|
XR Foot Complete Bilateral
|
Facility
|
OP
|
$1,032.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630552
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$987.42 |
| Rate for Payer: Aetna Commercial |
$965.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$923.02
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$697.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$536.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$515.17
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$568.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.58
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cigna Commercial |
$987.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$600.62
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$955.22
|
| Rate for Payer: HFN Commercial |
$987.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$858.62
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$987.42
|
| Rate for Payer: Quartz Beloit One Network |
$525.91
|
| Rate for Payer: Quartz Commercial |
$697.63
|
| Rate for Payer: Quartz Medicare Advantage |
$91.58
|
| Rate for Payer: The Alliance Commercial |
$366.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.58
|
| Rate for Payer: WEA Trust Commercial |
$590.30
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$794.95
|
|
|
XR Foot Complete Bilateral
|
Professional
|
Both
|
$1,032.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630552
|
| Min. Negotiated Rate |
$33.74 |
| Max. Negotiated Rate |
$1,019.62 |
| Rate for Payer: Aetna Commercial |
$1,019.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$923.02
|
| Rate for Payer: Aetna Managed Medicare |
$33.74
|
| Rate for Payer: Anthem Medicare Advantage |
$33.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.74
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cigna Commercial |
$1,019.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$536.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.74
|
| Rate for Payer: Health EOS Commercial |
$976.68
|
| Rate for Payer: HFN Commercial |
$1,019.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$120.27
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.74
|
| Rate for Payer: Multiplan Commercial |
$858.62
|
| Rate for Payer: NAPHCARE Commercial |
$50.61
|
| Rate for Payer: Preferred Network Access Commercial |
$1,019.62
|
| Rate for Payer: Quartz Beloit One Network |
$472.24
|
| Rate for Payer: Quartz Commercial |
$611.77
|
| Rate for Payer: Quartz Medicare Advantage |
$33.74
|
| Rate for Payer: The Alliance Commercial |
$128.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.74
|
| Rate for Payer: WEA Trust Commercial |
$590.30
|
| Rate for Payer: WPS Commercial |
$168.69
|
|
|
XR Foot Complete Bilateral
|
Facility
|
IP
|
$558.00
|
|
|
Service Code
|
CPT 73630 LT,TC
|
| Hospital Charge Code |
1537066
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$284.36 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna Commercial |
$522.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.57
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$533.89
|
| Rate for Payer: Health EOS Commercial |
$516.48
|
| Rate for Payer: HFN Commercial |
$533.89
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: Preferred Network Access Commercial |
$533.89
|
| Rate for Payer: Quartz Beloit One Network |
$284.36
|
| Rate for Payer: Quartz Commercial |
$348.19
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
XR Foot Complete Left
|
Professional
|
Both
|
$558.00
|
|
|
Service Code
|
CPT 73630 LT,TC
|
| Hospital Charge Code |
1537068
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$551.30 |
| Rate for Payer: Aetna Commercial |
$551.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$551.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$290.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$348.19
|
| Rate for Payer: Health EOS Commercial |
$528.09
|
| Rate for Payer: HFN Commercial |
$551.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$120.27
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: Preferred Network Access Commercial |
$551.30
|
| Rate for Payer: Quartz Beloit One Network |
$255.34
|
| Rate for Payer: Quartz Commercial |
$330.78
|
| Rate for Payer: The Alliance Commercial |
$290.16
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
XR Foot Complete Left
|
Facility
|
OP
|
$558.00
|
|
|
Service Code
|
CPT 73630 LT,TC
|
| Hospital Charge Code |
1537068
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$162.49 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna Commercial |
$522.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Aetna Managed Medicare |
$162.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.57
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$533.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$324.76
|
| Rate for Payer: Health EOS Commercial |
$516.48
|
| Rate for Payer: HFN Commercial |
$533.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$435.24
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: NAPHCARE Commercial |
$348.19
|
| Rate for Payer: Preferred Network Access Commercial |
