|
XR Upper GI w/ Air w/ Small Bowel
|
Professional
|
Both
|
$985.00
|
|
|
Service Code
|
CPT 74248 TC
|
| Hospital Charge Code |
1537447
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$174.03 |
| 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 |
$174.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$174.03
|
| 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 Upper GI w/ Air w/ Small Bowel
|
Facility
|
OP
|
$985.00
|
|
|
Service Code
|
CPT 74248 TC
|
| Hospital Charge Code |
1537447
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$275.80 |
| Max. Negotiated Rate |
$3,940.00 |
| Rate for Payer: Aetna Commercial |
$886.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$847.10
|
| Rate for Payer: Aetna Managed Medicare |
$275.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$640.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$492.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$472.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$522.05
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cigna Commercial |
$906.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$551.21
|
| Rate for Payer: Health EOS Commercial |
$876.65
|
| Rate for Payer: HFN Commercial |
$906.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$738.75
|
| 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 |
$640.25
|
| Rate for Payer: Quartz Medicare Advantage |
$591.00
|
| Rate for Payer: The Alliance Commercial |
$3,940.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$541.75
|
| Rate for Payer: WPS Commercial |
$729.59
|
|
|
XR Upper GI w/ Air w/ Small Bowel
|
Facility
|
IP
|
$985.00
|
|
|
Service Code
|
CPT 74248 TC
|
| Hospital Charge Code |
1537447
|
|
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 Upper GI w/ Air w/ Small Bowel
|
Facility
|
IP
|
$1,824.00
|
|
| Hospital Charge Code |
613602
|
| Min. Negotiated Rate |
$893.76 |
| Max. Negotiated Rate |
$1,678.08 |
| Rate for Payer: Aetna Commercial |
$1,641.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,568.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$966.72
|
| Rate for Payer: Cash Price |
$547.20
|
| Rate for Payer: Cigna Commercial |
$1,678.08
|
| Rate for Payer: Health EOS Commercial |
$1,623.36
|
| Rate for Payer: HFN Commercial |
$1,678.08
|
| Rate for Payer: Multiplan Commercial |
$1,459.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,094.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,678.08
|
| Rate for Payer: Quartz Beloit One Network |
$893.76
|
| Rate for Payer: Quartz Commercial |
$1,094.40
|
| Rate for Payer: WEA Trust Commercial |
$1,003.20
|
| Rate for Payer: WPS Commercial |
$1,351.04
|
|
|
XR Upper GI w/ Gastrografin
|
Facility
|
OP
|
$1,092.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
675803
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$1,004.64 |
| Rate for Payer: Aetna Commercial |
$982.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$939.12
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$709.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$546.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$524.16
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$578.76
|
| 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 |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,004.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$611.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$971.88
|
| Rate for Payer: HFN Commercial |
$1,004.64
|
| 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 |
$873.60
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,004.64
|
| Rate for Payer: Quartz Beloit One Network |
$535.08
|
| Rate for Payer: Quartz Commercial |
$709.80
|
| 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 |
$600.60
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$808.84
|
|
|
XR Upper GI w/ Gastrografin
|
Facility
|
IP
|
$1,092.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
675803
|
| Min. Negotiated Rate |
$535.08 |
| Max. Negotiated Rate |
$1,004.64 |
| Rate for Payer: Aetna Commercial |
$982.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$939.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$578.76
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,004.64
|
| Rate for Payer: Health EOS Commercial |
$971.88
|
| Rate for Payer: HFN Commercial |
$1,004.64
|
| Rate for Payer: Multiplan Commercial |
$873.60
|
| Rate for Payer: NAPHCARE Commercial |
$655.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,004.64
|
| Rate for Payer: Quartz Beloit One Network |
$535.08
|
| Rate for Payer: Quartz Commercial |
$655.20
|
| Rate for Payer: WEA Trust Commercial |
$600.60
|
| Rate for Payer: WPS Commercial |
$808.84
|
|
|
XR Upper GI w/ Gastrografin
|
Facility
|
IP
|
$1,156.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537449
