|
XR Orbits Complete Right
|
Facility
|
IP
|
$669.00
|
|
|
Service Code
|
CPT 70200 TC,RT
|
| Hospital Charge Code |
1537218
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$327.81 |
| Max. Negotiated Rate |
$615.48 |
| Rate for Payer: Aetna Commercial |
$602.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.57
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$615.48
|
| Rate for Payer: Health EOS Commercial |
$595.41
|
| Rate for Payer: HFN Commercial |
$615.48
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: NAPHCARE Commercial |
$401.40
|
| Rate for Payer: Preferred Network Access Commercial |
$615.48
|
| Rate for Payer: Quartz Beloit One Network |
$327.81
|
| Rate for Payer: Quartz Commercial |
$401.40
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
|
XR Orbits Complete Right
|
Facility
|
IP
|
$619.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
630297
|
| Min. Negotiated Rate |
$303.31 |
| Max. Negotiated Rate |
$569.48 |
| Rate for Payer: Aetna Commercial |
$557.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$532.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$328.07
|
| Rate for Payer: Cash Price |
$185.70
|
| Rate for Payer: Cigna Commercial |
$569.48
|
| Rate for Payer: Health EOS Commercial |
$550.91
|
| Rate for Payer: HFN Commercial |
$569.48
|
| Rate for Payer: Multiplan Commercial |
$495.20
|
| Rate for Payer: NAPHCARE Commercial |
$371.40
|
| Rate for Payer: Preferred Network Access Commercial |
$569.48
|
| Rate for Payer: Quartz Beloit One Network |
$303.31
|
| Rate for Payer: Quartz Commercial |
$371.40
|
| Rate for Payer: WEA Trust Commercial |
$340.45
|
| Rate for Payer: WPS Commercial |
$458.49
|
|
|
XR Orbits Complete Right
|
Professional
|
Both
|
$619.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
630297
|
| Min. Negotiated Rate |
$164.00 |
| Max. Negotiated Rate |
$588.05 |
| Rate for Payer: Aetna Commercial |
$588.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$532.34
|
| Rate for Payer: Cash Price |
$185.70
|
| Rate for Payer: Cash Price |
$185.70
|
| Rate for Payer: Cigna Commercial |
$588.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$309.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$371.40
|
| Rate for Payer: Health EOS Commercial |
$563.29
|
| Rate for Payer: HFN Commercial |
$588.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$164.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$164.00
|
| Rate for Payer: Multiplan Commercial |
$495.20
|
| Rate for Payer: Preferred Network Access Commercial |
$588.05
|
| Rate for Payer: Quartz Beloit One Network |
$272.36
|
| Rate for Payer: Quartz Commercial |
$352.83
|
| Rate for Payer: The Alliance Commercial |
$309.50
|
| Rate for Payer: WEA Trust Commercial |
$340.45
|
| Rate for Payer: WPS Commercial |
$458.49
|
|
|
XR Orbits Complete Right
|
Facility
|
IP
|
$669.00
|
|
|
Service Code
|
CPT 70200 TC,RT
|
| Hospital Charge Code |
2979985
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$327.81 |
| Max. Negotiated Rate |
$615.48 |
| Rate for Payer: Aetna Commercial |
$602.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.57
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$615.48
|
| Rate for Payer: Health EOS Commercial |
$595.41
|
| Rate for Payer: HFN Commercial |
$615.48
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: NAPHCARE Commercial |
$401.40
|
| Rate for Payer: Preferred Network Access Commercial |
$615.48
|
| Rate for Payer: Quartz Beloit One Network |
$327.81
|
| Rate for Payer: Quartz Commercial |
$401.40
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
|
XR Orbits Complete Right
|
Facility
|
OP
|
$619.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
630297
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$569.48 |
| Rate for Payer: Aetna Commercial |
$557.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$532.34
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$402.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$309.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$297.12
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$328.07
|
| 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 |
$185.70
|
| Rate for Payer: Cash Price |
$185.70
|
| Rate for Payer: Cigna Commercial |
$569.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$346.39
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$550.91
|
| Rate for Payer: HFN Commercial |
$569.48
|
| 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 |
$495.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$569.48
|
| Rate for Payer: Quartz Beloit One Network |
$303.31
|
| Rate for Payer: Quartz Commercial |
$402.35
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$340.45
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$458.49
|
|
|
XR Orbits Complete Right
|
Professional
|
Both
|
$669.00
|
|
|
