|
XR PAIN Fluoro Guided Joint
|
Facility
|
IP
|
$1,133.00
|
|
|
Service Code
|
CPT 77002
|
| Hospital Charge Code |
5963664
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$577.38 |
| Max. Negotiated Rate |
$1,084.05 |
| Rate for Payer: Aetna Commercial |
$1,060.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,013.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$624.51
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,084.05
|
| Rate for Payer: Health EOS Commercial |
$1,048.70
|
| Rate for Payer: HFN Commercial |
$1,084.05
|
| Rate for Payer: Multiplan Commercial |
$942.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,084.05
|
| Rate for Payer: Quartz Beloit One Network |
$577.38
|
| Rate for Payer: Quartz Commercial |
$706.99
|
| Rate for Payer: WEA Trust Commercial |
$648.08
|
| Rate for Payer: WPS Commercial |
$872.75
|
|
|
XR Panorex/Orthopantogram
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
630293
|
| Min. Negotiated Rate |
$244.10 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$298.90
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
XR Panorex/Orthopantogram
|
Facility
|
OP
|
$517.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
1537222
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$494.67 |
| Rate for Payer: Aetna Commercial |
$483.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$462.40
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.58
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$494.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$478.54
|
| Rate for Payer: HFN Commercial |
$494.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$430.14
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$494.67
|
| Rate for Payer: Quartz Beloit One Network |
$263.46
|
| Rate for Payer: Quartz Commercial |
$349.49
|
| Rate for Payer: Quartz Medicare Advantage |
$91.58
|
| Rate for Payer: The Alliance Commercial |
$366.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.58
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$295.72
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$398.25
|
|
|
XR Panorex/Orthopantogram
|
Facility
|
IP
|
$517.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
1537222
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$263.46 |
| Max. Negotiated Rate |
$494.67 |
| Rate for Payer: Aetna Commercial |
$483.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$462.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.97
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$494.67
|
| Rate for Payer: Health EOS Commercial |
$478.54
|
| Rate for Payer: HFN Commercial |
$494.67
|
| Rate for Payer: Multiplan Commercial |
$430.14
|
| Rate for Payer: Preferred Network Access Commercial |
$494.67
|
| Rate for Payer: Quartz Beloit One Network |
$263.46
|
| Rate for Payer: Quartz Commercial |
$322.61
|
| Rate for Payer: WEA Trust Commercial |
$295.72
|
| Rate for Payer: WPS Commercial |
$398.25
|
|
|
XR Panorex/Orthopantogram
|
Facility
|
OP
|
$479.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
630293
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$323.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$249.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$239.12
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.58
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$323.80
|
| Rate for Payer: Quartz Medicare Advantage |
$91.58
|
| Rate for Payer: The Alliance Commercial |
$366.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.58
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
XR Panorex/Orthopantogram
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
630293
|
| Min. Negotiated Rate |
$19.15 |
| Max. Negotiated Rate |
$473.25 |
| Rate for Payer: Aetna Commercial |
$473.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Aetna Managed Medicare |
$19.15
|
| Rate for Payer: Anthem Medicare Advantage |
$19.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.15
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$473.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$249.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.15
|
| Rate for Payer: Health EOS Commercial |
$453.33
|
| Rate for Payer: HFN Commercial |
$473.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.15
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: NAPHCARE Commercial |
$28.72
|
| Rate for Payer: Preferred Network Access Commercial |
$473.25
|
| Rate for Payer: Quartz Beloit One Network |
$219.19
|
| Rate for Payer: Quartz Commercial |
$283.95
|
| Rate for Payer: Quartz Medicare Advantage |
$19.15
|
| Rate for Payer: The Alliance Commercial |
$72.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.15
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$95.73
|
|
|
XR Panorex/Orthopantogram
|
Professional
|
Both
|
$517.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
1537222
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$19.15 |
| Max. Negotiated Rate |
$510.80 |
| Rate for Payer: Aetna Commercial |
$510.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$462.40
|
| Rate for Payer: Aetna Managed Medicare |
$19.15
|