$533.89
|
| Rate for Payer: Quartz Beloit One Network |
$284.36
|
| Rate for Payer: Quartz Commercial |
$377.21
|
| Rate for Payer: Quartz Medicare Advantage |
$348.19
|
| Rate for Payer: The Alliance Commercial |
$290.16
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
XR Foot Complete Left
|
Professional
|
Both
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630548
|
| Min. Negotiated Rate |
$33.74 |
| Max. Negotiated Rate |
$509.81 |
| Rate for Payer: Aetna Commercial |
$509.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.51
|
| Rate for Payer: Aetna Managed Medicare |
$33.74
|
| Rate for Payer: Anthem Medicare Advantage |
$33.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.74
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$509.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$268.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.74
|
| Rate for Payer: Health EOS Commercial |
$488.34
|
| Rate for Payer: HFN Commercial |
$509.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$120.27
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.74
|
| Rate for Payer: Multiplan Commercial |
$429.31
|
| Rate for Payer: NAPHCARE Commercial |
$50.61
|
| Rate for Payer: Preferred Network Access Commercial |
$509.81
|
| Rate for Payer: Quartz Beloit One Network |
$236.12
|
| Rate for Payer: Quartz Commercial |
$305.88
|
| Rate for Payer: Quartz Medicare Advantage |
$33.74
|
| Rate for Payer: The Alliance Commercial |
$128.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.74
|
| Rate for Payer: WEA Trust Commercial |
$295.15
|
| Rate for Payer: WPS Commercial |
$168.69
|
|
|
XR Foot Complete Left
|
Facility
|
IP
|
$558.00
|
|
|
Service Code
|
CPT 73630 LT,TC
|
| Hospital Charge Code |
1537068
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$284.36 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna Commercial |
$522.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.57
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$533.89
|
| Rate for Payer: Health EOS Commercial |
$516.48
|
| Rate for Payer: HFN Commercial |
$533.89
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: Preferred Network Access Commercial |
$533.89
|
| Rate for Payer: Quartz Beloit One Network |
$284.36
|
| Rate for Payer: Quartz Commercial |
$348.19
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
XR Foot Complete Left
|
Facility
|
OP
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630548
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$493.71 |
| Rate for Payer: Aetna Commercial |
$482.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.51
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$348.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$268.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$257.59
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.58
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$493.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$477.61
|
| Rate for Payer: HFN Commercial |
$493.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$429.31
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$493.71
|
| Rate for Payer: Quartz Beloit One Network |
$262.95
|
| Rate for Payer: Quartz Commercial |
$348.82
|
| Rate for Payer: Quartz Medicare Advantage |
$91.58
|
| Rate for Payer: The Alliance Commercial |
$366.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.58
|
| Rate for Payer: WEA Trust Commercial |
$295.15
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$397.47
|
|
|
XR Foot Complete Left
|
Facility
|
IP
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630548
|
| Min. Negotiated Rate |
$262.95 |
| Max. Negotiated Rate |
$493.71 |
| Rate for Payer: Aetna Commercial |
$482.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.42
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$493.71
|
| Rate for Payer: Health EOS Commercial |
$477.61
|
| Rate for Payer: HFN Commercial |
$493.71
|
| Rate for Payer: Multiplan Commercial |
$429.31
|
| Rate for Payer: Preferred Network Access Commercial |
$493.71
|
| Rate for Payer: Quartz Beloit One Network |
$262.95
|
| Rate for Payer: Quartz Commercial |
$321.98
|
| Rate for Payer: WEA Trust Commercial |
$295.15
|
| Rate for Payer: WPS Commercial |
$397.47
|
|
|
XR Foot Complete Right
|
Professional
|
Both
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630533
|
| Min. Negotiated Rate |
$33.74 |
| Max. Negotiated Rate |
$509.81 |
| Rate for Payer: Aetna Commercial |
$509.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.51
|
| Rate for Payer: Aetna Managed Medicare |
$33.74
|
| Rate for Payer: Anthem Medicare Advantage |
$33.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.74
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$509.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$268.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.74
|
| Rate for Payer: Health EOS Commercial |
$488.34
|
| Rate for Payer: HFN Commercial |
$509.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$120.27
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.74
|
| Rate for Payer: Multiplan Commercial |
$429.31
