|
XR OR Ureteral Cath/Stent Placement
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
6179863
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$561.20 |
| Rate for Payer: Aetna Commercial |
$549.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$407.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$326.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$309.71
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$561.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$542.90
|
| Rate for Payer: HFN Commercial |
$561.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$488.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$561.20
|
| Rate for Payer: Quartz Beloit One Network |
$298.90
|
| Rate for Payer: Quartz Commercial |
$396.50
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$335.50
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$451.83
|
|
|
XR OR Ureteral Cath/Stent Placement
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
6182210
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$145.37 |
| Max. Negotiated Rate |
$579.50 |
| Rate for Payer: Aetna Commercial |
$579.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$579.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$305.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$366.00
|
| Rate for Payer: Health EOS Commercial |
$555.10
|
| Rate for Payer: HFN Commercial |
$579.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$145.37
|
| Rate for Payer: Multiplan Commercial |
$488.00
|
| Rate for Payer: Preferred Network Access Commercial |
$579.50
|
| Rate for Payer: Quartz Beloit One Network |
$268.40
|
| Rate for Payer: Quartz Commercial |
$347.70
|
| Rate for Payer: The Alliance Commercial |
$305.00
|
| Rate for Payer: WEA Trust Commercial |
$335.50
|
| Rate for Payer: WPS Commercial |
$451.83
|
|
|
XR OR Ureteral Cath/Stent Placement
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
6179863
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$145.37 |
| Max. Negotiated Rate |
$579.50 |
| Rate for Payer: Aetna Commercial |
$579.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$579.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$305.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$366.00
|
| Rate for Payer: Health EOS Commercial |
$555.10
|
| Rate for Payer: HFN Commercial |
$579.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$145.37
|
| Rate for Payer: Multiplan Commercial |
$488.00
|
| Rate for Payer: Preferred Network Access Commercial |
$579.50
|
| Rate for Payer: Quartz Beloit One Network |
$268.40
|
| Rate for Payer: Quartz Commercial |
$347.70
|
| Rate for Payer: The Alliance Commercial |
$305.00
|
| Rate for Payer: WEA Trust Commercial |
$335.50
|
| Rate for Payer: WPS Commercial |
$451.83
|
|
|
XR OR Ureteral Cath/Stent Placement
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
6182210
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$561.20 |
| Rate for Payer: Aetna Commercial |
$549.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$407.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$326.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$309.71
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$561.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$542.90
|
| Rate for Payer: HFN Commercial |
$561.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$488.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$561.20
|
| Rate for Payer: Quartz Beloit One Network |
$298.90
|
| Rate for Payer: Quartz Commercial |
$396.50
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$335.50
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$451.83
|
|
|
XR OR Ureteral Cath/Stent Placement
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
6179863
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$298.90 |
| Max. Negotiated Rate |
$561.20 |
| Rate for Payer: Aetna Commercial |
$549.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.30
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$561.20
|
| Rate for Payer: Health EOS Commercial |
$542.90
|
| Rate for Payer: HFN Commercial |
$561.20
|
| Rate for Payer: Multiplan Commercial |
$488.00
|
| Rate for Payer: NAPHCARE Commercial |
$366.00
|
| Rate for Payer: Preferred Network Access Commercial |
$561.20
|
| Rate for Payer: Quartz Beloit One Network |
$298.90
|
| Rate for Payer: Quartz Commercial |
$366.00
|
| Rate for Payer: WEA Trust Commercial |
$335.50
|
| Rate for Payer: WPS Commercial |
$451.83
|
|
|
XR OR Urography Retrograde
|
Facility
|
IP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420
|
| Hospital Charge Code |
6179866
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$613.48 |
| Max. Negotiated Rate |
$1,151.84 |
| Rate for Payer: Aetna Commercial |
