|
XR Urography Retrograde
|
Facility
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 LT
|
| Hospital Charge Code |
1537459
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$5,008.00 |
| Rate for Payer: Aetna Commercial |
$1,126.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,076.72
|
| Rate for Payer: Aetna Managed Medicare |
$350.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$813.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$626.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$600.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$663.56
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,151.84
|
| Rate for Payer: Health EOS Commercial |
$1,114.28
|
| Rate for Payer: HFN Commercial |
$1,151.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$939.00
|
| Rate for Payer: Multiplan Commercial |
$1,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$751.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,151.84
|
| Rate for Payer: Quartz Beloit One Network |
$613.48
|
| Rate for Payer: Quartz Commercial |
$813.80
|
| Rate for Payer: Quartz Medicare Advantage |
$751.20
|
| Rate for Payer: The Alliance Commercial |
$5,008.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$927.36
|
|
|
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
|
|
|
XR Urography Retrograde LT
|
Professional
|
$1,002.00
|
|
|
Service Code
|
CPT 74420 TC,LT
|
| Hospital Charge Code |
3072645
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$440.88 |
| Max. Negotiated Rate |
$951.90 |
| Rate for Payer: Aetna Commercial |
$951.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$861.72
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$951.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$501.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$601.20
|
| Rate for Payer: Health EOS Commercial |
$911.82
|
| Rate for Payer: Multiplan Commercial |
$801.60
|
| Rate for Payer: Preferred Network Access Commercial |
$951.90
|
| Rate for Payer: Quartz Beloit One Network |
$440.88
|
| Rate for Payer: Quartz Commercial |
$571.14
|
| Rate for Payer: The Alliance Commercial |
$501.00
|
| Rate for Payer: WEA Trust Commercial |
$551.10
|
| Rate for Payer: WPS Commercial |
$742.18
|
|
|
XR Urography Retrograde LT
|
Facility
IP
|
$1,002.00
|
|
|
Service Code
|
CPT 74420 TC,LT
|
| Hospital Charge Code |
3072645
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$490.98 |
| Max. Negotiated Rate |
$921.84 |
| Rate for Payer: Aetna Commercial |
$901.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$531.06
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$921.84
|
| Rate for Payer: Health EOS Commercial |
$891.78
|
| Rate for Payer: HFN Commercial |
$921.84
|
| Rate for Payer: Multiplan Commercial |
$801.60
|
| Rate for Payer: NAPHCARE Commercial |
$601.20
|
| Rate for Payer: Preferred Network Access Commercial |
$921.84
|
| Rate for Payer: Quartz Beloit One Network |
$490.98
|
| Rate for Payer: Quartz Commercial |
$601.20
|
| Rate for Payer: WEA Trust Commercial |
$551.10
|
| Rate for Payer: WPS Commercial |
$742.18
|
|
|
XR Urography Retrograde LT
|
Facility
OP
|
$1,002.00
|
|
|
Service Code
|
CPT 74420 TC,LT
|
| Hospital Charge Code |
3072645
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$280.56 |
| Max. Negotiated Rate |
$4,008.00 |
| Rate for Payer: Aetna Commercial |
$901.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$861.72
|
| Rate for Payer: Aetna Managed Medicare |
$280.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$651.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$501.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$480.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$531.06
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$921.84
|
| Rate for Payer: Health EOS Commercial |
$891.78
|
| Rate for Payer: HFN Commercial |
$921.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$751.50
|
| Rate for Payer: Multiplan Commercial |
$801.60
|
| Rate for Payer: NAPHCARE Commercial |
$601.20
|
| Rate for Payer: Preferred Network Access Commercial |
$921.84
|
| Rate for Payer: Quartz Beloit One Network |
$490.98
|
| Rate for Payer: Quartz Commercial |
$651.30
|
| Rate for Payer: Quartz Medicare Advantage |
$601.20
|
| Rate for Payer: The Alliance Commercial |
$4,008.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$551.10
|
| Rate for Payer: WPS Commercial |
$742.18
|
|
|
XR Urography Retrograde RT
|
Professional
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC,RT
|
| Hospital Charge Code |
3072646
|
|
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
|
|
|
XR Urography Retrograde RT
|
Facility
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC,RT
|
| Hospital Charge Code |