|
| Rate for Payer: NAPHCARE Commercial |
$50.61
|
| Rate for Payer: Preferred Network Access Commercial |
$509.81
|
| Rate for Payer: Quartz Beloit One Network |
$236.12
|
| Rate for Payer: Quartz Commercial |
$305.88
|
| Rate for Payer: Quartz Medicare Advantage |
$33.74
|
| Rate for Payer: The Alliance Commercial |
$128.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.74
|
| Rate for Payer: WEA Trust Commercial |
$295.15
|
| Rate for Payer: WPS Commercial |
$168.69
|
|
|
XR Foot Complete Right
|
Facility
|
OP
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630533
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$493.71 |
| Rate for Payer: Aetna Commercial |
$482.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.51
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$348.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$268.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$257.59
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.58
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$493.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$477.61
|
| Rate for Payer: HFN Commercial |
$493.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$429.31
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$493.71
|
| Rate for Payer: Quartz Beloit One Network |
$262.95
|
| Rate for Payer: Quartz Commercial |
$348.82
|
| Rate for Payer: Quartz Medicare Advantage |
$91.58
|
| Rate for Payer: The Alliance Commercial |
$366.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.58
|
| Rate for Payer: WEA Trust Commercial |
$295.15
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$397.47
|
|
|
XR Foot Complete Right
|
Facility
|
IP
|
$516.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
630533
|
| Min. Negotiated Rate |
$262.95 |
| Max. Negotiated Rate |
$493.71 |
| Rate for Payer: Aetna Commercial |
$482.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.42
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$493.71
|
| Rate for Payer: Health EOS Commercial |
$477.61
|
| Rate for Payer: HFN Commercial |
$493.71
|
| Rate for Payer: Multiplan Commercial |
$429.31
|
| Rate for Payer: Preferred Network Access Commercial |
$493.71
|
| Rate for Payer: Quartz Beloit One Network |
$262.95
|
| Rate for Payer: Quartz Commercial |
$321.98
|
| Rate for Payer: WEA Trust Commercial |
$295.15
|
| Rate for Payer: WPS Commercial |
$397.47
|
|
|
XR Foot Complete Right
|
Facility
|
IP
|
$558.00
|
|
|
Service Code
|
CPT 73630 RT,TC
|
| Hospital Charge Code |
1537070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$284.36 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna Commercial |
$522.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.57
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$533.89
|
| Rate for Payer: Health EOS Commercial |
$516.48
|
| Rate for Payer: HFN Commercial |
$533.89
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: Preferred Network Access Commercial |
$533.89
|
| Rate for Payer: Quartz Beloit One Network |
$284.36
|
| Rate for Payer: Quartz Commercial |
$348.19
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
XR Foot Complete Right
|
Professional
|
Both
|
$558.00
|
|
|
Service Code
|
CPT 73630 RT,TC
|
| Hospital Charge Code |
1537070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$551.30 |
| Rate for Payer: Aetna Commercial |
$551.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$551.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$290.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$348.19
|
| Rate for Payer: Health EOS Commercial |
$528.09
|
| Rate for Payer: HFN Commercial |
$551.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$120.27
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: Preferred Network Access Commercial |
$551.30
|
| Rate for Payer: Quartz Beloit One Network |
$255.34
|
| Rate for Payer: Quartz Commercial |
$330.78
|
| Rate for Payer: The Alliance Commercial |
$290.16
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
XR Foot Complete Right
|
Facility
|
OP
|
$558.00
|
|
|
Service Code
|
CPT 73630 RT,TC
|
| Hospital Charge Code |
1537070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$162.49 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna Commercial |
$522.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Aetna Managed Medicare |
$162.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.57
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$533.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$324.76
|
| Rate for Payer: Health EOS Commercial |
$516.48
|
| Rate for Payer: HFN Commercial |
$533.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$435.24
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: NAPHCARE Commercial |
$348.19
|
| Rate for Payer: Preferred Network Access Commercial |
$533.89
|
| Rate for Payer: Quartz Beloit One Network |
$284.36
|
| Rate for Payer: Quartz Commercial |
$377.21
|
| Rate for Payer: Quartz Medicare Advantage |
$348.19
|
| Rate for Payer: The Alliance Commercial |
$290.16
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
XR Foot Complete Right
|
Facility
|
OP
|
$558.00