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$566.44 |
| Max. Negotiated Rate |
$1,063.52 |
| Rate for Payer: Aetna Commercial |
$1,040.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$994.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$612.68
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,063.52
|
| Rate for Payer: Health EOS Commercial |
$1,028.84
|
| Rate for Payer: HFN Commercial |
$1,063.52
|
| Rate for Payer: Multiplan Commercial |
$924.80
|
| Rate for Payer: NAPHCARE Commercial |
$693.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,063.52
|
| Rate for Payer: Quartz Beloit One Network |
$566.44
|
| Rate for Payer: Quartz Commercial |
$693.60
|
| Rate for Payer: WEA Trust Commercial |
$635.80
|
| Rate for Payer: WPS Commercial |
$856.25
|
|
|
XR Upper GI w/ Gastrografin
|
Facility
|
OP
|
$1,156.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537449
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$1,063.52 |
| Rate for Payer: Aetna Commercial |
$1,040.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$994.16
|
| 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 |
$612.68
|
| 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 |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,063.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$646.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$1,028.84
|
| Rate for Payer: HFN Commercial |
$1,063.52
|
| 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 |
$924.80
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,063.52
|
| Rate for Payer: Quartz Beloit One Network |
$566.44
|
| Rate for Payer: Quartz Commercial |
$751.40
|
| 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 |
$635.80
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$856.25
|
|
|
XR Upper GI w/ Gastrografin
|
Professional
|
Both
|
$1,156.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537449
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$427.55 |
| Max. Negotiated Rate |
$1,098.20 |
| Rate for Payer: Aetna Commercial |
$1,098.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$994.16
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,098.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$578.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$693.60
|
| Rate for Payer: Health EOS Commercial |
$1,051.96
|
| Rate for Payer: HFN Commercial |
$1,098.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$427.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$427.55
|
| Rate for Payer: Multiplan Commercial |
$924.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,098.20
|
| Rate for Payer: Quartz Beloit One Network |
$508.64
|
| Rate for Payer: Quartz Commercial |
$658.92
|
| Rate for Payer: The Alliance Commercial |
$578.00
|
| Rate for Payer: WEA Trust Commercial |
$635.80
|
| Rate for Payer: WPS Commercial |
$856.25
|
|
|
XR Upper GI w/ Gastrografin
|
Professional
|
Both
|
$1,092.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
675803
|
| Min. Negotiated Rate |
$427.55 |
| Max. Negotiated Rate |
$1,037.40 |
| Rate for Payer: Aetna Commercial |
$1,037.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$939.12
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,037.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$546.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$655.20
|
| Rate for Payer: Health EOS Commercial |
$993.72
|
| Rate for Payer: HFN Commercial |
$1,037.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$427.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$427.55
|
| Rate for Payer: Multiplan Commercial |
$873.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.40
|
| Rate for Payer: Quartz Beloit One Network |
$480.48
|
| Rate for Payer: Quartz Commercial |
$622.44
|
| Rate for Payer: The Alliance Commercial |
$546.00
|
| Rate for Payer: WEA Trust Commercial |
$600.60
|
| Rate for Payer: WPS Commercial |
$808.84
|
|
|
XR Upper GI w/ Small Bowel
|
Professional
|
Both
|
$1,867.00
|
|
| Hospital Charge Code |
613604
|
| Min. Negotiated Rate |
$821.48 |
| Max. Negotiated Rate |
$1,773.65 |
| Rate for Payer: Aetna Commercial |
$1,773.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,605.62
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,773.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$933.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,120.20
|
| Rate for Payer: Health EOS Commercial |
$1,698.97
|
| Rate for Payer: HFN Commercial |
$1,773.65
|
| Rate for Payer: Multiplan Commercial |
$1,493.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,773.65
|
| Rate for Payer: Quartz Beloit One Network |
$821.48
|
| Rate for Payer: Quartz Commercial |
$1,064.19
|
| Rate for Payer: The Alliance Commercial |
$933.50
|
| Rate for Payer: WEA Trust Commercial |
