|
XR Upper GI w/ Small Bowel Gastrografin
|
Professional
|
$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: 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
|
$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: 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 |
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 |
675805
|
| Min. Negotiated Rate |
$914.83 |
| Max. Negotiated Rate |
$1,717.64 |
| Rate for Payer: Aetna Commercial |
$1,680.30
|
| 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 Ureteral Cath/Stent Place Left
|
Professional
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587322
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$41.56 |
| Max. Negotiated Rate |
$579.50 |
| Rate for Payer: Aetna Commercial |
$579.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| Rate for Payer: Aetna Managed Medicare |
$41.56
|
| Rate for Payer: Anthem Medicare Advantage |
$41.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.56
|
| 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 |
$41.56
|
| Rate for Payer: Health EOS Commercial |
$555.10
|
| 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: Independent Care Health Plan Medicare |
$41.56
|
| 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: Quartz Medicare Advantage |
$41.56
|
| Rate for Payer: The Alliance Commercial |
$157.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.56
|
| Rate for Payer: WEA Trust Commercial |
$335.50
|
| Rate for Payer: WPS Commercial |
$207.80
|
|
|
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: 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
|
|
|
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 |
$69.24 |
| 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 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 |
$69.24
|
| 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 Right
|
Facility
OP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587325
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$69.24 |
| 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 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 |
$69.24
|
| 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 Right
|
Facility
IP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587325
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$298.90 |
| Max. Negotiated Rate |
$561.20 |
| Rate for Payer: Aetna Commercial |
$549.00
|
| 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
|
|
|
XR Ureteral Cath/Stent Place Right
|
Professional
|
$588.00
|
|
|
Service Code
|
CPT 74021 TC,RT
|
| Hospital Charge Code |
5577652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$258.72 |
| Max. Negotiated Rate |
$558.60 |
| Rate for Payer: Aetna Commercial |
$558.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$505.68
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$558.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$294.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$352.80
|
| Rate for Payer: Health EOS Commercial |
$535.08
|
| Rate for Payer: Multiplan Commercial |
$470.40
|
| Rate for Payer: Preferred Network Access Commercial |
$558.60
|
| Rate for Payer: Quartz Beloit One Network |
$258.72
|
| Rate for Payer: Quartz Commercial |
$335.16
|
| Rate for Payer: The Alliance Commercial |
$294.00
|
| Rate for Payer: WEA Trust Commercial |
$323.40
|
| Rate for Payer: WPS Commercial |
$435.53
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
IP
|
$565.00
|
|
|
Service Code
|
CPT 74020
|
| Hospital Charge Code |
2448819
|
| Min. Negotiated Rate |
$276.85 |
| Max. Negotiated Rate |
$519.80 |
| Rate for Payer: Aetna Commercial |
$508.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$299.45
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$519.80
|
| Rate for Payer: Health EOS Commercial |
$502.85
|
| Rate for Payer: HFN Commercial |
$519.80
|
| Rate for Payer: Multiplan Commercial |
$452.00
|
| Rate for Payer: NAPHCARE Commercial |
$339.00
|
| Rate for Payer: Preferred Network Access Commercial |
$519.80
|
| Rate for Payer: Quartz Beloit One Network |
$276.85
|
| Rate for Payer: Quartz Commercial |
$339.00
|
| Rate for Payer: WEA Trust Commercial |
$310.75
|
| Rate for Payer: WPS Commercial |
$418.50
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
OP
|
$565.00
|
|
|
Service Code
|
CPT 74020
|
| Hospital Charge Code |
2448819
|
| Min. Negotiated Rate |
$158.20 |
| Max. Negotiated Rate |
$2,260.00 |
| Rate for Payer: Aetna Commercial |
$508.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$485.90
|
| Rate for Payer: Aetna Managed Medicare |
$158.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$367.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$282.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$271.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$299.45
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$519.80
|
| Rate for Payer: Health EOS Commercial |
$502.85
|
| Rate for Payer: HFN Commercial |
$519.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.75
|
| Rate for Payer: Multiplan Commercial |
$452.00
|
| Rate for Payer: NAPHCARE Commercial |
$339.00
|
| Rate for Payer: Preferred Network Access Commercial |
$519.80
|
| Rate for Payer: Quartz Beloit One Network |
$276.85
|
| Rate for Payer: Quartz Commercial |
$367.25
|
| Rate for Payer: Quartz Medicare Advantage |
$339.00
|
| Rate for Payer: The Alliance Commercial |
$2,260.00
|
| Rate for Payer: WEA Trust Commercial |
$310.75
|
| Rate for Payer: WPS Commercial |
$418.50
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
IP
|
$588.00
|
|
|
Service Code
|
CPT 74021 TC,RT
|
| Hospital Charge Code |
5577652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$288.12 |
| Max. Negotiated Rate |
$540.96 |
| Rate for Payer: Aetna Commercial |
$529.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.64
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$540.96
|
| Rate for Payer: Health EOS Commercial |
$523.32
|
| Rate for Payer: HFN Commercial |
$540.96
|
| Rate for Payer: Multiplan Commercial |
$470.40
|
