75
|
| Rate for Payer: WPS Commercial |
$729.59
|
|
|
XR Small Bowel w/ Serial Films
|
Facility
|
OP
|
$912.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
630084
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$839.04 |
| Rate for Payer: Aetna Commercial |
$820.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$784.32
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$592.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$456.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$437.76
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$483.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cigna Commercial |
$839.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$510.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$811.68
|
| Rate for Payer: HFN Commercial |
$839.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$729.60
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$839.04
|
| Rate for Payer: Quartz Beloit One Network |
$446.88
|
| Rate for Payer: Quartz Commercial |
$592.80
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$726.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: WEA Trust Commercial |
$501.60
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$675.52
|
|
|
XR Small Bowel w/ Serial Films
|
Facility
|
IP
|
$912.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
630084
|
| Min. Negotiated Rate |
$446.88 |
| Max. Negotiated Rate |
$839.04 |
| Rate for Payer: Aetna Commercial |
$820.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$784.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$483.36
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cigna Commercial |
$839.04
|
| Rate for Payer: Health EOS Commercial |
$811.68
|
| Rate for Payer: HFN Commercial |
$839.04
|
| Rate for Payer: Multiplan Commercial |
$729.60
|
| Rate for Payer: NAPHCARE Commercial |
$547.20
|
| Rate for Payer: Preferred Network Access Commercial |
$839.04
|
| Rate for Payer: Quartz Beloit One Network |
$446.88
|
| Rate for Payer: Quartz Commercial |
$547.20
|
| Rate for Payer: WEA Trust Commercial |
$501.60
|
| Rate for Payer: WPS Commercial |
$675.52
|
|
|
XR Small Bowel w/ Serial Films
|
Professional
|
Both
|
$912.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
630084
|
| Min. Negotiated Rate |
$401.28 |
| Max. Negotiated Rate |
$866.40 |
| Rate for Payer: Aetna Commercial |
$866.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$784.32
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cigna Commercial |
$866.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$456.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$547.20
|
| Rate for Payer: Health EOS Commercial |
$829.92
|
| Rate for Payer: HFN Commercial |
$866.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$428.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$428.79
|
| Rate for Payer: Multiplan Commercial |
$729.60
|
| Rate for Payer: Preferred Network Access Commercial |
$866.40
|
| Rate for Payer: Quartz Beloit One Network |
$401.28
|
| Rate for Payer: Quartz Commercial |
$519.84
|
| Rate for Payer: The Alliance Commercial |
$456.00
|
| Rate for Payer: WEA Trust Commercial |
$501.60
|
| Rate for Payer: WPS Commercial |
$675.52
|
|
|
XR Sniff Test
|
Facility
|
IP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000 TC
|
| Hospital Charge Code |
5084629
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$519.40 |
| Max. Negotiated Rate |
$975.20 |
| Rate for Payer: Aetna Commercial |
$954.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$561.80
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$975.20
|
| Rate for Payer: Health EOS Commercial |
$943.40
|
| Rate for Payer: HFN Commercial |
$975.20
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: NAPHCARE Commercial |
$636.00
|
| Rate for Payer: Preferred Network Access Commercial |
$975.20
|
| Rate for Payer: Quartz Beloit One Network |
$519.40
|
| Rate for Payer: Quartz Commercial |
$636.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR Sniff Test
|
Professional
|
Both
|
$1,060.00
|
|
|
Service Code
|
CPT 76000 TC
|
| Hospital Charge Code |
5084629
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$92.03 |
| Max. Negotiated Rate |
$1,007.00 |
| Rate for Payer: Aetna Commercial |
$1,007.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$1,007.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$530.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.00
|
| Rate for Payer: Health EOS Commercial |
$964.60
|
| Rate for Payer: HFN Commercial |
$1,007.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$92.03
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,007.00
|
| Rate for Payer: Quartz Beloit One Network |
$466.40
|
| Rate for Payer: Quartz Commercial |
$604.20
|
| Rate for Payer: The Alliance Commercial |
$530.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR Sniff Test
|
Facility
|
OP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000 TC
|
| Hospital Charge Code |
5084629
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$975.20 |
| Rate for Payer: Aetna Commercial |
$954.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$908.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$726.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$690.27
|
| Rate for Payer: Anthem Medicare Advantage |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$561.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$975.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$593.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$943.40
|
| Rate for Payer: HFN Commercial |
$975.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$975.20
|
| Rate for Payer: Quartz Beloit One Network |
$519.40
|
| Rate for Payer: Quartz Commercial |
$689.00
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR Spine 1 View Cervical
|
Facility
|
IP
|
$560.00
|
|
|
Service Code
|
CPT 72020 TC
|
| Hospital Charge Code |
1537323
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$274.40 |
| Max. Negotiated Rate |
$515.20 |
| Rate for Payer: Aetna Commercial |
$504.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$481.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$296.80
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cigna Commercial |
$515.20
|
| Rate for Payer: Health EOS Commercial |
$498.40
|
| Rate for Payer: HFN Commercial |
$515.20
|
| Rate for Payer: Multiplan Commercial |
$448.00
|
| Rate for Payer: NAPHCARE Commercial |
$336.00
|
| Rate for Payer: Preferred Network Access Commercial |
$515.20
|
| Rate for Payer: Quartz Beloit One Network |
$274.40
|
| Rate for Payer: Quartz Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$308.00
|
| Rate for Payer: WPS Commercial |
$414.79
|
|
|
XR Spine 1 View Cervical
|
Facility
|
OP
|
$560.00
|
|
|
Service Code
|
CPT 72020 TC
|
| Hospital Charge Code |
1537323
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$515.20 |
| Rate for Payer: Aetna Commercial |
$504.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$481.60
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.99
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$296.80
|
| 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 |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cigna Commercial |
$515.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$313.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$498.40
|
| Rate for Payer: HFN Commercial |
$515.20
|
| 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 |
$448.00
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$515.20
|
| Rate for Payer: Quartz Beloit One Network |
$274.40
|
| Rate for Payer: Quartz Commercial |
$364.00
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$308.00
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$414.79
|
|