$1,026.85
|
| Rate for Payer: WPS Commercial |
$1,382.89
|
|
|
XR Upper GI w/ Small Bowel
|
Facility
|
OP
|
$1,940.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537451
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$1,784.80 |
| Rate for Payer: Aetna Commercial |
$1,746.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,668.40
|
| 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 |
$1,028.20
|
| 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 |
$582.00
|
| Rate for Payer: Cash Price |
$582.00
|
| Rate for Payer: Cash Price |
$582.00
|
| Rate for Payer: Cigna Commercial |
$1,784.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,085.62
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$1,726.60
|
| Rate for Payer: HFN Commercial |
$1,784.80
|
| 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 |
$1,552.00
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,784.80
|
| Rate for Payer: Quartz Beloit One Network |
$950.60
|
| Rate for Payer: Quartz Commercial |
$1,261.00
|
| 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 |
$1,067.00
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$1,436.96
|
|
|
XR Upper GI w/ Small Bowel
|
Facility
|
IP
|
$1,867.00
|
|
| Hospital Charge Code |
613604
|
| Min. Negotiated Rate |
$914.83 |
| Max. Negotiated Rate |
$1,717.64 |
| Rate for Payer: Aetna Commercial |
$1,680.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,605.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$989.51
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,717.64
|
| Rate for Payer: Health EOS Commercial |
$1,661.63
|
| Rate for Payer: HFN Commercial |
$1,717.64
|
| Rate for Payer: Multiplan Commercial |
$1,493.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,120.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,717.64
|
| Rate for Payer: Quartz Beloit One Network |
$914.83
|
| Rate for Payer: Quartz Commercial |
$1,120.20
|
| Rate for Payer: WEA Trust Commercial |
$1,026.85
|
| Rate for Payer: WPS Commercial |
$1,382.89
|
|
|
XR Upper GI w/ Small Bowel
|
Professional
|
Both
|
$1,092.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537451
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$427.55 |
| Max. Negotiated Rate |
$1,037.40 |
| Rate for Payer: Aetna Commercial |
$1,037.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$939.12
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,037.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$546.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$655.20
|
| Rate for Payer: Health EOS Commercial |
$993.72
|
| Rate for Payer: HFN Commercial |
$1,037.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$427.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$427.55
|
| Rate for Payer: Multiplan Commercial |
$873.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.40
|
| Rate for Payer: Quartz Beloit One Network |
$480.48
|
| Rate for Payer: Quartz Commercial |
$622.44
|
| Rate for Payer: The Alliance Commercial |
$546.00
|
| Rate for Payer: WEA Trust Commercial |
$600.60
|
| Rate for Payer: WPS Commercial |
$808.84
|
|
|
XR Upper GI w/ Small Bowel
|
Facility
|
IP
|
$1,940.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537451
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$950.60 |
| Max. Negotiated Rate |
$1,784.80 |
| Rate for Payer: Aetna Commercial |
$1,746.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,668.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,028.20
|
| Rate for Payer: Cash Price |
$582.00
|
| Rate for Payer: Cigna Commercial |
$1,784.80
|
| Rate for Payer: Health EOS Commercial |
$1,726.60
|
| Rate for Payer: HFN Commercial |
$1,784.80
|
| Rate for Payer: Multiplan Commercial |
$1,552.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,164.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,784.80
|
| Rate for Payer: Quartz Beloit One Network |
$950.60
|
| Rate for Payer: Quartz Commercial |
$1,164.00
|
| Rate for Payer: WEA Trust Commercial |
$1,067.00
|
| Rate for Payer: WPS Commercial |
$1,436.96
|
|
|
XR Upper GI w/ Small Bowel
|
Facility
|
OP
|
$1,867.00
|
|
| Hospital Charge Code |
613604
|
| Min. Negotiated Rate |
$522.76 |
| Max. Negotiated Rate |
$7,468.00 |
| Rate for Payer: Aetna Commercial |
$1,680.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,605.62
|
| Rate for Payer: Aetna Managed Medicare |
$522.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,213.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$933.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$896.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$989.51
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,717.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,044.77
|
| Rate for Payer: Health EOS Commercial |
$1,661.63
|