| Rate for Payer: NAPHCARE Commercial |
$352.80
|
| Rate for Payer: Preferred Network Access Commercial |
$540.96
|
| Rate for Payer: Quartz Beloit One Network |
$288.12
|
| Rate for Payer: Quartz Commercial |
$352.80
|
| Rate for Payer: WEA Trust Commercial |
$323.40
|
| Rate for Payer: WPS Commercial |
$435.53
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
OP
|
$588.00
|
|
|
Service Code
|
CPT 74021 TC,RT
|
| Hospital Charge Code |
5577652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$164.64 |
| Max. Negotiated Rate |
$2,352.00 |
| Rate for Payer: Aetna Commercial |
$529.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$505.68
|
| Rate for Payer: Aetna Managed Medicare |
$164.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$382.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$294.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.64
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$540.96
|
| Rate for Payer: Health EOS Commercial |
$523.32
|
| Rate for Payer: HFN Commercial |
$540.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$441.00
|
| Rate for Payer: Multiplan Commercial |
$470.40
|
| Rate for Payer: NAPHCARE Commercial |
$352.80
|
| Rate for Payer: Preferred Network Access Commercial |
$540.96
|
| Rate for Payer: Quartz Beloit One Network |
$288.12
|
| Rate for Payer: Quartz Commercial |
$382.20
|
| Rate for Payer: Quartz Medicare Advantage |
$352.80
|
| Rate for Payer: The Alliance Commercial |
$2,352.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$323.40
|
| Rate for Payer: WPS Commercial |
$435.53
|
|
|
XR Urethrocystography Retrograde
|
Facility
OP
|
$720.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1537455
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$25.08 |
| Max. Negotiated Rate |
$908.25 |
| Rate for Payer: Aetna Commercial |
$648.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.20
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$908.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$726.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$690.27
|
| Rate for Payer: Anthem Medicare Advantage |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$662.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$640.80
|
| Rate for Payer: HFN Commercial |
$662.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$576.00
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$662.40
|
| Rate for Payer: Quartz Beloit One Network |
$352.80
|
| Rate for Payer: Quartz Commercial |
$468.00
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$25.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$396.00
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$533.30
|
|
|
XR Urethrocystography Retrograde
|
Facility
OP
|
$683.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
613606
|
| Min. Negotiated Rate |
$25.08 |
| Max. Negotiated Rate |
$900.98 |
| Rate for Payer: Aetna Commercial |
$614.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$587.38
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$443.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$341.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$327.84
|
| Rate for Payer: Anthem Medicare Advantage |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$361.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cigna Commercial |
$628.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$607.87
|
| Rate for Payer: HFN Commercial |
$628.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$546.40
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$628.36
|
| Rate for Payer: Quartz Beloit One Network |
$334.67
|
| Rate for Payer: Quartz Commercial |
$443.95
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$25.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: WEA Trust Commercial |
$375.65
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$505.90
|
|
|
XR Urethrocystography Retrograde
|
Professional
|
$683.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
613606
|
| Min. Negotiated Rate |
$262.88 |
| Max. Negotiated Rate |
$648.85 |
| Rate for Payer: Aetna Commercial |
$648.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$587.38
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cigna Commercial |
$648.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$341.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$409.80
|
| Rate for Payer: Health EOS Commercial |
$621.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$262.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$262.88
|
| Rate for Payer: Multiplan Commercial |
$546.40
|
| Rate for Payer: Preferred Network Access Commercial |
$648.85
|
| Rate for Payer: Quartz Beloit One Network |
$300.52
|
| Rate for Payer: Quartz Commercial |
$389.31
|
| Rate for Payer: The Alliance Commercial |
$341.50
|
| Rate for Payer: WEA Trust Commercial |
$375.65
|
| Rate for Payer: WPS Commercial |
$505.90
|
|
|
XR Urethrocystography Retrograde
|
Facility
IP
|
$720.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1537455
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$352.80 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Aetna Commercial |
$648.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.60
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$662.40
|
| Rate for Payer: Health EOS Commercial |
$640.80
|
| Rate for Payer: HFN Commercial |
$662.40
|
| Rate for Payer: Multiplan Commercial |
$576.00
|
| Rate for Payer: NAPHCARE Commercial |
$432.00
|
| Rate for Payer: Preferred Network Access Commercial |
$662.40
|
| Rate for Payer: Quartz Beloit One Network |
$352.80
|
| Rate for Payer: Quartz Commercial |
$432.00
|
| Rate for Payer: WEA Trust Commercial |
$396.00
|
| Rate for Payer: WPS Commercial |
$533.30
|
|
|
XR Urethrocystography Retrograde
|
Facility
IP
|
$683.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
613606
|
| Min. Negotiated Rate |
$334.67 |
| Max. Negotiated Rate |
$628.36 |
| Rate for Payer: Aetna Commercial |
$614.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$361.99
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cigna Commercial |