Service Code
|
CPT 70200 TC,RT
|
| Hospital Charge Code |
1537218
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$294.36 |
| Max. Negotiated Rate |
$635.55 |
| Rate for Payer: Aetna Commercial |
$635.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.34
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$635.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$334.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$401.40
|
| Rate for Payer: Health EOS Commercial |
$608.79
|
| Rate for Payer: HFN Commercial |
$635.55
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: Preferred Network Access Commercial |
$635.55
|
| Rate for Payer: Quartz Beloit One Network |
$294.36
|
| Rate for Payer: Quartz Commercial |
$381.33
|
| Rate for Payer: The Alliance Commercial |
$334.50
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
|
XR Orbits Complete Right
|
Facility
|
OP
|
$669.00
|
|
|
Service Code
|
CPT 70200 TC,RT
|
| Hospital Charge Code |
2979985
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$187.32 |
| Max. Negotiated Rate |
$2,676.00 |
| Rate for Payer: Aetna Commercial |
$602.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.34
|
| Rate for Payer: Aetna Managed Medicare |
$187.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$434.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$334.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$321.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.57
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$615.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$374.37
|
| Rate for Payer: Health EOS Commercial |
$595.41
|
| Rate for Payer: HFN Commercial |
$615.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$501.75
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: NAPHCARE Commercial |
$401.40
|
| Rate for Payer: Preferred Network Access Commercial |
$615.48
|
| Rate for Payer: Quartz Beloit One Network |
$327.81
|
| Rate for Payer: Quartz Commercial |
$434.85
|
| Rate for Payer: Quartz Medicare Advantage |
$401.40
|
| Rate for Payer: The Alliance Commercial |
$2,676.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
|
XR Orbits Complete Right
|
Professional
|
Both
|
$669.00
|
|
|
Service Code
|
CPT 70200 TC,RT
|
| Hospital Charge Code |
2979985
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$294.36 |
| Max. Negotiated Rate |
$635.55 |
| Rate for Payer: Aetna Commercial |
$635.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.34
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$635.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$334.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$401.40
|
| Rate for Payer: Health EOS Commercial |
$608.79
|
| Rate for Payer: HFN Commercial |
$635.55
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: Preferred Network Access Commercial |
$635.55
|
| Rate for Payer: Quartz Beloit One Network |
$294.36
|
| Rate for Payer: Quartz Commercial |
$381.33
|
| Rate for Payer: The Alliance Commercial |
$334.50
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
|
XR OR Cholangiogram
|
Facility
|
OP
|
$1,266.00
|
|
|
Service Code
|
CPT 74300
|
| Hospital Charge Code |
1536942
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$5,064.00 |
| Rate for Payer: Aetna Commercial |
$1,139.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,088.76
|
| Rate for Payer: Aetna Managed Medicare |
$354.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$822.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$633.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$607.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$670.98
|
| Rate for Payer: Cash Price |
$379.80
|
| Rate for Payer: Cash Price |
$379.80
|
| Rate for Payer: Cigna Commercial |
$1,164.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$708.45
|
| Rate for Payer: Health EOS Commercial |
$1,126.74
|
| Rate for Payer: HFN Commercial |
$1,164.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$949.50
|
| Rate for Payer: Multiplan Commercial |
$1,012.80
|
| Rate for Payer: NAPHCARE Commercial |
$759.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,164.72
|
| Rate for Payer: Quartz Beloit One Network |
$620.34
|
| Rate for Payer: Quartz Commercial |
$822.90
|
| Rate for Payer: Quartz Medicare Advantage |
$759.60
|
| Rate for Payer: The Alliance Commercial |
$5,064.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$696.30
|
| Rate for Payer: WPS Commercial |
$937.73
|
|
|
XR OR Cholangiogram
|
Facility
|
IP
|
$1,266.00
|
|
|
Service Code
|
CPT 74300
|
| Hospital Charge Code |
1536942
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$620.34 |
| Max. Negotiated Rate |
$1,164.72 |
| Rate for Payer: Aetna Commercial |
$1,139.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,088.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$670.98
|
| Rate for Payer: Cash Price |