| Rate for Payer: Anthem Medicare Advantage |
$19.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.15
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$510.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$268.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.15
|
| Rate for Payer: Health EOS Commercial |
$489.29
|
| Rate for Payer: HFN Commercial |
$510.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.15
|
| Rate for Payer: Multiplan Commercial |
$430.14
|
| Rate for Payer: NAPHCARE Commercial |
$28.72
|
| Rate for Payer: Preferred Network Access Commercial |
$510.80
|
| Rate for Payer: Quartz Beloit One Network |
$236.58
|
| Rate for Payer: Quartz Commercial |
$306.48
|
| Rate for Payer: Quartz Medicare Advantage |
$19.15
|
| Rate for Payer: The Alliance Commercial |
$72.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.15
|
| Rate for Payer: WEA Trust Commercial |
$295.72
|
| Rate for Payer: WPS Commercial |
$95.73
|
|
|
XR Pelvimetry
|
Facility
|
IP
|
$577.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
1537224
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$294.04 |
| Max. Negotiated Rate |
$552.07 |
| Rate for Payer: Aetna Commercial |
$540.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.04
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$552.07
|
| Rate for Payer: Health EOS Commercial |
$534.07
|
| Rate for Payer: HFN Commercial |
$552.07
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: Preferred Network Access Commercial |
$552.07
|
| Rate for Payer: Quartz Beloit One Network |
$294.04
|
| Rate for Payer: Quartz Commercial |
$360.05
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$444.46
|
|
|
XR Pelvimetry
|
Professional
|
Both
|
$577.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
1537224
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$27.75 |
| Max. Negotiated Rate |
$570.08 |
| Rate for Payer: Aetna Commercial |
$570.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Aetna Managed Medicare |
$27.75
|
| Rate for Payer: Anthem Medicare Advantage |
$27.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.75
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$570.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$300.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.75
|
| Rate for Payer: Health EOS Commercial |
$546.07
|
| Rate for Payer: HFN Commercial |
$570.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$97.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: NAPHCARE Commercial |
$41.62
|
| Rate for Payer: Preferred Network Access Commercial |
$570.08
|
| Rate for Payer: Quartz Beloit One Network |
$264.04
|
| Rate for Payer: Quartz Commercial |
$342.05
|
| Rate for Payer: Quartz Medicare Advantage |
$27.75
|
| Rate for Payer: The Alliance Commercial |
$105.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.75
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$138.74
|
|
|
XR Pelvimetry
|
Facility
|
IP
|
$754.00
|
|
|
Service Code
|
CPT 74710
|
| Hospital Charge Code |
630291
|
| Min. Negotiated Rate |
$384.24 |
| Max. Negotiated Rate |
$721.43 |
| Rate for Payer: Aetna Commercial |
$705.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$674.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$415.60
|
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Cigna Commercial |
$721.43
|
| Rate for Payer: Health EOS Commercial |
$697.90
|
| Rate for Payer: HFN Commercial |
$721.43
|
| Rate for Payer: Multiplan Commercial |
$627.33
|
| Rate for Payer: Preferred Network Access Commercial |
$721.43
|
| Rate for Payer: Quartz Beloit One Network |
$384.24
|
| Rate for Payer: Quartz Commercial |
$470.50
|
| Rate for Payer: WEA Trust Commercial |
$431.29
|
| Rate for Payer: WPS Commercial |
$580.81
|
|
|
XR Pelvimetry
|
Professional
|
Both
|
$754.00
|
|
|
Service Code
|
CPT 74710
|
| Hospital Charge Code |
630291
|
| Min. Negotiated Rate |
$141.23 |
| Max. Negotiated Rate |
$744.95 |
| Rate for Payer: Aetna Commercial |
$744.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$674.38
|
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Cigna Commercial |
$744.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$392.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$470.50
|
| Rate for Payer: Health EOS Commercial |
$713.59
|
| Rate for Payer: HFN Commercial |
$744.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$141.23
|
| Rate for Payer: Multiplan Commercial |
$627.33
|
| Rate for Payer: Preferred Network Access Commercial |
$744.95
|
| Rate for Payer: Quartz Beloit One Network |
$345.03
|
| Rate for Payer: Quartz Commercial |
$446.97
|
| Rate for Payer: The Alliance Commercial |
$392.08
|
| Rate for Payer: WEA Trust Commercial |
$431.29
|
| Rate for Payer: WPS Commercial |
$580.81
|
|
|
XR Pelvimetry
|
Facility
|
OP
|
$754.00
|
|
|
Service Code
|
CPT 74710
|
| Hospital Charge Code |
630291
|
| Min. Negotiated Rate |
$219.56 |
| Max. Negotiated Rate |
$721.43 |
| Rate for Payer: Aetna Commercial |
$705.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$674.38
|
| Rate for Payer: Aetna Managed Medicare |
