|
XR Spine Cervical 2 or 3 Views
|
Professional
|
$665.00
|
|
|
Service Code
|
CPT 72040 TC
|
| Hospital Charge Code |
5510672
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$27.79 |
| Max. Negotiated Rate |
$631.75 |
| Rate for Payer: Aetna Commercial |
$631.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$571.90
|
| Rate for Payer: Aetna Managed Medicare |
$27.79
|
| Rate for Payer: Anthem Medicare Advantage |
$27.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.79
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cigna Commercial |
$631.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$332.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.79
|
| Rate for Payer: Health EOS Commercial |
$605.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$95.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.79
|
| Rate for Payer: Multiplan Commercial |
$532.00
|
| Rate for Payer: Preferred Network Access Commercial |
$631.75
|
| Rate for Payer: Quartz Beloit One Network |
$292.60
|
| Rate for Payer: Quartz Commercial |
$379.05
|
| Rate for Payer: Quartz Medicare Advantage |
$27.79
|
| Rate for Payer: The Alliance Commercial |
$105.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.79
|
| Rate for Payer: WEA Trust Commercial |
$365.75
|
| Rate for Payer: WPS Commercial |
$138.95
|
|
|
XR Spine Cervical 2 or 3 Views
|
Facility
IP
|
$665.00
|
|
|
Service Code
|
CPT 72040 TC
|
| Hospital Charge Code |
1537329
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$325.85 |
| Max. Negotiated Rate |
$611.80 |
| Rate for Payer: Aetna Commercial |
$598.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$352.45
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cigna Commercial |
$611.80
|
| Rate for Payer: Health EOS Commercial |
$591.85
|
| Rate for Payer: HFN Commercial |
$611.80
|
| Rate for Payer: Multiplan Commercial |
$532.00
|
| Rate for Payer: NAPHCARE Commercial |
$399.00
|
| Rate for Payer: Preferred Network Access Commercial |
$611.80
|
| Rate for Payer: Quartz Beloit One Network |
$325.85
|
| Rate for Payer: Quartz Commercial |
$399.00
|
| Rate for Payer: WEA Trust Commercial |
$365.75
|
| Rate for Payer: WPS Commercial |
$492.57
|
|
|
XR Spine Cervical 2 or 3 Views
|
Facility
IP
|
$665.00
|
|
|
Service Code
|
CPT 72040 TC
|
| Hospital Charge Code |
5510672
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$325.85 |
| Max. Negotiated Rate |
$611.80 |
| Rate for Payer: Aetna Commercial |
$598.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$352.45
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cigna Commercial |
$611.80
|
| Rate for Payer: Health EOS Commercial |
$591.85
|
| Rate for Payer: HFN Commercial |
$611.80
|
| Rate for Payer: Multiplan Commercial |
$532.00
|
| Rate for Payer: NAPHCARE Commercial |
$399.00
|
| Rate for Payer: Preferred Network Access Commercial |
$611.80
|
| Rate for Payer: Quartz Beloit One Network |
$325.85
|
| Rate for Payer: Quartz Commercial |
$399.00
|
| Rate for Payer: WEA Trust Commercial |
$365.75
|
| Rate for Payer: WPS Commercial |
$492.57
|
|
|
XR Spine Cervical 2 or 3 Views
|
Facility
OP
|
$665.00
|
|
|
Service Code
|
CPT 72040 TC
|
| Hospital Charge Code |
1537329
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$186.20 |
| Max. Negotiated Rate |
$2,660.00 |
| Rate for Payer: Aetna Commercial |
$598.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$571.90
|
| Rate for Payer: Aetna Managed Medicare |
$186.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$432.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$332.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$319.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$352.45
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cigna Commercial |
$611.80
|
| Rate for Payer: Health EOS Commercial |
$591.85
|
| Rate for Payer: HFN Commercial |
$611.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$498.75
|
| Rate for Payer: Multiplan Commercial |
$532.00
|
| Rate for Payer: NAPHCARE Commercial |
$399.00
|
| Rate for Payer: Preferred Network Access Commercial |
$611.80
|
| Rate for Payer: Quartz Beloit One Network |
$325.85
|
| Rate for Payer: Quartz Commercial |
$432.25
|
| Rate for Payer: Quartz Medicare Advantage |
$399.00
|
| Rate for Payer: The Alliance Commercial |
$2,660.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$365.75
|
| Rate for Payer: WPS Commercial |
$492.57
|
|
|
XR Spine Cervical 2 or 3 Views
|
Professional
|
$615.00
|
|
|
Service Code
|
CPT 72040
|
| Hospital Charge Code |
629600