$379.80
|
| Rate for Payer: Cigna Commercial |
$1,164.72
|
| Rate for Payer: Health EOS Commercial |
$1,126.74
|
| Rate for Payer: HFN Commercial |
$1,164.72
|
| Rate for Payer: Multiplan Commercial |
$1,012.80
|
| Rate for Payer: NAPHCARE Commercial |
$759.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,164.72
|
| Rate for Payer: Quartz Beloit One Network |
$620.34
|
| Rate for Payer: Quartz Commercial |
$759.60
|
| Rate for Payer: WEA Trust Commercial |
$696.30
|
| Rate for Payer: WPS Commercial |
$937.73
|
|
|
XR OR Cholangiogram
|
Professional
|
Both
|
$1,266.00
|
|
|
Service Code
|
CPT 74300
|
| Hospital Charge Code |
1536942
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$217.27 |
| Max. Negotiated Rate |
$1,202.70 |
| Rate for Payer: Aetna Commercial |
$1,202.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,088.76
|
| Rate for Payer: Cash Price |
$379.80
|
| Rate for Payer: Cash Price |
$379.80
|
| Rate for Payer: Cigna Commercial |
$1,202.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$633.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$759.60
|
| Rate for Payer: Health EOS Commercial |
$1,152.06
|
| Rate for Payer: HFN Commercial |
$1,202.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$217.27
|
| Rate for Payer: Multiplan Commercial |
$1,012.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,202.70
|
| Rate for Payer: Quartz Beloit One Network |
$557.04
|
| Rate for Payer: Quartz Commercial |
$721.62
|
| Rate for Payer: The Alliance Commercial |
$633.00
|
| Rate for Payer: WEA Trust Commercial |
$696.30
|
| Rate for Payer: WPS Commercial |
$937.73
|
|
|
XR OR Cholangiogram
|
Facility
|
OP
|
$973.00
|
|
|
Service Code
|
CPT 74300
|
| Hospital Charge Code |
629736
|
| Min. Negotiated Rate |
$272.44 |
| Max. Negotiated Rate |
$3,892.00 |
| Rate for Payer: Aetna Commercial |
$875.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$836.78
|
| Rate for Payer: Aetna Managed Medicare |
$272.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$632.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$486.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$467.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$515.69
|
| Rate for Payer: Cash Price |
$291.90
|
| Rate for Payer: Cigna Commercial |
$895.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$544.49
|
| Rate for Payer: Health EOS Commercial |
$865.97
|
| Rate for Payer: HFN Commercial |
$895.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$729.75
|
| Rate for Payer: Multiplan Commercial |
$778.40
|
| Rate for Payer: NAPHCARE Commercial |
$583.80
|
| Rate for Payer: Preferred Network Access Commercial |
$895.16
|
| Rate for Payer: Quartz Beloit One Network |
$476.77
|
| Rate for Payer: Quartz Commercial |
$632.45
|
| Rate for Payer: Quartz Medicare Advantage |
$583.80
|
| Rate for Payer: The Alliance Commercial |
$3,892.00
|
| Rate for Payer: WEA Trust Commercial |
$535.15
|
| Rate for Payer: WPS Commercial |
$720.70
|
|
|
XR OR Cholangiogram
|
Facility
|
IP
|
$973.00
|
|
|
Service Code
|
CPT 74300
|
| Hospital Charge Code |
629736
|
| Min. Negotiated Rate |
$476.77 |
| Max. Negotiated Rate |
$895.16 |
| Rate for Payer: Aetna Commercial |
$875.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$836.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$515.69
|
| Rate for Payer: Cash Price |
$291.90
|
| Rate for Payer: Cigna Commercial |
$895.16
|
| Rate for Payer: Health EOS Commercial |
$865.97
|
| Rate for Payer: HFN Commercial |
$895.16
|
| Rate for Payer: Multiplan Commercial |
$778.40
|
| Rate for Payer: NAPHCARE Commercial |
$583.80
|
| Rate for Payer: Preferred Network Access Commercial |
$895.16
|
| Rate for Payer: Quartz Beloit One Network |
$476.77
|
| Rate for Payer: Quartz Commercial |
$583.80
|
| Rate for Payer: WEA Trust Commercial |
$535.15
|
| Rate for Payer: WPS Commercial |
$720.70
|
|
|
XR OR Cholangiogram
|
Professional
|
Both
|
$973.00
|
|
|
Service Code
|
CPT 74300
|
| Hospital Charge Code |
629736
|
| Min. Negotiated Rate |
$217.27 |
| Max. Negotiated Rate |
$924.35 |
| Rate for Payer: Aetna Commercial |
$924.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$836.78
|
| Rate for Payer: Cash Price |
$291.90
|
| Rate for Payer: Cash Price |
$291.90
|
| Rate for Payer: Cigna Commercial |
$924.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$486.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$583.80
|
| Rate for Payer: Health EOS Commercial |
$885.43
|
| Rate for Payer: HFN Commercial |
$924.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$217.27
|
| Rate for Payer: Multiplan Commercial |
$778.40
|
| Rate for Payer: Preferred Network Access Commercial |
$924.35
|
| Rate for Payer: Quartz Beloit One Network |
$428.12
|
| Rate for Payer: Quartz Commercial |
$554.61
|
| Rate for Payer: The Alliance Commercial |
$486.50
|