$219.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$509.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$392.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$376.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$415.60
|
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Cigna Commercial |
$721.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$438.83
|
| Rate for Payer: Health EOS Commercial |
$697.90
|
| Rate for Payer: HFN Commercial |
$721.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$588.12
|
| Rate for Payer: Multiplan Commercial |
$627.33
|
| Rate for Payer: NAPHCARE Commercial |
$470.50
|
| Rate for Payer: Preferred Network Access Commercial |
$721.43
|
| Rate for Payer: Quartz Beloit One Network |
$384.24
|
| Rate for Payer: Quartz Commercial |
$509.70
|
| Rate for Payer: Quartz Medicare Advantage |
$470.50
|
| Rate for Payer: The Alliance Commercial |
$392.08
|
| Rate for Payer: WEA Trust Commercial |
$431.29
|
| Rate for Payer: WPS Commercial |
$580.81
|
|
|
XR Pelvimetry
|
Facility
|
OP
|
$577.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
1537224
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$552.07 |
| Rate for Payer: Aetna Commercial |
$540.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Aetna Managed Medicare |
$110.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.10
|
| Rate for Payer: Anthem Medicare Advantage |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$110.02
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$552.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$110.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$335.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$110.02
|
| Rate for Payer: Health EOS Commercial |
$534.07
|
| Rate for Payer: HFN Commercial |
$552.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$409.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$110.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$110.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$110.02
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: NAPHCARE Commercial |
$165.03
|
| Rate for Payer: Preferred Network Access Commercial |
$552.07
|
| Rate for Payer: Quartz Beloit One Network |
$294.04
|
| Rate for Payer: Quartz Commercial |
$390.05
|
| Rate for Payer: Quartz Medicare Advantage |
$110.02
|
| Rate for Payer: The Alliance Commercial |
$440.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.02
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: Wellcare Medicare |
$110.02
|
| Rate for Payer: WPS Commercial |
$444.46
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
|
OP
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
1537228
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$77.63 |
| Max. Negotiated Rate |
$552.07 |
| Rate for Payer: Aetna Commercial |
$540.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Aetna Managed Medicare |
$168.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.04
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$552.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$335.81
|
| Rate for Payer: Health EOS Commercial |
$534.07
|
| Rate for Payer: HFN Commercial |
$552.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$450.06
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: NAPHCARE Commercial |
$360.05
|
| Rate for Payer: Preferred Network Access Commercial |
$552.07
|
| Rate for Payer: Quartz Beloit One Network |
$294.04
|
| Rate for Payer: Quartz Commercial |
$390.05
|
| Rate for Payer: Quartz Medicare Advantage |
$360.05
|
| Rate for Payer: The Alliance Commercial |
$77.63
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$444.46
|
|
|
XR Pelvis 1 or 2 Views
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
630285
|
| Min. Negotiated Rate |
$27.75 |
| Max. Negotiated Rate |
$528.58 |
| Rate for Payer: Aetna Commercial |
$528.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.50
|
| Rate for Payer: Aetna Managed Medicare |
$27.75
|
| Rate for Payer: Anthem Medicare Advantage |
$27.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.75
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$528.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$278.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.75
|
| Rate for Payer: Health EOS Commercial |
$506.32
|
| Rate for Payer: HFN Commercial |
$528.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$97.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$445.12
|
| Rate for Payer: NAPHCARE Commercial |
$41.62
|
| Rate for Payer: Preferred Network Access Commercial |
$528.58
|
| Rate for Payer: Quartz Beloit One Network |
$244.82
|
| Rate for Payer: Quartz Commercial |
$317.15
|
| Rate for Payer: Quartz Medicare Advantage |
$27.75
|
| Rate for Payer: The Alliance Commercial |
$105.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.75
|
| Rate for Payer: WEA Trust Commercial |
$306.02
|
| Rate for Payer: WPS Commercial |
$138.74
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
|
IP
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
1537228
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$294.04 |
| Max. Negotiated Rate |
$552.07 |
| Rate for Payer: Aetna Commercial |