|
| Min. Negotiated Rate |
$38.25 |
| Max. Negotiated Rate |
$584.25 |
| Rate for Payer: Aetna Commercial |
$584.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.90
|
| Rate for Payer: Aetna Managed Medicare |
$38.25
|
| Rate for Payer: Anthem Medicare Advantage |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$38.25
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$584.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$307.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.25
|
| Rate for Payer: Health EOS Commercial |
$559.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$133.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$38.25
|
| Rate for Payer: Multiplan Commercial |
$492.00
|
| Rate for Payer: Preferred Network Access Commercial |
$584.25
|
| Rate for Payer: Quartz Beloit One Network |
$270.60
|
| Rate for Payer: Quartz Commercial |
$350.55
|
| Rate for Payer: Quartz Medicare Advantage |
$38.25
|
| Rate for Payer: The Alliance Commercial |
$145.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.25
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: WPS Commercial |
$191.25
|
|
|
XR Spine Cervical 2 or 3 Views
|
Facility
OP
|
$665.00
|
|
|
Service Code
|
CPT 72040 TC
|
| Hospital Charge Code |
5510672
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$186.20 |
| Max. Negotiated Rate |
$2,660.00 |
| Rate for Payer: Aetna Commercial |
$598.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$571.90
|
| Rate for Payer: Aetna Managed Medicare |
$186.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$432.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$332.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$319.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$352.45
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cigna Commercial |
$611.80
|
| Rate for Payer: Health EOS Commercial |
$591.85
|
| Rate for Payer: HFN Commercial |
$611.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$498.75
|
| Rate for Payer: Multiplan Commercial |
$532.00
|
| Rate for Payer: NAPHCARE Commercial |
$399.00
|
| Rate for Payer: Preferred Network Access Commercial |
$611.80
|
| Rate for Payer: Quartz Beloit One Network |
$325.85
|
| Rate for Payer: Quartz Commercial |
$432.25
|
| Rate for Payer: Quartz Medicare Advantage |
$399.00
|
| Rate for Payer: The Alliance Commercial |
$2,660.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$365.75
|
| Rate for Payer: WPS Commercial |
$492.57
|
|
|
XR Spine Cervical 2 or 3 Views
|
Facility
IP
|
$615.00
|
|
|
Service Code
|
CPT 72040
|
| Hospital Charge Code |
629600
|
| Min. Negotiated Rate |
$301.35 |
| Max. Negotiated Rate |
$565.80 |
| Rate for Payer: Aetna Commercial |
$553.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.95
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$565.80
|
| Rate for Payer: Health EOS Commercial |
$547.35
|
| Rate for Payer: HFN Commercial |
$565.80
|
| Rate for Payer: Multiplan Commercial |
$492.00
|
| Rate for Payer: NAPHCARE Commercial |
$369.00
|
| Rate for Payer: Preferred Network Access Commercial |
$565.80
|
| Rate for Payer: Quartz Beloit One Network |
$301.35
|
| Rate for Payer: Quartz Commercial |
$369.00
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: WPS Commercial |
$455.53
|
|
|
XR Spine Cervical 2 or 3 Views
|
Facility
OP
|
$615.00
|
|
|
Service Code
|
CPT 72040
|
| Hospital Charge Code |
629600
|
| Min. Negotiated Rate |
$88.00 |
| Max. Negotiated Rate |
$565.80 |
| Rate for Payer: Aetna Commercial |
$553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.90
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$399.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$295.20
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.95
|
| 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 |
$184.50
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$565.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$547.35
|
| Rate for Payer: HFN Commercial |
$565.80
|
| 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 |
$492.00
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$565.80
|
| Rate for Payer: Quartz Beloit One Network |
$301.35
|
| Rate for Payer: Quartz Commercial |
$399.75
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$88.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$455.53
|
|
|
XR Spine Cervical Comp w/ Obliques
|
Facility
IP
|
$932.00
|
|
|
Service Code
|
CPT 72050 TC
|
| Hospital Charge Code |
1537331
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$456.68 |