| Rate for Payer: HFN Commercial |
$1,717.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,400.25
|
| Rate for Payer: Multiplan Commercial |
$1,493.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,120.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,717.64
|
| Rate for Payer: Quartz Beloit One Network |
$914.83
|
| Rate for Payer: Quartz Commercial |
$1,213.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,120.20
|
| Rate for Payer: The Alliance Commercial |
$7,468.00
|
| Rate for Payer: WEA Trust Commercial |
$1,026.85
|
| Rate for Payer: WPS Commercial |
$1,382.89
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Facility
|
OP
|
$1,867.00
|
|
| Hospital Charge Code |
1537453
|
| Min. Negotiated Rate |
$522.76 |
| Max. Negotiated Rate |
$7,468.00 |
| Rate for Payer: Aetna Commercial |
$1,680.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,605.62
|
| Rate for Payer: Aetna Managed Medicare |
$522.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,213.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$933.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$896.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$989.51
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,717.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,044.77
|
| Rate for Payer: Health EOS Commercial |
$1,661.63
|
| Rate for Payer: HFN Commercial |
$1,717.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,400.25
|
| Rate for Payer: Multiplan Commercial |
$1,493.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,120.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,717.64
|
| Rate for Payer: Quartz Beloit One Network |
$914.83
|
| Rate for Payer: Quartz Commercial |
$1,213.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,120.20
|
| Rate for Payer: The Alliance Commercial |
$7,468.00
|
| Rate for Payer: WEA Trust Commercial |
$1,026.85
|
| Rate for Payer: WPS Commercial |
$1,382.89
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Facility
|
IP
|
$1,867.00
|
|
| Hospital Charge Code |
1537453
|
| Min. Negotiated Rate |
$914.83 |
| Max. Negotiated Rate |
$1,717.64 |
| Rate for Payer: Aetna Commercial |
$1,680.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,605.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$989.51
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,717.64
|
| Rate for Payer: Health EOS Commercial |
$1,661.63
|
| Rate for Payer: HFN Commercial |
$1,717.64
|
| Rate for Payer: Multiplan Commercial |
$1,493.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,120.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,717.64
|
| Rate for Payer: Quartz Beloit One Network |
$914.83
|
| Rate for Payer: Quartz Commercial |
$1,120.20
|
| Rate for Payer: WEA Trust Commercial |
$1,026.85
|
| Rate for Payer: WPS Commercial |
$1,382.89
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Facility
|
IP
|
$1,867.00
|
|
| Hospital Charge Code |
675805
|
| Min. Negotiated Rate |
$914.83 |
| Max. Negotiated Rate |
$1,717.64 |
| Rate for Payer: Aetna Commercial |
$1,680.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,605.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$989.51
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,717.64
|
| Rate for Payer: Health EOS Commercial |
$1,661.63
|
| Rate for Payer: HFN Commercial |
$1,717.64
|
| Rate for Payer: Multiplan Commercial |
$1,493.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,120.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,717.64
|
| Rate for Payer: Quartz Beloit One Network |
$914.83
|
| Rate for Payer: Quartz Commercial |
$1,120.20
|
| Rate for Payer: WEA Trust Commercial |
$1,026.85
|
| Rate for Payer: WPS Commercial |
$1,382.89
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Professional
|
Both
|
$1,867.00
|
|
| Hospital Charge Code |
675805
|
| Min. Negotiated Rate |
$821.48 |
| Max. Negotiated Rate |
$1,773.65 |
| Rate for Payer: Aetna Commercial |
$1,773.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,605.62
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,773.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$933.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,120.20
|
| Rate for Payer: Health EOS Commercial |
$1,698.97
|
| Rate for Payer: HFN Commercial |
$1,773.65
|
| Rate for Payer: Multiplan Commercial |
$1,493.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,773.65
|
| Rate for Payer: Quartz Beloit One Network |
$821.48
|
| Rate for Payer: Quartz Commercial |
$1,064.19
|
| Rate for Payer: The Alliance Commercial |
$933.50
|
| Rate for Payer: WEA Trust Commercial |
$1,026.85
|
| Rate for Payer: WPS Commercial |
$1,382.89
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Facility
|
OP
|
$1,867.00
|
|
| Hospital Charge Code |
675805
|
| Min. Negotiated Rate |
$522.76 |