|
|
|
Service Code
|
CPT 73630 TC,RT
|
| Hospital Charge Code |
2980067
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$162.49 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna Commercial |
$522.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Aetna Managed Medicare |
$162.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.57
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$533.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$324.76
|
| Rate for Payer: Health EOS Commercial |
$516.48
|
| Rate for Payer: HFN Commercial |
$533.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$435.24
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: NAPHCARE Commercial |
$348.19
|
| Rate for Payer: Preferred Network Access Commercial |
$533.89
|
| Rate for Payer: Quartz Beloit One Network |
$284.36
|
| Rate for Payer: Quartz Commercial |
$377.21
|
| Rate for Payer: Quartz Medicare Advantage |
$348.19
|
| Rate for Payer: The Alliance Commercial |
$290.16
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
XR Foot Complete Right
|
Facility
|
IP
|
$558.00
|
|
|
Service Code
|
CPT 73630 TC,RT
|
| Hospital Charge Code |
2980067
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$284.36 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna Commercial |
$522.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.57
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$533.89
|
| Rate for Payer: Health EOS Commercial |
$516.48
|
| Rate for Payer: HFN Commercial |
$533.89
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: Preferred Network Access Commercial |
$533.89
|
| Rate for Payer: Quartz Beloit One Network |
$284.36
|
| Rate for Payer: Quartz Commercial |
$348.19
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
XR Foot Complete Right
|
Professional
|
Both
|
$558.00
|
|
|
Service Code
|
CPT 73630 TC,RT
|
| Hospital Charge Code |
2980067
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$551.30 |
| Rate for Payer: Aetna Commercial |
$551.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$551.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$290.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$348.19
|
| Rate for Payer: Health EOS Commercial |
$528.09
|
| Rate for Payer: HFN Commercial |
$551.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$120.27
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: Preferred Network Access Commercial |
$551.30
|
| Rate for Payer: Quartz Beloit One Network |
$255.34
|
| Rate for Payer: Quartz Commercial |
$330.78
|
| Rate for Payer: The Alliance Commercial |
$290.16
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
XR Forearm 2 Views Bilateral
|
Facility
|
OP
|
$1,013.00
|
|
|
Service Code
|
CPT 73090
|
| Hospital Charge Code |
630527
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$969.24 |
| Rate for Payer: Aetna Commercial |
$948.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$906.03
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$684.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$526.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$505.69
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$558.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.58
|
| Rate for Payer: Cash Price |
$303.90
|
| Rate for Payer: Cash Price |
$303.90
|
| Rate for Payer: Cigna Commercial |
$969.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$589.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$937.63
|
| Rate for Payer: HFN Commercial |
$969.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$842.82
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$969.24
|
| Rate for Payer: Quartz Beloit One Network |
$516.22
|
| Rate for Payer: Quartz Commercial |
$684.79
|
| Rate for Payer: Quartz Medicare Advantage |
$91.58
|
| Rate for Payer: The Alliance Commercial |
$366.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.58
|
| Rate for Payer: WEA Trust Commercial |
$579.44
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$780.31
|
|
|
XR Forearm 2 Views Bilateral
|
Facility
|
IP
|
$1,013.00
|
|
|
Service Code
|
CPT 73090
|
| Hospital Charge Code |
630527
|
| Min. Negotiated Rate |
$516.22 |
| Max. Negotiated Rate |
$969.24 |
| Rate for Payer: Aetna Commercial |
$948.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$906.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$558.37
|
| Rate for Payer: Cash Price |
$303.90
|
| Rate for Payer: Cigna Commercial |
$969.24
|
| Rate for Payer: Health EOS Commercial |
$937.63
|
| Rate for Payer: HFN Commercial |
$969.24
|
| Rate for Payer: Multiplan Commercial |
$842.82
|
| Rate for Payer: Preferred Network Access Commercial |
$969.24
|
| Rate for Payer: Quartz Beloit One Network |
$516.22
|
| Rate for Payer: Quartz Commercial |
$632.11
|
| Rate for Payer: WEA Trust Commercial |
$579.44
|
| Rate for Payer: WPS Commercial |
$780.31
|
|
|
XR Forearm 2 Views Bilateral
|
Facility
|
IP
|
$526.00
|
|
|
Service Code
|
CPT 73090 LT,TC
|
| Hospital Charge Code |
1537072
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$268.05 |
| Max. Negotiated Rate |
$503.28 |
| Rate for Payer: Aetna Commercial |