$1,126.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,076.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$663.56
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,151.84
|
| Rate for Payer: Health EOS Commercial |
$1,114.28
|
| Rate for Payer: HFN Commercial |
$1,151.84
|
| Rate for Payer: Multiplan Commercial |
$1,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$751.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,151.84
|
| Rate for Payer: Quartz Beloit One Network |
$613.48
|
| Rate for Payer: Quartz Commercial |
$751.20
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$927.36
|
|
|
XR OR Urography Retrograde
|
Professional
|
Both
|
$1,252.00
|
|
|
Service Code
|
CPT 74420
|
| Hospital Charge Code |
6179866
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$261.22 |
| Max. Negotiated Rate |
$1,189.40 |
| Rate for Payer: Aetna Commercial |
$1,189.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,076.72
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,189.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$626.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$751.20
|
| Rate for Payer: Health EOS Commercial |
$1,139.32
|
| Rate for Payer: HFN Commercial |
$1,189.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$261.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$261.22
|
| Rate for Payer: Multiplan Commercial |
$1,001.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,189.40
|
| Rate for Payer: Quartz Beloit One Network |
$550.88
|
| Rate for Payer: Quartz Commercial |
$713.64
|
| Rate for Payer: The Alliance Commercial |
$626.00
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: WPS Commercial |
$927.36
|
|
|
XR OR Urography Retrograde
|
Facility
|
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420
|
| Hospital Charge Code |
6179866
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$1,520.48 |
| Rate for Payer: Aetna Commercial |
$1,126.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,076.72
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,425.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,140.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,083.34
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$663.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$380.12
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,151.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$700.62
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$1,114.28
|
| Rate for Payer: HFN Commercial |
$1,151.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,414.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$380.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$380.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$380.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$380.12
|
| Rate for Payer: Multiplan Commercial |
$1,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,151.84
|
| Rate for Payer: Quartz Beloit One Network |
$613.48
|
| Rate for Payer: Quartz Commercial |
$813.80
|
| Rate for Payer: Quartz Medicare Advantage |
$380.12
|
| Rate for Payer: The Alliance Commercial |
$1,520.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$380.12
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$688.60
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$927.36
|
|
|
XR OR Venous Access
|
Professional
|
Both
|
$1,231.00
|
|
|
Service Code
|
CPT 77001
|
| Hospital Charge Code |
6179872
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$347.99 |
| Max. Negotiated Rate |
$1,169.45 |
| Rate for Payer: Aetna Commercial |
$1,169.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,058.66
|
| Rate for Payer: Cash Price |
$369.30
|
| Rate for Payer: Cash Price |
$369.30
|
| Rate for Payer: Cigna Commercial |
$1,169.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$615.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$738.60
|
| Rate for Payer: Health EOS Commercial |
$1,120.21
|
| Rate for Payer: HFN Commercial |
$1,169.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$347.99
|
| Rate for Payer: Multiplan Commercial |
$984.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,169.45
|
| Rate for Payer: Quartz Beloit One Network |
$541.64
|
| Rate for Payer: Quartz Commercial |
$701.67
|
| Rate for Payer: The Alliance Commercial |
$615.50
|
| Rate for Payer: WEA Trust Commercial |
$677.05
|
| Rate for Payer: WPS Commercial |
$911.80
|
|
|
XR OR Venous Access
|
Facility
|
OP
|
$1,231.00
|
|
|
Service Code
|
CPT 77001
|
| Hospital Charge Code |
6179872
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$4,924.00 |
| Rate for Payer: Aetna Commercial |
$1,107.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,058.66
|
| Rate for Payer: Aetna Managed Medicare |