| Max. Negotiated Rate |
$7,468.00 |
| Rate for Payer: Aetna Commercial |
$1,680.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,605.62
|
| Rate for Payer: Aetna Managed Medicare |
$522.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,213.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$933.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$896.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$989.51
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,717.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,044.77
|
| Rate for Payer: Health EOS Commercial |
$1,661.63
|
| Rate for Payer: HFN Commercial |
$1,717.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,400.25
|
| Rate for Payer: Multiplan Commercial |
$1,493.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,120.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,717.64
|
| Rate for Payer: Quartz Beloit One Network |
$914.83
|
| Rate for Payer: Quartz Commercial |
$1,213.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,120.20
|
| Rate for Payer: The Alliance Commercial |
$7,468.00
|
| Rate for Payer: WEA Trust Commercial |
$1,026.85
|
| Rate for Payer: WPS Commercial |
$1,382.89
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Professional
|
Both
|
$1,867.00
|
|
| Hospital Charge Code |
1537453
|
| Min. Negotiated Rate |
$821.48 |
| Max. Negotiated Rate |
$1,773.65 |
| Rate for Payer: Aetna Commercial |
$1,773.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,605.62
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,773.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$933.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,120.20
|
| Rate for Payer: Health EOS Commercial |
$1,698.97
|
| Rate for Payer: HFN Commercial |
$1,773.65
|
| Rate for Payer: Multiplan Commercial |
$1,493.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,773.65
|
| Rate for Payer: Quartz Beloit One Network |
$821.48
|
| Rate for Payer: Quartz Commercial |
$1,064.19
|
| Rate for Payer: The Alliance Commercial |
$933.50
|
| Rate for Payer: WEA Trust Commercial |
$1,026.85
|
| Rate for Payer: WPS Commercial |
$1,382.89
|
|
|
XR Ureteral Cath/Stent Place Left
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587322
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$561.20 |
| Rate for Payer: Aetna Commercial |
$549.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| 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 |
$323.30
|
| 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 |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$561.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$542.90
|
| Rate for Payer: HFN Commercial |
$561.20
|
| 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 |
$488.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$561.20
|
| Rate for Payer: Quartz Beloit One Network |
$298.90
|
| Rate for Payer: Quartz Commercial |
$396.50
|
| 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 |
$335.50
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$451.83
|
|
|
XR Ureteral Cath/Stent Place Left
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587322
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$145.37 |
| Max. Negotiated Rate |
$579.50 |
| Rate for Payer: Aetna Commercial |
$579.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$579.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$305.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$366.00
|
| Rate for Payer: Health EOS Commercial |
$555.10
|
| Rate for Payer: HFN Commercial |
$579.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$145.37
|
| Rate for Payer: Multiplan Commercial |
$488.00
|
| Rate for Payer: Preferred Network Access Commercial |
$579.50
|
| Rate for Payer: Quartz Beloit One Network |
$268.40
|
| Rate for Payer: Quartz Commercial |
$347.70
|
| Rate for Payer: The Alliance Commercial |
$305.00
|
| Rate for Payer: WEA Trust Commercial |
$335.50
|
| Rate for Payer: WPS Commercial |
$451.83
|
|
|
XR Ureteral Cath/Stent Place Left
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587322
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$298.90 |
| Max. Negotiated Rate |
$561.20 |
| Rate for Payer: Aetna Commercial |
$549.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.30
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$561.20
|
| Rate for Payer: Health EOS Commercial |
$542.90
|
| Rate for Payer: HFN Commercial |
$561.20
|
| Rate for Payer: Multiplan Commercial |
$488.00
|
| Rate for Payer: NAPHCARE Commercial |
$366.00
|
| Rate for Payer: Preferred Network Access Commercial |
$561.20
|
| Rate for Payer: Quartz Beloit One Network |
$298.90
|
| Rate for Payer: Quartz Commercial |
$366.00
|
| Rate for Payer: WEA Trust Commercial |
$335.50
|
| Rate for Payer: WPS Commercial |
$451.83
|
|