3072646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$5,008.00 |
| Rate for Payer: Aetna Commercial |
$1,126.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,076.72
|
| Rate for Payer: Aetna Managed Medicare |
$350.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$813.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$626.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$600.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$663.56
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,151.84
|
| Rate for Payer: Health EOS Commercial |
$1,114.28
|
| Rate for Payer: HFN Commercial |
$1,151.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$939.00
|
| Rate for Payer: Multiplan Commercial |
$1,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$751.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,151.84
|
| Rate for Payer: Quartz Beloit One Network |
$613.48
|
| Rate for Payer: Quartz Commercial |
$813.80
|
| Rate for Payer: Quartz Medicare Advantage |
$751.20
|
| Rate for Payer: The Alliance Commercial |
$5,008.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$927.36
|
|
|
XR Urography Retrograde RT
|
Facility
IP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC,RT
|
| Hospital Charge Code |
3072646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$613.48 |
| Max. Negotiated Rate |
$1,151.84 |
| Rate for Payer: Aetna Commercial |
$1,126.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$663.56
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,151.84
|
| Rate for Payer: Health EOS Commercial |
$1,114.28
|
| Rate for Payer: HFN Commercial |
$1,151.84
|
| Rate for Payer: Multiplan Commercial |
$1,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$751.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,151.84
|
| Rate for Payer: Quartz Beloit One Network |
$613.48
|
| Rate for Payer: Quartz Commercial |
$751.20
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$927.36
|
|
|
XR Urography Retro Lt
|
Facility
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596968
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$5,008.00 |
| Rate for Payer: Aetna Commercial |
$1,126.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,076.72
|
| Rate for Payer: Aetna Managed Medicare |
$350.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$813.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$626.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$600.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$663.56
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,151.84
|
| Rate for Payer: Health EOS Commercial |
$1,114.28
|
| Rate for Payer: HFN Commercial |
$1,151.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$939.00
|
| Rate for Payer: Multiplan Commercial |
$1,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$751.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,151.84
|
| Rate for Payer: Quartz Beloit One Network |
$613.48
|
| Rate for Payer: Quartz Commercial |
$813.80
|
| Rate for Payer: Quartz Medicare Advantage |
$751.20
|
| Rate for Payer: The Alliance Commercial |
$5,008.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$927.36
|
|
|
XR Urography Retro Lt
|
Professional
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596968
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$50.97 |
| 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: Aetna Managed Medicare |
$50.97
|
| Rate for Payer: Anthem Medicare Advantage |
$50.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$50.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$50.97
|
| 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 |
$50.97
|
| Rate for Payer: Health EOS Commercial |
$1,139.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$175.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$50.97
|
| 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: Quartz Medicare Advantage |
$50.97
|
| Rate for Payer: The Alliance Commercial |
$193.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.97
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$254.85
|
|
|
XR Urography Retro Lt
|
Facility
IP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596968
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$613.48 |
| Max. Negotiated Rate |
$1,151.84 |
| Rate for Payer: Aetna Commercial |
$1,126.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$663.56
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,151.84
|
| Rate for Payer: Health EOS Commercial |
$1,114.28
|
| Rate for Payer: HFN Commercial |
$1,151.84
|
| Rate for Payer: Multiplan Commercial |
$1,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$751.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,151.84
|
| Rate for Payer: Quartz Beloit One Network |
$613.48
|
| Rate for Payer: Quartz Commercial |