$540.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.04
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$552.07
|
| Rate for Payer: Health EOS Commercial |
$534.07
|
| Rate for Payer: HFN Commercial |
$552.07
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: Preferred Network Access Commercial |
$552.07
|
| Rate for Payer: Quartz Beloit One Network |
$294.04
|
| Rate for Payer: Quartz Commercial |
$360.05
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$444.46
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
630285
|
| Min. Negotiated Rate |
$272.64 |
| Max. Negotiated Rate |
$511.89 |
| Rate for Payer: Aetna Commercial |
$500.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.89
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$511.89
|
| Rate for Payer: Health EOS Commercial |
$495.20
|
| Rate for Payer: HFN Commercial |
$511.89
|
| Rate for Payer: Multiplan Commercial |
$445.12
|
| Rate for Payer: Preferred Network Access Commercial |
$511.89
|
| Rate for Payer: Quartz Beloit One Network |
$272.64
|
| Rate for Payer: Quartz Commercial |
$333.84
|
| Rate for Payer: WEA Trust Commercial |
$306.02
|
| Rate for Payer: WPS Commercial |
$412.11
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
630285
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$511.89 |
| Rate for Payer: Aetna Commercial |
$500.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.50
|
| Rate for Payer: Aetna Managed Medicare |
$110.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$361.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$278.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$267.07
|
| Rate for Payer: Anthem Medicare Advantage |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$110.02
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$511.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$110.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$311.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$110.02
|
| Rate for Payer: Health EOS Commercial |
$495.20
|
| Rate for Payer: HFN Commercial |
$511.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$409.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$110.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$110.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$110.02
|
| Rate for Payer: Multiplan Commercial |
$445.12
|
| Rate for Payer: NAPHCARE Commercial |
$165.03
|
| Rate for Payer: Preferred Network Access Commercial |
$511.89
|
| Rate for Payer: Quartz Beloit One Network |
$272.64
|
| Rate for Payer: Quartz Commercial |
$361.66
|
| Rate for Payer: Quartz Medicare Advantage |
$110.02
|
| Rate for Payer: The Alliance Commercial |
$440.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.02
|
| Rate for Payer: WEA Trust Commercial |
$306.02
|
| Rate for Payer: Wellcare Medicare |
$110.02
|
| Rate for Payer: WPS Commercial |
$412.11
|
|
|
XR Pelvis 1 or 2 Views
|
Professional
|
Both
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
1537228
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$19.41 |
| Max. Negotiated Rate |
$570.08 |
| Rate for Payer: Aetna Commercial |
$570.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Aetna Managed Medicare |
$19.41
|
| Rate for Payer: Anthem Medicare Advantage |
$19.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.41
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$570.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$300.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.41
|
| Rate for Payer: Health EOS Commercial |
$546.07
|
| Rate for Payer: HFN Commercial |
$570.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.41
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: NAPHCARE Commercial |
$29.11
|
| Rate for Payer: Preferred Network Access Commercial |
$570.08
|
| Rate for Payer: Quartz Beloit One Network |
$264.04
|
| Rate for Payer: Quartz Commercial |
$342.05
|
| Rate for Payer: Quartz Medicare Advantage |
$19.41
|
| Rate for Payer: The Alliance Commercial |
$73.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.41
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$97.03
|
|
|
XR Pelvis 1 View
|
Facility
|
IP
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
6182059
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$294.04 |
| Max. Negotiated Rate |
$552.07 |
| Rate for Payer: Aetna Commercial |
$540.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.04
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$552.07
|
| Rate for Payer: Health EOS Commercial |
$534.07
|
| Rate for Payer: HFN Commercial |
$552.07
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: Preferred Network Access Commercial |
$552.07
|
| Rate for Payer: Quartz Beloit One Network |
$294.04
|
| Rate for Payer: Quartz Commercial |
$360.05
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$444.46
|
|
|
XR Pelvis 1 View
|
Facility
|
OP
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
6182059
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$77.63 |
| Max. Negotiated Rate |
$552.07 |
| Rate for Payer: Aetna Commercial |
$540.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Aetna Managed Medicare |