$344.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$800.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$615.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$590.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$652.43
|
| Rate for Payer: Cash Price |
$369.30
|
| Rate for Payer: Cash Price |
$369.30
|
| Rate for Payer: Cigna Commercial |
$1,132.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$688.87
|
| Rate for Payer: Health EOS Commercial |
$1,095.59
|
| Rate for Payer: HFN Commercial |
$1,132.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$923.25
|
| Rate for Payer: Multiplan Commercial |
$984.80
|
| Rate for Payer: NAPHCARE Commercial |
$738.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,132.52
|
| Rate for Payer: Quartz Beloit One Network |
$603.19
|
| Rate for Payer: Quartz Commercial |
$800.15
|
| Rate for Payer: Quartz Medicare Advantage |
$738.60
|
| Rate for Payer: The Alliance Commercial |
$4,924.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$677.05
|
| Rate for Payer: WPS Commercial |
$911.80
|
|
|
XR OR Venous Access
|
Facility
|
IP
|
$1,231.00
|
|
|
Service Code
|
CPT 77001
|
| Hospital Charge Code |
6179872
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$603.19 |
| Max. Negotiated Rate |
$1,132.52 |
| Rate for Payer: Aetna Commercial |
$1,107.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,058.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$652.43
|
| Rate for Payer: Cash Price |
$369.30
|
| Rate for Payer: Cigna Commercial |
$1,132.52
|
| Rate for Payer: Health EOS Commercial |
$1,095.59
|
| Rate for Payer: HFN Commercial |
$1,132.52
|
| Rate for Payer: Multiplan Commercial |
$984.80
|
| Rate for Payer: NAPHCARE Commercial |
$738.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,132.52
|
| Rate for Payer: Quartz Beloit One Network |
$603.19
|
| Rate for Payer: Quartz Commercial |
$738.60
|
| Rate for Payer: WEA Trust Commercial |
$677.05
|
| Rate for Payer: WPS Commercial |
$911.80
|
|
|
XR OR Wrist
|
Professional
|
Both
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724226
|
|
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 Wrist
|
Facility
|
IP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724226
|
|
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 Wrist
|
Facility
|
OP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724226
|
|
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 Pacemaker Insertion
|
Facility
|
OP
|
$1,020.00
|
|
| Hospital Charge Code |
1537220
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$285.60 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$918.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$877.20
|
| Rate for Payer: Aetna Managed Medicare |
$285.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$663.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$510.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$489.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$540.60
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$938.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$570.79
|
| Rate for Payer: Health EOS Commercial |
$907.80
|
| Rate for Payer: HFN Commercial |
$938.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$765.00
|
| Rate for Payer: Multiplan Commercial |
$816.00
|
| Rate for Payer: NAPHCARE Commercial |
$612.00
|
| Rate for Payer: Preferred Network Access Commercial |
$938.40
|
| Rate for Payer: Quartz Beloit One Network |
$499.80
|
| Rate for Payer: Quartz Commercial |
$663.00
|
| Rate for Payer: Quartz Medicare Advantage |
$612.00
|
| Rate for Payer: The Alliance Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$561.00
|
| Rate for Payer: WPS Commercial |
$755.51
|
|
|
XR Pacemaker Insertion
|
Facility
|
OP
|
$981.00
|
|
| Hospital Charge Code |
630295
|
| Min. Negotiated Rate |
$274.68 |
| Max. Negotiated Rate |
$3,924.00 |
| Rate for Payer: Aetna Commercial |
$882.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$843.66
|
| Rate for Payer: Aetna Managed Medicare |
$274.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$637.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$490.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$470.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$519.93
|
| Rate for Payer: Cash Price |
$294.30
|
| Rate for Payer: Cigna Commercial |
$902.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$548.97
|
| Rate for Payer: Health EOS Commercial |
$873.09
|
| Rate for Payer: HFN Commercial |
$902.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$735.75
|
| Rate for Payer: Multiplan Commercial |
$784.80
|
| Rate for Payer: NAPHCARE Commercial |
$588.60
|
| Rate for Payer: Preferred Network Access Commercial |
$902.52
|
| Rate for Payer: Quartz Beloit One Network |
$480.69
|
| Rate for Payer: Quartz Commercial |