| Max. Negotiated Rate |
$857.44 |
| Rate for Payer: Aetna Commercial |
$838.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$493.96
|
| Rate for Payer: Cash Price |
$279.60
|
| Rate for Payer: Cigna Commercial |
$857.44
|
| Rate for Payer: Health EOS Commercial |
$829.48
|
| Rate for Payer: HFN Commercial |
$857.44
|
| Rate for Payer: Multiplan Commercial |
$745.60
|
| Rate for Payer: NAPHCARE Commercial |
$559.20
|
| Rate for Payer: Preferred Network Access Commercial |
$857.44
|
| Rate for Payer: Quartz Beloit One Network |
$456.68
|
| Rate for Payer: Quartz Commercial |
$559.20
|
| Rate for Payer: WEA Trust Commercial |
$512.60
|
| Rate for Payer: WPS Commercial |
$690.33
|
|
|
XR Spine Cervical Comp w/ Obliques
|
Facility
OP
|
$932.00
|
|
|
Service Code
|
CPT 72050 TC
|
| Hospital Charge Code |
1537331
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$260.96 |
| Max. Negotiated Rate |
$3,728.00 |
| Rate for Payer: Aetna Commercial |
$838.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$801.52
|
| Rate for Payer: Aetna Managed Medicare |
$260.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$605.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$466.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$447.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$493.96
|
| Rate for Payer: Cash Price |
$279.60
|
| Rate for Payer: Cash Price |
$279.60
|
| Rate for Payer: Cash Price |
$279.60
|
| Rate for Payer: Cigna Commercial |
$857.44
|
| Rate for Payer: Health EOS Commercial |
$829.48
|
| Rate for Payer: HFN Commercial |
$857.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$699.00
|
| Rate for Payer: Multiplan Commercial |
$745.60
|
| Rate for Payer: NAPHCARE Commercial |
$559.20
|
| Rate for Payer: Preferred Network Access Commercial |
$857.44
|
| Rate for Payer: Quartz Beloit One Network |
$456.68
|
| Rate for Payer: Quartz Commercial |
$605.80
|
| Rate for Payer: Quartz Medicare Advantage |
$559.20
|
| Rate for Payer: The Alliance Commercial |
$3,728.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$512.60
|
| Rate for Payer: WPS Commercial |
$690.33
|
|
|
XR Spine Cervical Comp w/ Obliques
|
Facility
IP
|
$1,138.00
|
|
|
Service Code
|
CPT 72052
|
| Hospital Charge Code |
629602
|
| Min. Negotiated Rate |
$557.62 |
| Max. Negotiated Rate |
$1,046.96 |
| Rate for Payer: Aetna Commercial |
$1,024.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.14
|
| Rate for Payer: Cash Price |
$341.40
|
| Rate for Payer: Cigna Commercial |
$1,046.96
|
| Rate for Payer: Health EOS Commercial |
$1,012.82
|
| Rate for Payer: HFN Commercial |
$1,046.96
|
| Rate for Payer: Multiplan Commercial |
$910.40
|
| Rate for Payer: NAPHCARE Commercial |
$682.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.96
|
| Rate for Payer: Quartz Beloit One Network |
$557.62
|
| Rate for Payer: Quartz Commercial |
$682.80
|
| Rate for Payer: WEA Trust Commercial |
$625.90
|
| Rate for Payer: WPS Commercial |
$842.92
|
|
|
XR Spine Cervical Comp w/ Obliques
|
Professional
|
$1,138.00
|
|
|
Service Code
|
CPT 72052
|
| Hospital Charge Code |
629602
|
| Min. Negotiated Rate |
$60.06 |
| Max. Negotiated Rate |
$1,081.10 |
| Rate for Payer: Aetna Commercial |
$1,081.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$978.68
|
| Rate for Payer: Aetna Managed Medicare |
$60.06
|
| Rate for Payer: Anthem Medicare Advantage |
$60.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.06
|
| Rate for Payer: Cash Price |
$341.40
|
| Rate for Payer: Cash Price |
$341.40
|
| Rate for Payer: Cigna Commercial |
$1,081.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$569.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.06
|
| Rate for Payer: Health EOS Commercial |
$1,035.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$210.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.06
|
| Rate for Payer: Multiplan Commercial |
$910.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,081.10
|
| Rate for Payer: Quartz Beloit One Network |
$500.72
|
| Rate for Payer: Quartz Commercial |
$648.66
|
| Rate for Payer: Quartz Medicare Advantage |
$60.06
|
| Rate for Payer: The Alliance Commercial |
$228.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.06
|
| Rate for Payer: WEA Trust Commercial |
$625.90
|
| Rate for Payer: WPS Commercial |
$300.30
|
|
|
XR Spine Cervical Comp w/ Obliques
|
Facility
OP
|
$1,138.00
|
|
|
Service Code
|
CPT 72052
|
| Hospital Charge Code |
629602
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$5,247.00 |
| Rate for Payer: Aetna Commercial |