$168.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.04
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$552.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$335.81
|
| Rate for Payer: Health EOS Commercial |
$534.07
|
| Rate for Payer: HFN Commercial |
$552.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$450.06
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: NAPHCARE Commercial |
$360.05
|
| Rate for Payer: Preferred Network Access Commercial |
$552.07
|
| Rate for Payer: Quartz Beloit One Network |
$294.04
|
| Rate for Payer: Quartz Commercial |
$390.05
|
| Rate for Payer: Quartz Medicare Advantage |
$360.05
|
| Rate for Payer: The Alliance Commercial |
$77.63
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$444.46
|
|
|
XR Pelvis 1 View
|
Professional
|
Both
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
6182059
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$19.41 |
| Max. Negotiated Rate |
$570.08 |
| Rate for Payer: Aetna Commercial |
$570.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.07
|
| Rate for Payer: Aetna Managed Medicare |
$19.41
|
| Rate for Payer: Anthem Medicare Advantage |
$19.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.41
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$570.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$300.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.41
|
| Rate for Payer: Health EOS Commercial |
$546.07
|
| Rate for Payer: HFN Commercial |
$570.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.41
|
| Rate for Payer: Multiplan Commercial |
$480.06
|
| Rate for Payer: NAPHCARE Commercial |
$29.11
|
| Rate for Payer: Preferred Network Access Commercial |
$570.08
|
| Rate for Payer: Quartz Beloit One Network |
$264.04
|
| Rate for Payer: Quartz Commercial |
$342.05
|
| Rate for Payer: Quartz Medicare Advantage |
$19.41
|
| Rate for Payer: The Alliance Commercial |
$73.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.41
|
| Rate for Payer: WEA Trust Commercial |
$330.04
|
| Rate for Payer: WPS Commercial |
$97.03
|
|
|
XR Pelvis Complete Minimum 3 Views
|
Facility
|
IP
|
$684.00
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
630281
|
| Min. Negotiated Rate |
$348.57 |
| Max. Negotiated Rate |
$654.45 |
| Rate for Payer: Aetna Commercial |
$640.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$611.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$377.02
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$654.45
|
| Rate for Payer: Health EOS Commercial |
$633.11
|
| Rate for Payer: HFN Commercial |
$654.45
|
| Rate for Payer: Multiplan Commercial |
$569.09
|
| Rate for Payer: Preferred Network Access Commercial |
$654.45
|
| Rate for Payer: Quartz Beloit One Network |
$348.57
|
| Rate for Payer: Quartz Commercial |
$426.82
|
| Rate for Payer: WEA Trust Commercial |
$391.25
|
| Rate for Payer: WPS Commercial |
$526.89
|
|
|
XR Pelvis Complete Minimum 3 Views
|
Facility
|
IP
|
$711.00
|
|
|
Service Code
|
CPT 72190 TC
|
| Hospital Charge Code |
1537230
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$362.33 |
| Max. Negotiated Rate |
$680.28 |
| Rate for Payer: Aetna Commercial |
$665.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$635.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$391.90
|
| Rate for Payer: Cash Price |
$213.30
|
| Rate for Payer: Cigna Commercial |
$680.28
|
| Rate for Payer: Health EOS Commercial |
$658.10
|
| Rate for Payer: HFN Commercial |
$680.28
|
| Rate for Payer: Multiplan Commercial |
$591.55
|
| Rate for Payer: Preferred Network Access Commercial |
$680.28
|
| Rate for Payer: Quartz Beloit One Network |
$362.33
|
| Rate for Payer: Quartz Commercial |
$443.66
|
| Rate for Payer: WEA Trust Commercial |
$406.69
|
| Rate for Payer: WPS Commercial |
$547.68
|
|
|
XR Pelvis Complete Minimum 3 Views
|
Facility
|
OP
|
$711.00
|
|
|
Service Code
|
CPT 72190 TC
|
| Hospital Charge Code |
1537230
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$122.89 |
| Max. Negotiated Rate |
$680.28 |
| Rate for Payer: Aetna Commercial |
$665.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$635.92
|
| Rate for Payer: Aetna Managed Medicare |
$207.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$391.90
|
| Rate for Payer: Cash Price |
$213.30
|
| Rate for Payer: Cash Price |
$213.30
|
| Rate for Payer: Cash Price |
$213.30
|
| Rate for Payer: Cigna Commercial |
$680.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$413.80
|
| Rate for Payer: Health EOS Commercial |
$658.10
|
| Rate for Payer: HFN Commercial |
$680.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$554.58
|
| Rate for Payer: Multiplan Commercial |
$591.55
|
| Rate for Payer: NAPHCARE Commercial |
$443.66
|
| Rate for Payer: Preferred Network Access Commercial |
$680.28
|
| Rate for Payer: Quartz Beloit One Network |
$362.33
|
| Rate for Payer: Quartz Commercial |
$480.64
|
| Rate for Payer: Quartz Medicare Advantage |
$443.66
|
| Rate for Payer: The Alliance Commercial |
$122.89
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$406.69
|
| Rate for Payer: WPS Commercial |
$547.68
|
|