| Rate for Payer: WEA Trust Commercial |
$535.15
|
| Rate for Payer: WPS Commercial |
$720.70
|
|
|
XR OR Clavicle
|
Professional
|
Both
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724187
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$143.21 |
| Max. Negotiated Rate |
$1,007.00 |
| Rate for Payer: Aetna Commercial |
$1,007.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$1,007.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$530.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.00
|
| Rate for Payer: Health EOS Commercial |
$964.60
|
| Rate for Payer: HFN Commercial |
$1,007.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$143.21
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,007.00
|
| Rate for Payer: Quartz Beloit One Network |
$466.40
|
| Rate for Payer: Quartz Commercial |
$604.20
|
| Rate for Payer: The Alliance Commercial |
$530.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR OR Clavicle
|
Facility
|
IP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724187
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$519.40 |
| Max. Negotiated Rate |
$975.20 |
| Rate for Payer: Aetna Commercial |
$954.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$561.80
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$975.20
|
| Rate for Payer: Health EOS Commercial |
$943.40
|
| Rate for Payer: HFN Commercial |
$975.20
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: NAPHCARE Commercial |
$636.00
|
| Rate for Payer: Preferred Network Access Commercial |
$975.20
|
| Rate for Payer: Quartz Beloit One Network |
$519.40
|
| Rate for Payer: Quartz Commercial |
$636.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR OR Clavicle
|
Facility
|
OP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724187
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$975.20 |
| Rate for Payer: Aetna Commercial |
$954.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| 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 |
$561.80
|
| 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 |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$975.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$593.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$943.40
|
| Rate for Payer: HFN Commercial |
$975.20
|
| 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 |
$848.00
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$975.20
|
| Rate for Payer: Quartz Beloit One Network |
$519.40
|
| Rate for Payer: Quartz Commercial |
$689.00
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR OR Cystography
|
Facility
|
OP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
6179845
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$975.20 |
| Rate for Payer: Aetna Commercial |
$954.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| 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 |
$561.80
|
| 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 |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$975.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$593.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$943.40
|
| Rate for Payer: HFN Commercial |
$975.20
|
| 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 |
$848.00
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$975.20
|
| Rate for Payer: Quartz Beloit One Network |
$519.40
|
| Rate for Payer: Quartz Commercial |
$689.00
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR OR Cystography
|
Professional
|
Both
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
6179845
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$143.21 |
| Max. Negotiated Rate |
$1,007.00 |
| Rate for Payer: Aetna Commercial |
$1,007.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$1,007.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$530.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.00
|
| Rate for Payer: Health EOS Commercial |
$964.60
|
| Rate for Payer: HFN Commercial |
$1,007.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$143.21
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,007.00
|
| Rate for Payer: Quartz Beloit One Network |
$466.40
|
| Rate for Payer: Quartz Commercial |
$604.20
|
| Rate for Payer: The Alliance Commercial |
$530.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR OR Cystography
|
Facility
|
IP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
6179845
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$519.40 |
| Max. Negotiated Rate |
$975.20 |
| Rate for Payer: Aetna Commercial |
$954.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$561.80
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$975.20
|
| Rate for Payer: Health EOS Commercial |
$943.40
|
| Rate for Payer: HFN Commercial |
$975.20
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: NAPHCARE Commercial |
$636.00
|