$1,024.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$978.68
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$739.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$569.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$546.24
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.14
|
| 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 |
$341.40
|
| Rate for Payer: Cash Price |
$341.40
|
| Rate for Payer: Cigna Commercial |
$1,046.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,012.82
|
| Rate for Payer: HFN Commercial |
$1,046.96
|
| 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 |
$910.40
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.96
|
| Rate for Payer: Quartz Beloit One Network |
$557.62
|
| Rate for Payer: Quartz Commercial |
$739.70
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$5,247.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$625.90
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$842.92
|
|
|
XR Spine Cervical Comp w/ Obliques
|
Professional
|
$932.00
|
|
|
Service Code
|
CPT 72050 TC
|
| Hospital Charge Code |
1537331
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$38.74 |
| Max. Negotiated Rate |
$885.40 |
| Rate for Payer: Aetna Commercial |
$885.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$801.52
|
| Rate for Payer: Aetna Managed Medicare |
$38.74
|
| Rate for Payer: Anthem Medicare Advantage |
$38.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$38.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$38.74
|
| Rate for Payer: Cash Price |
$279.60
|
| Rate for Payer: Cash Price |
$279.60
|
| Rate for Payer: Cigna Commercial |
$885.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$466.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.74
|
| Rate for Payer: Health EOS Commercial |
$848.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$132.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$132.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$38.74
|
| Rate for Payer: Multiplan Commercial |
$745.60
|
| Rate for Payer: Preferred Network Access Commercial |
$885.40
|
| Rate for Payer: Quartz Beloit One Network |
$410.08
|
| Rate for Payer: Quartz Commercial |
$531.24
|
| Rate for Payer: Quartz Medicare Advantage |
$38.74
|
| Rate for Payer: The Alliance Commercial |
$147.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.74
|
| Rate for Payer: WEA Trust Commercial |
$512.60
|
| Rate for Payer: WPS Commercial |
$193.70
|
|
|
XR Spine Cervical Cross-Table Lateral
|
Facility
IP
|
$430.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
629604
|
| Min. Negotiated Rate |
$210.70 |
| Max. Negotiated Rate |
$395.60 |
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$258.00
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$258.00
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
XR Spine Cervical Cross-Table Lateral
|
Facility
OP
|
$447.00
|
|
|
Service Code
|
CPT 72020 TC
|
| Hospital Charge Code |
1537333
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$125.16 |
| Max. Negotiated Rate |
$1,788.00 |
| Rate for Payer: Aetna Commercial |
$402.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Aetna Managed Medicare |
$125.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$290.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$223.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$214.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$236.91
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$411.24
|
| Rate for Payer: Health EOS Commercial |
$397.83
|
| Rate for Payer: HFN Commercial |
$411.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$335.25
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: NAPHCARE Commercial |
$268.20
|
| Rate for Payer: Preferred Network Access Commercial |
$411.24
|
| Rate for Payer: Quartz Beloit One Network |
$219.03
|
| Rate for Payer: Quartz Commercial |
$290.55
|
| Rate for Payer: Quartz Medicare Advantage |
$268.20
|
| Rate for Payer: The Alliance Commercial |
$1,788.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
|
XR Spine Cervical Cross-Table Lateral
|
Facility
IP
|
$447.00
|
|
|
Service Code
|
CPT 72020 TC
|
| Hospital Charge Code |
1537333
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$219.03 |
| Max. Negotiated Rate |
$411.24 |
| Rate for Payer: Aetna Commercial |
$402.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$236.91
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$411.24
|
| Rate for Payer: Health EOS Commercial |
$397.83