$492.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.93
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cigna Commercial |
$503.28
|
| Rate for Payer: Health EOS Commercial |
$486.87
|
| Rate for Payer: HFN Commercial |
$503.28
|
| Rate for Payer: Multiplan Commercial |
$437.63
|
| Rate for Payer: Preferred Network Access Commercial |
$503.28
|
| Rate for Payer: Quartz Beloit One Network |
$268.05
|
| Rate for Payer: Quartz Commercial |
$328.22
|
| Rate for Payer: WEA Trust Commercial |
$300.87
|
| Rate for Payer: WPS Commercial |
$405.18
|
|
|
XR Forearm 2 Views Bilateral
|
Facility
|
OP
|
$526.00
|
|
|
Service Code
|
CPT 73090 LT,TC
|
| Hospital Charge Code |
1537072
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$153.17 |
| Max. Negotiated Rate |
$503.28 |
| Rate for Payer: Aetna Commercial |
$492.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.45
|
| Rate for Payer: Aetna Managed Medicare |
$153.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.93
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cigna Commercial |
$503.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.13
|
| Rate for Payer: Health EOS Commercial |
$486.87
|
| Rate for Payer: HFN Commercial |
$503.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$410.28
|
| Rate for Payer: Multiplan Commercial |
$437.63
|
| Rate for Payer: NAPHCARE Commercial |
$328.22
|
| Rate for Payer: Preferred Network Access Commercial |
$503.28
|
| Rate for Payer: Quartz Beloit One Network |
$268.05
|
| Rate for Payer: Quartz Commercial |
$355.58
|
| Rate for Payer: Quartz Medicare Advantage |
$328.22
|
| Rate for Payer: The Alliance Commercial |
$273.52
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$300.87
|
| Rate for Payer: WPS Commercial |
$405.18
|
|
|
XR Forearm 2 Views Bilateral
|
Professional
|
Both
|
$526.00
|
|
|
Service Code
|
CPT 73090 LT,TC
|
| Hospital Charge Code |
1537072
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.10 |
| Max. Negotiated Rate |
$519.69 |
| Rate for Payer: Aetna Commercial |
$519.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.45
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cigna Commercial |
$519.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$273.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$328.22
|
| Rate for Payer: Health EOS Commercial |
$497.81
|
| Rate for Payer: HFN Commercial |
$519.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$102.10
|
| Rate for Payer: Multiplan Commercial |
$437.63
|
| Rate for Payer: Preferred Network Access Commercial |
$519.69
|
| Rate for Payer: Quartz Beloit One Network |
$240.70
|
| Rate for Payer: Quartz Commercial |
$311.81
|
| Rate for Payer: The Alliance Commercial |
$273.52
|
| Rate for Payer: WEA Trust Commercial |
$300.87
|
| Rate for Payer: WPS Commercial |
$405.18
|
|
|
XR Forearm 2 Views Bilateral
|
Professional
|
Both
|
$1,013.00
|
|
|
Service Code
|
CPT 73090
|
| Hospital Charge Code |
630527
|
| Min. Negotiated Rate |
$28.74 |
| Max. Negotiated Rate |
$1,000.84 |
| Rate for Payer: Aetna Commercial |
$1,000.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$906.03
|
| Rate for Payer: Aetna Managed Medicare |
$28.74
|
| Rate for Payer: Anthem Medicare Advantage |
$28.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.74
|
| Rate for Payer: Cash Price |
$303.90
|
| Rate for Payer: Cash Price |
$303.90
|
| Rate for Payer: Cash Price |
$303.90
|
| Rate for Payer: Cigna Commercial |
$1,000.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$526.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.74
|
| Rate for Payer: Health EOS Commercial |
$958.70
|
| Rate for Payer: HFN Commercial |
$1,000.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$102.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.74
|
| Rate for Payer: Multiplan Commercial |
$842.82
|
| Rate for Payer: NAPHCARE Commercial |
$43.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,000.84
|
| Rate for Payer: Quartz Beloit One Network |
$463.55
|
| Rate for Payer: Quartz Commercial |
$600.51
|
| Rate for Payer: Quartz Medicare Advantage |
$28.74
|
| Rate for Payer: The Alliance Commercial |
$109.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.74
|
| Rate for Payer: WEA Trust Commercial |
$579.44
|
| Rate for Payer: WPS Commercial |
$143.68
|
|
|
XR Forearm 2 Views Left
|
Facility
|
IP
|
$546.00
|
|
|
Service Code
|
CPT 73090 LT,TC
|
| Hospital Charge Code |
1537074
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$278.24 |
| Max. Negotiated Rate |
$522.41 |
| Rate for Payer: Aetna Commercial |
$511.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$300.96
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cigna Commercial |
$522.41
|
| Rate for Payer: Health EOS Commercial |
$505.38
|
| Rate for Payer: HFN Commercial |
$522.41
|
| Rate for Payer: Multiplan Commercial |
$454.27
|
| Rate for Payer: Preferred Network Access Commercial |
$522.41
|
| Rate for Payer: Quartz Beloit One Network |
$278.24
|
| Rate for Payer: Quartz Commercial |
$340.70
|
| Rate for Payer: WEA Trust Commercial |
$312.31
|
| Rate for Payer: WPS Commercial |
$420.58
|
|