$751.20
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$927.36
|
|
|
XR Urography Retro Rt
|
Facility
IP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596965
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$613.48 |
| Max. Negotiated Rate |
$1,151.84 |
| Rate for Payer: Aetna Commercial |
$1,126.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$663.56
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,151.84
|
| Rate for Payer: Health EOS Commercial |
$1,114.28
|
| Rate for Payer: HFN Commercial |
$1,151.84
|
| Rate for Payer: Multiplan Commercial |
$1,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$751.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,151.84
|
| Rate for Payer: Quartz Beloit One Network |
$613.48
|
| Rate for Payer: Quartz Commercial |
$751.20
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$927.36
|
|
|
XR Urography Retro Rt
|
Facility
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596965
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$5,008.00 |
| Rate for Payer: Aetna Commercial |
$1,126.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,076.72
|
| Rate for Payer: Aetna Managed Medicare |
$350.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$813.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$626.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$600.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$663.56
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,151.84
|
| Rate for Payer: Health EOS Commercial |
$1,114.28
|
| Rate for Payer: HFN Commercial |
$1,151.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$939.00
|
| Rate for Payer: Multiplan Commercial |
$1,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$751.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,151.84
|
| Rate for Payer: Quartz Beloit One Network |
$613.48
|
| Rate for Payer: Quartz Commercial |
$813.80
|
| Rate for Payer: Quartz Medicare Advantage |
$751.20
|
| Rate for Payer: The Alliance Commercial |
$5,008.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$927.36
|
|
|
XR Urography Retro Rt
|
Professional
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596965
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$50.97 |
| 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: Aetna Managed Medicare |
$50.97
|
| Rate for Payer: Anthem Medicare Advantage |
$50.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$50.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$50.97
|
| 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 |
$50.97
|
| Rate for Payer: Health EOS Commercial |
$1,139.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$175.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$50.97
|
| 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: Quartz Medicare Advantage |
$50.97
|
| Rate for Payer: The Alliance Commercial |
$193.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.97
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$254.85
|
|
|
XR US Guidance
|
Facility
OP
|
$454.00
|
|
|
Service Code
|
CPT 76937
|
| Hospital Charge Code |
3242195
|
| Min. Negotiated Rate |
$96.52 |
| Max. Negotiated Rate |
$417.68 |
| Rate for Payer: Aetna Commercial |
$408.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$390.44
|
| Rate for Payer: Aetna Managed Medicare |
$127.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$295.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$227.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$217.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$240.62
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$417.68
|
| Rate for Payer: Health EOS Commercial |
$404.06
|
| Rate for Payer: HFN Commercial |
$417.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.50
|
| Rate for Payer: Multiplan Commercial |
$363.20
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$417.68
|
| Rate for Payer: Quartz Beloit One Network |
$222.46
|
| Rate for Payer: Quartz Commercial |
$295.10
|
| Rate for Payer: Quartz Medicare Advantage |
$272.40
|
| Rate for Payer: The Alliance Commercial |
$96.52
|
| Rate for Payer: WEA Trust Commercial |
$249.70
|
| Rate for Payer: WPS Commercial |
$336.28
|
|
|
XR US Guidance
|
Professional
|
$454.00
|
|
|
Service Code
|
CPT 76937
|
| Hospital Charge Code |
3242195
|
| Min. Negotiated Rate |
$37.63 |
| Max. Negotiated Rate |
$431.30 |
| Rate for Payer: Aetna Commercial |
$431.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$390.44
|
| Rate for Payer: Aetna Managed Medicare |
$37.63
|
| Rate for Payer: Anthem Medicare Advantage |
$37.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$37.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$37.63