|
| Rate for Payer: HFN Commercial |
$411.24
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: NAPHCARE Commercial |
$268.20
|
| Rate for Payer: Preferred Network Access Commercial |
$411.24
|
| Rate for Payer: Quartz Beloit One Network |
$219.03
|
| Rate for Payer: Quartz Commercial |
$268.20
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
|
XR Spine Cervical Cross-Table Lateral
|
Facility
OP
|
$430.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
629604
|
| Min. Negotiated Rate |
$69.48 |
| Max. Negotiated Rate |
$395.60 |
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.80
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$279.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$215.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$206.40
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| 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 |
$129.00
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| 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 |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$279.50
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$69.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
XR Spine Cervical Cross-Table Lateral
|
Professional
|
$447.00
|
|
|
Service Code
|
CPT 72020 TC
|
| Hospital Charge Code |
1537333
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$16.20 |
| Max. Negotiated Rate |
$424.65 |
| Rate for Payer: Aetna Commercial |
$424.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Aetna Managed Medicare |
$16.20
|
| Rate for Payer: Anthem Medicare Advantage |
$16.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.20
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$424.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$223.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.20
|
| Rate for Payer: Health EOS Commercial |
$406.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.20
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: Preferred Network Access Commercial |
$424.65
|
| Rate for Payer: Quartz Beloit One Network |
$196.68
|
| Rate for Payer: Quartz Commercial |
$254.79
|
| Rate for Payer: Quartz Medicare Advantage |
$16.20
|
| Rate for Payer: The Alliance Commercial |
$61.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$81.00
|
|
|
XR Spine Cervical Cross-Table Lateral
|
Professional
|
$430.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
629604
|
| Min. Negotiated Rate |
$23.66 |
| Max. Negotiated Rate |
$408.50 |
| Rate for Payer: Aetna Commercial |
$408.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.80
|
| Rate for Payer: Aetna Managed Medicare |
$23.66
|
| Rate for Payer: Anthem Medicare Advantage |
$23.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23.66
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$408.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$215.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.66
|
| Rate for Payer: Health EOS Commercial |
$391.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23.66
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: Preferred Network Access Commercial |
$408.50
|
| Rate for Payer: Quartz Beloit One Network |
$189.20
|
| Rate for Payer: Quartz Commercial |
$245.10
|
| Rate for Payer: Quartz Medicare Advantage |
$23.66
|
| Rate for Payer: The Alliance Commercial |
$89.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.66
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$118.30
|
|
|
XR Spine Cervical Flexion + Extension
|
Facility
IP
|
$615.00
|
|
|
Service Code
|
CPT 72040
|
| Hospital Charge Code |
711795
|
| Min. Negotiated Rate |
$301.35 |
| Max. Negotiated Rate |
$565.80 |
| Rate for Payer: Aetna Commercial |
$553.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.95
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$565.80
|
| Rate for Payer: Health EOS Commercial |
$547.35
|
| Rate for Payer: HFN Commercial |
$565.80
|
| Rate for Payer: Multiplan Commercial |
$492.00
|
| Rate for Payer: NAPHCARE Commercial |
$369.00
|
| Rate for Payer: Preferred Network Access Commercial |
$565.80
|
| Rate for Payer: Quartz Beloit One Network |
$301.35
|
| Rate for Payer: Quartz Commercial |
$369.00
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: WPS Commercial |
$455.53
|
|
|
XR Spine Cervical Flexion + Extension
|
Facility
IP
|
$640.00
|
|
|
Service Code
|
CPT 72040 TC
|
| Hospital Charge Code |
1537335
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.60 |
| Max. Negotiated Rate |
$588.80 |
| Rate for Payer: Aetna Commercial |