$628.36
|
| Rate for Payer: Health EOS Commercial |
$607.87
|
| Rate for Payer: HFN Commercial |
$628.36
|
| Rate for Payer: Multiplan Commercial |
$546.40
|
| Rate for Payer: NAPHCARE Commercial |
$409.80
|
| Rate for Payer: Preferred Network Access Commercial |
$628.36
|
| Rate for Payer: Quartz Beloit One Network |
$334.67
|
| Rate for Payer: Quartz Commercial |
$409.80
|
| Rate for Payer: WEA Trust Commercial |
$375.65
|
| Rate for Payer: WPS Commercial |
$505.90
|
|
|
XR Urethrocystography Retrograde
|
Professional
|
$720.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1537455
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$262.88 |
| Max. Negotiated Rate |
$684.00 |
| Rate for Payer: Aetna Commercial |
$684.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.20
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$684.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$360.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$432.00
|
| Rate for Payer: Health EOS Commercial |
$655.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$262.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$262.88
|
| Rate for Payer: Multiplan Commercial |
$576.00
|
| Rate for Payer: Preferred Network Access Commercial |
$684.00
|
| Rate for Payer: Quartz Beloit One Network |
$316.80
|
| Rate for Payer: Quartz Commercial |
$410.40
|
| Rate for Payer: The Alliance Commercial |
$360.00
|
| Rate for Payer: WEA Trust Commercial |
$396.00
|
| Rate for Payer: WPS Commercial |
$533.30
|
|
|
XR Urethrocystography Voiding
|
Facility
IP
|
$1,161.00
|
|
|
Service Code
|
CPT 74455 TC
|
| Hospital Charge Code |
3072720
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$568.89 |
| Max. Negotiated Rate |
$1,068.12 |
| Rate for Payer: Aetna Commercial |
$1,044.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$615.33
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cigna Commercial |
$1,068.12
|
| Rate for Payer: Health EOS Commercial |
$1,033.29
|
| Rate for Payer: HFN Commercial |
$1,068.12
|
| Rate for Payer: Multiplan Commercial |
$928.80
|
| Rate for Payer: NAPHCARE Commercial |
$696.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,068.12
|
| Rate for Payer: Quartz Beloit One Network |
$568.89
|
| Rate for Payer: Quartz Commercial |
$696.60
|
| Rate for Payer: WEA Trust Commercial |
$638.55
|
| Rate for Payer: WPS Commercial |
$859.95
|
|
|
XR Urethrocystography Voiding
|
Professional
|
$1,161.00
|
|
|
Service Code
|
CPT 74455 TC
|
| Hospital Charge Code |
3072720
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$86.38 |
| Max. Negotiated Rate |
$1,102.95 |
| Rate for Payer: Aetna Commercial |
$1,102.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$998.46
|
| Rate for Payer: Aetna Managed Medicare |
$86.38
|
| Rate for Payer: Anthem Medicare Advantage |
$86.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$86.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$86.38
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cigna Commercial |
$1,102.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$580.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.38
|
| Rate for Payer: Health EOS Commercial |
$1,056.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$305.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$305.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$86.38
|
| Rate for Payer: Multiplan Commercial |
$928.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,102.95
|
| Rate for Payer: Quartz Beloit One Network |
$510.84
|
| Rate for Payer: Quartz Commercial |
$661.77
|
| Rate for Payer: Quartz Medicare Advantage |
$86.38
|
| Rate for Payer: The Alliance Commercial |
$328.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$86.38
|
| Rate for Payer: WEA Trust Commercial |
$638.55
|
| Rate for Payer: WPS Commercial |
$431.90
|
|
|
XR Urethrocystography Voiding
|
Facility
OP
|
$1,161.00
|
|
|
Service Code
|
CPT 74455 TC
|
| Hospital Charge Code |
3072720
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$4,644.00 |
| Rate for Payer: Aetna Commercial |
$1,044.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$998.46
|
| Rate for Payer: Aetna Managed Medicare |
$325.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$754.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$580.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$557.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$615.33
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cigna Commercial |
$1,068.12
|
| Rate for Payer: Health EOS Commercial |
$1,033.29
|
| Rate for Payer: HFN Commercial |
$1,068.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$870.75
|
| Rate for Payer: Multiplan Commercial |
$928.80
|
| Rate for Payer: NAPHCARE Commercial |
$696.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,068.12
|
| Rate for Payer: Quartz Beloit One Network |
$568.89
|
| Rate for Payer: Quartz Commercial |
$754.65
|
| Rate for Payer: Quartz Medicare Advantage |
$696.60
|
| Rate for Payer: The Alliance Commercial |
$4,644.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$638.55
|
| Rate for Payer: WPS Commercial |
$859.95
|
|
|
XR Urography Retrograde
|
Professional
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 LT
|
| Hospital Charge Code |
1537459
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$550.88 |
| Max. Negotiated Rate |
$1,189.40 |
| Rate for Payer: Aetna Commercial |
$1,189.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,076.72
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,189.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$626.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$751.20
|
| Rate for Payer: Health EOS Commercial |
$1,139.32
|
| Rate for Payer: Multiplan Commercial |
$1,001.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,189.40
|
| Rate for Payer: Quartz Beloit One Network |
$550.88
|
| Rate for Payer: Quartz Commercial |
$713.64
|
| Rate for Payer: The Alliance Commercial |
$626.00
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$927.36
|
|
