|
XR Venogram Lower Extremity Left
|
Facility
IP
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,LT
|
| Hospital Charge Code |
3072728
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$615.44 |
| Max. Negotiated Rate |
$1,155.52 |
| Rate for Payer: Aetna Commercial |
$1,130.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$665.68
|
| 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: 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 |
$753.60
|
| Rate for Payer: WEA Trust Commercial |
$690.80
|
| Rate for Payer: WPS Commercial |
$930.32
|
|
|
XR Venogram Lower Extremity Right
|
Professional
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,RT
|
| Hospital Charge Code |
3072729
|
|
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
|
|
|
XR Venogram Lower Extremity Right
|
Facility
IP
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,RT
|
| Hospital Charge Code |
3072729
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$615.44 |
| Max. Negotiated Rate |
$1,155.52 |
| Rate for Payer: Aetna Commercial |
$1,130.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$665.68
|
| 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: 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 |
$753.60
|
| Rate for Payer: WEA Trust Commercial |
$690.80
|
| Rate for Payer: WPS Commercial |
$930.32
|
|
|
XR Venogram Lower Extremity Right
|
Facility
OP
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,RT
|
| Hospital Charge Code |
3072729
|
|
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 Upper Extremity Bilateral
|
Professional
|
$1,723.00
|
|
|
Service Code
|
CPT 75822 TC
|
| Hospital Charge Code |
3072722
|
|
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 Upper Extremity Bilateral
|
Facility
OP
|
$1,723.00
|
|
|
Service Code
|
CPT 75822 TC
|
| Hospital Charge Code |
3072722
|
|
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 Upper Extremity Bilateral
|
Facility
IP
|
$1,723.00
|
|
|
Service Code
|
CPT 75822 TC
|
| Hospital Charge Code |
3072722
|
|
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 Upper Extremity Left
|
Facility
OP
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,LT
|
| Hospital Charge Code |
3072730
|
|
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 Upper Extremity Left
|
Facility
IP
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,LT
|
| Hospital Charge Code |
3072730
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$615.44 |
| Max. Negotiated Rate |
$1,155.52 |
| Rate for Payer: Aetna Commercial |
$1,130.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$665.68
|
| 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: 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 |
$753.60
|
| Rate for Payer: WEA Trust Commercial |
$690.80
|
| Rate for Payer: WPS Commercial |
$930.32
|
|
|
XR Venogram Upper Extremity Left
|
Professional
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,LT
|
| Hospital Charge Code |
3072730
|
|
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
|
|
|
XR Venogram Upper Extremity Right
|
Facility
IP
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,RT
|
| Hospital Charge Code |
3072731
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$615.44 |
| Max. Negotiated Rate |
$1,155.52 |
| Rate for Payer: Aetna Commercial |
$1,130.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$665.68
|
| 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: 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 |
$753.60
|
| Rate for Payer: WEA Trust Commercial |
$690.80
|
| Rate for Payer: WPS Commercial |
$930.32
|
|
|
XR Venogram Upper Extremity Right
|
Professional
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,RT
|
| Hospital Charge Code |
3072731
|
|
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
|
|
|
XR Venogram Upper Extremity Right
|
Facility
OP
|
$1,256.00
|
|
|
Service Code
|
CPT 75820 TC,RT
|
| Hospital Charge Code |
3072731
|
|
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 Venous Access Patency Check
|
Facility
OP
|
$1,017.00
|
|
|
Service Code
|
CPT 36598 TC
|
| Hospital Charge Code |
6219656
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$284.76 |
| Max. Negotiated Rate |
$4,068.00 |
| Rate for Payer: Aetna Commercial |
$915.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$874.62
|
| Rate for Payer: Aetna Managed Medicare |
$284.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$661.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$508.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$488.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$539.01
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cigna Commercial |
$935.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$569.11
|
| Rate for Payer: Health EOS Commercial |
$905.13
|
| Rate for Payer: HFN Commercial |
$935.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$762.75
|
| Rate for Payer: Multiplan Commercial |
$813.60
|
| Rate for Payer: NAPHCARE Commercial |
$610.20
|
| Rate for Payer: Preferred Network Access Commercial |
$935.64
|
| Rate for Payer: Quartz Beloit One Network |
$498.33
|
| Rate for Payer: Quartz Commercial |