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$431.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$227.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.63
|
| Rate for Payer: Health EOS Commercial |
$413.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$37.63
|
| Rate for Payer: Multiplan Commercial |
$363.20
|
| Rate for Payer: Preferred Network Access Commercial |
$431.30
|
| Rate for Payer: Quartz Beloit One Network |
$199.76
|
| Rate for Payer: Quartz Commercial |
$258.78
|
| Rate for Payer: Quartz Medicare Advantage |
$37.63
|
| Rate for Payer: The Alliance Commercial |
$142.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.63
|
| Rate for Payer: WEA Trust Commercial |
$249.70
|
| Rate for Payer: WPS Commercial |
$188.15
|
|
|
XR US Guidance
|
Facility
IP
|
$454.00
|
|
|
Service Code
|
CPT 76937
|
| Hospital Charge Code |
3242195
|
| Min. Negotiated Rate |
$222.46 |
| Max. Negotiated Rate |
$417.68 |
| Rate for Payer: Aetna Commercial |
$408.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$240.62
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$417.68
|
| Rate for Payer: Health EOS Commercial |
$404.06
|
| Rate for Payer: HFN Commercial |
$417.68
|
| Rate for Payer: Multiplan Commercial |
$363.20
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$417.68
|
| Rate for Payer: Quartz Beloit One Network |
$222.46
|
| Rate for Payer: Quartz Commercial |
$272.40
|
| Rate for Payer: WEA Trust Commercial |
$249.70
|
| Rate for Payer: WPS Commercial |
$336.28
|
|
|
XR US Guided Midline
|
Professional
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552128
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$24.47 |
| Max. Negotiated Rate |
$422.75 |
| Rate for Payer: Aetna Commercial |
$422.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Aetna Managed Medicare |
$24.47
|
| Rate for Payer: Anthem Medicare Advantage |
$24.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.47
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$422.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$222.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.47
|
| Rate for Payer: Health EOS Commercial |
$404.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.47
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: Preferred Network Access Commercial |
$422.75
|
| Rate for Payer: Quartz Beloit One Network |
$195.80
|
| Rate for Payer: Quartz Commercial |
$253.65
|
| Rate for Payer: Quartz Medicare Advantage |
$24.47
|
| Rate for Payer: The Alliance Commercial |
$92.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.47
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$122.35
|
|
|
XR US Guided Midline
|
Facility
IP
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552128
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$218.05 |
| Max. Negotiated Rate |
$409.40 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
XR US Guided Midline
|
Facility
OP
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552128
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$124.60 |
| Max. Negotiated Rate |
$1,780.00 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Aetna Managed Medicare |
$124.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.75
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$289.25
|
| Rate for Payer: Quartz Medicare Advantage |
$267.00
|
| Rate for Payer: The Alliance Commercial |
$1,780.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
XR Venogram Lower Extremity Bilateral
|
Facility
OP
|
$1,723.00
|
|
|
Service Code
|
CPT 75822 TC
|
| Hospital Charge Code |
3072721
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$482.44 |
| Max. Negotiated Rate |
$6,892.00 |
| Rate for Payer: Aetna Commercial |
$1,550.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,481.78
|
| Rate for Payer: Aetna Managed Medicare |
$482.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,119.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$861.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$827.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$913.19
|
| Rate for Payer: Cash Price |
$516.90
|
| Rate for Payer: Cash Price |
$516.90
|
| Rate for Payer: Cigna Commercial |
$1,585.16
|
| Rate for Payer: Health EOS Commercial |
$1,533.47
|
| Rate for Payer: HFN Commercial |
$1,585.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,292.25
|
| Rate for Payer: Multiplan Commercial |
$1,378.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,033.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,585.16
|
| Rate for Payer: Quartz Beloit One Network |
$844.27
|
| Rate for Payer: Quartz Commercial |
$1,119.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,033.80
|
| Rate for Payer: The Alliance Commercial |
$6,892.00
|
| Rate for Payer: WEA Trust Commercial |
$947.65