$576.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$339.20
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cigna Commercial |
$588.80
|
| Rate for Payer: Health EOS Commercial |
$569.60
|
| Rate for Payer: HFN Commercial |
$588.80
|
| Rate for Payer: Multiplan Commercial |
$512.00
|
| Rate for Payer: NAPHCARE Commercial |
$384.00
|
| Rate for Payer: Preferred Network Access Commercial |
$588.80
|
| Rate for Payer: Quartz Beloit One Network |
$313.60
|
| Rate for Payer: Quartz Commercial |
$384.00
|
| Rate for Payer: WEA Trust Commercial |
$352.00
|
| Rate for Payer: WPS Commercial |
$474.05
|
|
|
XR Spine Cervical Flexion + Extension
|
Professional
|
$640.00
|
|
|
Service Code
|
CPT 72040 TC
|
| Hospital Charge Code |
1537335
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$27.79 |
| Max. Negotiated Rate |
$608.00 |
| Rate for Payer: Aetna Commercial |
$608.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$550.40
|
| Rate for Payer: Aetna Managed Medicare |
$27.79
|
| Rate for Payer: Anthem Medicare Advantage |
$27.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.79
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cigna Commercial |
$608.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$320.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.79
|
| Rate for Payer: Health EOS Commercial |
$582.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$95.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.79
|
| Rate for Payer: Multiplan Commercial |
$512.00
|
| Rate for Payer: Preferred Network Access Commercial |
$608.00
|
| Rate for Payer: Quartz Beloit One Network |
$281.60
|
| Rate for Payer: Quartz Commercial |
$364.80
|
| Rate for Payer: Quartz Medicare Advantage |
$27.79
|
| Rate for Payer: The Alliance Commercial |
$105.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.79
|
| Rate for Payer: WEA Trust Commercial |
$352.00
|
| Rate for Payer: WPS Commercial |
$138.95
|
|
|
XR Spine Cervical Flexion + Extension
|
Professional
|
$615.00
|
|
|
Service Code
|
CPT 72040
|
| Hospital Charge Code |
711795
|
| Min. Negotiated Rate |
$38.25 |
| Max. Negotiated Rate |
$584.25 |
| Rate for Payer: Aetna Commercial |
$584.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.90
|
| Rate for Payer: Aetna Managed Medicare |
$38.25
|
| Rate for Payer: Anthem Medicare Advantage |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$38.25
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$584.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$307.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.25
|
| Rate for Payer: Health EOS Commercial |
$559.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$133.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$38.25
|
| Rate for Payer: Multiplan Commercial |
$492.00
|
| Rate for Payer: Preferred Network Access Commercial |
$584.25
|
| Rate for Payer: Quartz Beloit One Network |
$270.60
|
| Rate for Payer: Quartz Commercial |
$350.55
|
| Rate for Payer: Quartz Medicare Advantage |
$38.25
|
| Rate for Payer: The Alliance Commercial |
$145.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.25
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: WPS Commercial |
$191.25
|
|
|
XR Spine Cervical Flexion + Extension
|
Facility
OP
|
$640.00
|
|
|
Service Code
|
CPT 72040 TC
|
| Hospital Charge Code |
1537335
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$2,560.00 |
| Rate for Payer: Aetna Commercial |
$576.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$550.40
|
| Rate for Payer: Aetna Managed Medicare |
$179.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$416.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$320.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$307.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$339.20
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cigna Commercial |
$588.80
|
| Rate for Payer: Health EOS Commercial |
$569.60
|
| Rate for Payer: HFN Commercial |
$588.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$480.00
|
| Rate for Payer: Multiplan Commercial |
$512.00
|
| Rate for Payer: NAPHCARE Commercial |
$384.00
|
| Rate for Payer: Preferred Network Access Commercial |
$588.80
|
| Rate for Payer: Quartz Beloit One Network |
$313.60
|
| Rate for Payer: Quartz Commercial |
$416.00
|
| Rate for Payer: Quartz Medicare Advantage |
$384.00
|
| Rate for Payer: The Alliance Commercial |
$2,560.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$352.00
|
| Rate for Payer: WPS Commercial |
$474.05
|
|