| Rate for Payer: Preferred Network Access Commercial |
$975.20
|
| Rate for Payer: Quartz Beloit One Network |
$519.40
|
| Rate for Payer: Quartz Commercial |
$636.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR OR Elbow
|
Professional
|
Both
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724190
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$143.21 |
| Max. Negotiated Rate |
$1,007.00 |
| Rate for Payer: Aetna Commercial |
$1,007.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$1,007.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$530.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.00
|
| Rate for Payer: Health EOS Commercial |
$964.60
|
| Rate for Payer: HFN Commercial |
$1,007.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$143.21
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,007.00
|
| Rate for Payer: Quartz Beloit One Network |
$466.40
|
| Rate for Payer: Quartz Commercial |
$604.20
|
| Rate for Payer: The Alliance Commercial |
$530.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR OR Elbow
|
Facility
|
OP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724190
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$975.20 |
| Rate for Payer: Aetna Commercial |
$954.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| 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 |
$561.80
|
| 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 |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$975.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$593.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$943.40
|
| Rate for Payer: HFN Commercial |
$975.20
|
| 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 |
$848.00
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$975.20
|
| Rate for Payer: Quartz Beloit One Network |
$519.40
|
| Rate for Payer: Quartz Commercial |
$689.00
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR OR Elbow
|
Facility
|
IP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724190
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$519.40 |
| Max. Negotiated Rate |
$975.20 |
| Rate for Payer: Aetna Commercial |
$954.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$561.80
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$975.20
|
| Rate for Payer: Health EOS Commercial |
$943.40
|
| Rate for Payer: HFN Commercial |
$975.20
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: NAPHCARE Commercial |
$636.00
|
| Rate for Payer: Preferred Network Access Commercial |
$975.20
|
| Rate for Payer: Quartz Beloit One Network |
$519.40
|
| Rate for Payer: Quartz Commercial |
$636.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR OR Esophageal Dilation
|
Professional
|
Both
|
$1,060.00
|
|
|
Service Code
|
CPT 74360
|
| Hospital Charge Code |
2587226
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$466.40 |
| Max. Negotiated Rate |
$1,007.00 |
| Rate for Payer: Aetna Commercial |
$1,007.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$1,007.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$530.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.00
|
| Rate for Payer: Health EOS Commercial |
$964.60
|
| Rate for Payer: HFN Commercial |
$1,007.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$542.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$542.00
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,007.00
|
| Rate for Payer: Quartz Beloit One Network |
$466.40
|
| Rate for Payer: Quartz Commercial |
$604.20
|
| Rate for Payer: The Alliance Commercial |
$530.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR OR Esophageal Dilation
|
Facility
|
OP
|
$1,060.00
|
|
|
Service Code
|
CPT 74360
|
| Hospital Charge Code |
2587226
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$296.80 |
| Max. Negotiated Rate |
$4,240.00 |
| Rate for Payer: Aetna Commercial |
$954.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Aetna Managed Medicare |
$296.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$689.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$530.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$508.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$561.80
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$975.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$593.18
|
| Rate for Payer: Health EOS Commercial |
$943.40
|
| Rate for Payer: HFN Commercial |
$975.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$795.00
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: NAPHCARE Commercial |
$636.00
|
| Rate for Payer: Preferred Network Access Commercial |
$975.20
|
| Rate for Payer: Quartz Beloit One Network |
$519.40
|
| Rate for Payer: Quartz Commercial |
$689.00
|
| Rate for Payer: Quartz Medicare Advantage |
$636.00
|
| Rate for Payer: The Alliance Commercial |
$4,240.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