|
| Rate for Payer: WPS Commercial |
$1,276.23
|
|
|
XR Venogram Lower Extremity Bilateral
|
Facility
IP
|
$1,723.00
|
|
|
Service Code
|
CPT 75822 TC
|
| Hospital Charge Code |
3072721
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$844.27 |
| Max. Negotiated Rate |
$1,585.16 |
| Rate for Payer: Aetna Commercial |
$1,550.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$913.19
|
| Rate for Payer: Cash Price |
$516.90
|
| Rate for Payer: Cigna Commercial |
$1,585.16
|
| Rate for Payer: Health EOS Commercial |
$1,533.47
|
| Rate for Payer: HFN Commercial |
$1,585.16
|
| Rate for Payer: Multiplan Commercial |
$1,378.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,033.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,585.16
|
| Rate for Payer: Quartz Beloit One Network |
$844.27
|
| Rate for Payer: Quartz Commercial |
$1,033.80
|
| Rate for Payer: WEA Trust Commercial |
$947.65
|
| Rate for Payer: WPS Commercial |
$1,276.23
|
|
|
XR Venogram Lower Extremity Bilateral
|
Professional
|
$1,723.00
|
|
|
Service Code
|
CPT 75822 TC
|
| Hospital Charge Code |
3072721
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$62.88 |
| Max. Negotiated Rate |
$1,636.85 |
| Rate for Payer: Aetna Commercial |
$1,636.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,481.78
|
| Rate for Payer: Aetna Managed Medicare |
$62.88
|
| Rate for Payer: Anthem Medicare Advantage |
$62.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.88
|
| Rate for Payer: Cash Price |
$516.90
|
| Rate for Payer: Cash Price |
$516.90
|
| Rate for Payer: Cigna Commercial |
$1,636.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$861.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.88
|
| Rate for Payer: Health EOS Commercial |
$1,567.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$241.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$241.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.88
|
| Rate for Payer: Multiplan Commercial |
$1,378.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,636.85
|
| Rate for Payer: Quartz Beloit One Network |
$758.12
|
| Rate for Payer: Quartz Commercial |
$982.11
|
| Rate for Payer: Quartz Medicare Advantage |
$62.88
|
| Rate for Payer: The Alliance Commercial |
$238.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.88
|
| Rate for Payer: WEA Trust Commercial |
$947.65
|
| Rate for Payer: WPS Commercial |
$314.40
|
|
|
XR Venogram Lower Extremity Left
|
Facility
OP
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,LT
|
| Hospital Charge Code |
3072728
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$5,024.00 |
| Rate for Payer: Aetna Commercial |
$1,130.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,080.16
|
| Rate for Payer: Aetna Managed Medicare |
$351.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$628.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$602.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$665.68
|
| Rate for Payer: Cash Price |
$376.80
|
| Rate for Payer: Cash Price |
$376.80
|
| Rate for Payer: Cash Price |
$376.80
|
| Rate for Payer: Cigna Commercial |
$1,155.52
|
| Rate for Payer: Health EOS Commercial |
$1,117.84
|
| Rate for Payer: HFN Commercial |
$1,155.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$942.00
|
| Rate for Payer: Multiplan Commercial |
$1,004.80
|
| Rate for Payer: NAPHCARE Commercial |
$753.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,155.52
|
| Rate for Payer: Quartz Beloit One Network |
$615.44
|
| Rate for Payer: Quartz Commercial |
$816.40
|
| Rate for Payer: Quartz Medicare Advantage |
$753.60
|
| Rate for Payer: The Alliance Commercial |
$5,024.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$690.80
|
| Rate for Payer: WPS Commercial |
$930.32
|
|
|
XR Venogram Lower Extremity Left
|
Professional
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,LT
|
| Hospital Charge Code |
3072728
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$552.64 |
| Max. Negotiated Rate |
$1,193.20 |
| Rate for Payer: Aetna Commercial |
$1,193.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,080.16
|
| Rate for Payer: Cash Price |
$376.80
|
| Rate for Payer: Cash Price |
$376.80
|
| Rate for Payer: Cigna Commercial |
$1,193.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$628.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$753.60
|
| Rate for Payer: Health EOS Commercial |
$1,142.96
|
| Rate for Payer: Multiplan Commercial |
$1,004.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,193.20
|
| Rate for Payer: Quartz Beloit One Network |
$552.64
|
| Rate for Payer: Quartz Commercial |
$715.92
|
| Rate for Payer: The Alliance Commercial |
$628.00
|
| Rate for Payer: WEA Trust Commercial |
$690.80
|
| Rate for Payer: WPS Commercial |
$930.32
|
|