$661.05
|
| Rate for Payer: Quartz Medicare Advantage |
$610.20
|
| Rate for Payer: The Alliance Commercial |
$4,068.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$559.35
|
| Rate for Payer: WPS Commercial |
$753.29
|
|
|
XR Venous Access Patency Check
|
Facility
IP
|
$1,017.00
|
|
|
Service Code
|
CPT 36598 TC
|
| Hospital Charge Code |
6219656
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$498.33 |
| Max. Negotiated Rate |
$935.64 |
| Rate for Payer: Aetna Commercial |
$915.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$539.01
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cigna Commercial |
$935.64
|
| Rate for Payer: Health EOS Commercial |
$905.13
|
| Rate for Payer: HFN Commercial |
$935.64
|
| Rate for Payer: Multiplan Commercial |
$813.60
|
| Rate for Payer: NAPHCARE Commercial |
$610.20
|
| Rate for Payer: Preferred Network Access Commercial |
$935.64
|
| Rate for Payer: Quartz Beloit One Network |
$498.33
|
| Rate for Payer: Quartz Commercial |
$610.20
|
| Rate for Payer: WEA Trust Commercial |
$559.35
|
| Rate for Payer: WPS Commercial |
$753.29
|
|
|
XR Venous Access Patency Check
|
Professional
|
$1,017.00
|
|
|
Service Code
|
CPT 36598 TC
|
| Hospital Charge Code |
6219656
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$447.48 |
| Max. Negotiated Rate |
$966.15 |
| Rate for Payer: Aetna Commercial |
$966.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$874.62
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cigna Commercial |
$966.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$508.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$610.20
|
| Rate for Payer: Health EOS Commercial |
$925.47
|
| Rate for Payer: Multiplan Commercial |
$813.60
|
| Rate for Payer: Preferred Network Access Commercial |
$966.15
|
| Rate for Payer: Quartz Beloit One Network |
$447.48
|
| Rate for Payer: Quartz Commercial |
$579.69
|
| Rate for Payer: The Alliance Commercial |
$508.50
|
| Rate for Payer: WEA Trust Commercial |
$559.35
|
| Rate for Payer: WPS Commercial |
$753.29
|
|
|
XR Wrist 2 Views Bilateral
|
Facility
IP
|
$456.00
|
|
|
Service Code
|
CPT 73100 LT,TC
|
| Hospital Charge Code |
1537481
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$223.44 |
| Max. Negotiated Rate |
$419.52 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$273.60
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
XR Wrist 2 Views Bilateral
|
Facility
OP
|
$456.00
|
|
|
Service Code
|
CPT 73100 LT,TC
|
| Hospital Charge Code |
1537481
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$127.68 |
| Max. Negotiated Rate |
$1,824.00 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Aetna Managed Medicare |
$127.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$296.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$218.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$342.00
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$296.40
|
| Rate for Payer: Quartz Medicare Advantage |
$273.60
|
| Rate for Payer: The Alliance Commercial |
$1,824.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
XR Wrist 2 Views Bilateral
|
Professional
|
$456.00
|
|
|
Service Code
|
CPT 73100 LT,TC
|
| Hospital Charge Code |
1537481
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$200.64 |
| Max. Negotiated Rate |
$433.20 |
| Rate for Payer: Aetna Commercial |
$433.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$433.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$228.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$273.60
|
| Rate for Payer: Health EOS Commercial |
$414.96
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: Preferred Network Access Commercial |
$433.20
|
| Rate for Payer: Quartz Beloit One Network |
$200.64
|
| Rate for Payer: Quartz Commercial |
$259.92
|
| Rate for Payer: The Alliance Commercial |
$228.00
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
XR Wrist 2 Views Bilateral
|
Facility
IP
|
$875.00
|
|
|
Service Code
|
CPT 73100
|
| Hospital Charge Code |
613630
|
| Min. Negotiated Rate |
$428.75 |
| Max. Negotiated Rate |
$805.00 |
| Rate for Payer: Aetna Commercial |
$787.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$463.75
|
| Rate for Payer: Cash Price |
$262.50
|
| Rate for Payer: Cigna Commercial |
$805.00
|
| Rate for Payer: Health EOS Commercial |
$778.75
|
| Rate for Payer: HFN Commercial |
$805.00
|
| Rate for Payer: Multiplan Commercial |
$700.00
|
| Rate for Payer: NAPHCARE Commercial |
$525.00
|
| Rate for Payer: Preferred Network Access Commercial |
$805.00
|
| Rate for Payer: Quartz Beloit One Network |
$428.75
|
| Rate for Payer: Quartz Commercial |
$525.00
|
| Rate for Payer: WEA Trust Commercial |
$481.25
|
| Rate for Payer: WPS Commercial |
$648.11
|
|
|
XR Wrist 2 Views Bilateral
|
Professional
|
$875.00
|
|
|
Service Code
|
CPT 73100
|
| Hospital Charge Code |
613630
|
| Min. Negotiated Rate |
$32.68 |
| Max. Negotiated Rate |
$831.25 |
| Rate for Payer: Aetna Commercial |
$831.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$752.50
|
| Rate for Payer: Aetna Managed Medicare |
$32.68
|
| Rate for Payer: Anthem Medicare Advantage |
$32.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32.68
|
| Rate for Payer: Cash Price |
$262.50
|
| Rate for Payer: Cash Price |
$262.50
|
| Rate for Payer: Cigna Commercial |
$831.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$437.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.68
|
| Rate for Payer: Health EOS Commercial |
$796.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$114.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32.68
|
| Rate for Payer: Multiplan Commercial |
$700.00
|
| Rate for Payer: Preferred Network Access Commercial |
$831.25
|
| Rate for Payer: Quartz Beloit One Network |
$385.00
|
| Rate for Payer: Quartz Commercial |
$498.75
|
| Rate for Payer: Quartz Medicare Advantage |
$32.68
|
| Rate for Payer: The Alliance Commercial |
$124.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.68
|
| Rate for Payer: WEA Trust Commercial |
$481.25
|
| Rate for Payer: WPS Commercial |
$163.40
|
|
|
XR Wrist 2 Views Bilateral
|
Facility
OP
|
$875.00
|
|
|
Service Code
|
CPT 73100
|
| Hospital Charge Code |
613630
|
| Min. Negotiated Rate |
$87.32 |
| Max. Negotiated Rate |
$805.00 |
| Rate for Payer: Aetna Commercial |
$787.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$752.50
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$568.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$437.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$420.00
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$463.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$262.50
|
| Rate for Payer: Cash Price |
$262.50
|
| Rate for Payer: Cigna Commercial |
$805.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$778.75
|
| Rate for Payer: HFN Commercial |
$805.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$700.00
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$805.00
|
| Rate for Payer: Quartz Beloit One Network |
$428.75
|
| Rate for Payer: Quartz Commercial |
$568.75
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$87.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$481.25
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$648.11
|
|
|
XR Wrist 2 Views Left
|
Professional
|
$438.00
|
|
|
Service Code
|
CPT 73100
|
| Hospital Charge Code |
613632
|
| Min. Negotiated Rate |
$32.68 |
| Max. Negotiated Rate |
$416.10 |
| Rate for Payer: Aetna Commercial |
$416.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$376.68
|
| Rate for Payer: Aetna Managed Medicare |
$32.68
|
| Rate for Payer: Anthem Medicare Advantage |
$32.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32.68
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$416.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$219.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.68
|
| Rate for Payer: Health EOS Commercial |
$398.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$114.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32.68
|
| Rate for Payer: Multiplan Commercial |
$350.40
|
| Rate for Payer: Preferred Network Access Commercial |
$416.10
|
| Rate for Payer: Quartz Beloit One Network |
$192.72
|
| Rate for Payer: Quartz Commercial |
$249.66
|
| Rate for Payer: Quartz Medicare Advantage |
$32.68
|
| Rate for Payer: The Alliance Commercial |
$124.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.68
|
| Rate for Payer: WEA Trust Commercial |
$240.90
|
| Rate for Payer: WPS Commercial |
$163.40
|
|
|
XR Wrist 2 Views Left
|
Professional
|
$494.00
|
|
|
Service Code
|
CPT 73100 LT,TC
|
| Hospital Charge Code |
1537483
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$217.36 |
| Max. Negotiated Rate |
$469.30 |
| Rate for Payer: Aetna Commercial |
$469.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$424.84
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cigna Commercial |
$469.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$247.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$296.40
|
| Rate for Payer: Health EOS Commercial |
$449.54
|
| Rate for Payer: Multiplan Commercial |
$395.20
|
| Rate for Payer: Preferred Network Access Commercial |
$469.30
|
| Rate for Payer: Quartz Beloit One Network |
$217.36
|
| Rate for Payer: Quartz Commercial |
$281.58
|
| Rate for Payer: The Alliance Commercial |
$247.00
|
| Rate for Payer: WEA Trust Commercial |
$271.70
|
| Rate for Payer: WPS Commercial |
$365.91
|
|
|
XR Wrist 2 Views Left
|
Facility
IP
|
$438.00
|
|
|
Service Code
|
CPT 73100
|
| Hospital Charge Code |
613632
|
| Min. Negotiated Rate |
$214.62 |
| Max. Negotiated Rate |
$402.96 |
| Rate for Payer: Aetna Commercial |
$394.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$232.14
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$402.96
|
| Rate for Payer: Health EOS Commercial |
$389.82
|
| Rate for Payer: HFN Commercial |
$402.96
|
| Rate for Payer: Multiplan Commercial |
$350.40
|
| Rate for Payer: NAPHCARE Commercial |
$262.80
|
| Rate for Payer: Preferred Network Access Commercial |
$402.96
|
| Rate for Payer: Quartz Beloit One Network |
$214.62
|
| Rate for Payer: Quartz Commercial |
$262.80
|
| Rate for Payer: WEA Trust Commercial |
$240.90
|
| Rate for Payer: WPS Commercial |
$324.43
|
|