$637.65
|
| Rate for Payer: Quartz Medicare Advantage |
$588.60
|
| Rate for Payer: The Alliance Commercial |
$3,924.00
|
| Rate for Payer: WEA Trust Commercial |
$539.55
|
| Rate for Payer: WPS Commercial |
$726.63
|
|
|
XR Pacemaker Insertion
|
Facility
|
IP
|
$981.00
|
|
| Hospital Charge Code |
630295
|
| Min. Negotiated Rate |
$480.69 |
| Max. Negotiated Rate |
$902.52 |
| Rate for Payer: Aetna Commercial |
$882.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$843.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$519.93
|
| Rate for Payer: Cash Price |
$294.30
|
| Rate for Payer: Cigna Commercial |
$902.52
|
| Rate for Payer: Health EOS Commercial |
$873.09
|
| Rate for Payer: HFN Commercial |
$902.52
|
| Rate for Payer: Multiplan Commercial |
$784.80
|
| Rate for Payer: NAPHCARE Commercial |
$588.60
|
| Rate for Payer: Preferred Network Access Commercial |
$902.52
|
| Rate for Payer: Quartz Beloit One Network |
$480.69
|
| Rate for Payer: Quartz Commercial |
$588.60
|
| Rate for Payer: WEA Trust Commercial |
$539.55
|
| Rate for Payer: WPS Commercial |
$726.63
|
|
|
XR Pacemaker Insertion
|
Professional
|
Both
|
$1,020.00
|
|
| Hospital Charge Code |
1537220
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$448.80 |
| Max. Negotiated Rate |
$969.00 |
| Rate for Payer: Aetna Commercial |
$969.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$877.20
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$969.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$510.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$612.00
|
| Rate for Payer: Health EOS Commercial |
$928.20
|
| Rate for Payer: HFN Commercial |
$969.00
|
| Rate for Payer: Multiplan Commercial |
$816.00
|
| Rate for Payer: Preferred Network Access Commercial |
$969.00
|
| Rate for Payer: Quartz Beloit One Network |
$448.80
|
| Rate for Payer: Quartz Commercial |
$581.40
|
| Rate for Payer: The Alliance Commercial |
$510.00
|
| Rate for Payer: WEA Trust Commercial |
$561.00
|
| Rate for Payer: WPS Commercial |
$755.51
|
|
|
XR Pacemaker Insertion
|
Facility
|
IP
|
$1,020.00
|
|
| Hospital Charge Code |
1537220
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$499.80 |
| Max. Negotiated Rate |
$938.40 |
| Rate for Payer: Aetna Commercial |
$918.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$877.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$540.60
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$938.40
|
| Rate for Payer: Health EOS Commercial |
$907.80
|
| Rate for Payer: HFN Commercial |
$938.40
|
| Rate for Payer: Multiplan Commercial |
$816.00
|
| Rate for Payer: NAPHCARE Commercial |
$612.00
|
| Rate for Payer: Preferred Network Access Commercial |
$938.40
|
| Rate for Payer: Quartz Beloit One Network |
$499.80
|
| Rate for Payer: Quartz Commercial |
$612.00
|
| Rate for Payer: WEA Trust Commercial |
$561.00
|
| Rate for Payer: WPS Commercial |
$755.51
|
|
|
XR Pacemaker Insertion
|
Professional
|
Both
|
$981.00
|
|
| Hospital Charge Code |
630295
|
| Min. Negotiated Rate |
$431.64 |
| Max. Negotiated Rate |
$931.95 |
| Rate for Payer: Aetna Commercial |
$931.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$843.66
|
| Rate for Payer: Cash Price |
$294.30
|
| Rate for Payer: Cigna Commercial |
$931.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$490.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$588.60
|
| Rate for Payer: Health EOS Commercial |
$892.71
|
| Rate for Payer: HFN Commercial |
$931.95
|
| Rate for Payer: Multiplan Commercial |
$784.80
|
| Rate for Payer: Preferred Network Access Commercial |
$931.95
|
| Rate for Payer: Quartz Beloit One Network |
$431.64
|
| Rate for Payer: Quartz Commercial |
$559.17
|
| Rate for Payer: The Alliance Commercial |
$490.50
|
| Rate for Payer: WEA Trust Commercial |
$539.55
|
| Rate for Payer: WPS Commercial |
$726.63
|
|
|
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 |
$555.17 |
| Max. Negotiated Rate |
$1,042.36 |
| Rate for Payer: Aetna Commercial |
$1,019.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$600.49
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,042.36
|
| Rate for Payer: Health EOS Commercial |
$1,008.37
|
| Rate for Payer: HFN Commercial |
$1,042.36
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: NAPHCARE Commercial |
$679.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,042.36
|
| Rate for Payer: Quartz Beloit One Network |
$555.17
|
| Rate for Payer: Quartz Commercial |
$679.80
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
XR PAIN Fluoro Guided Joint
|
Professional
|
Both
|
$1,133.00
|
|
|
Service Code
|
CPT 77002
|
| Hospital Charge Code |
5963664
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$395.54 |
| Max. Negotiated Rate |
$1,076.35 |
| Rate for Payer: Aetna Commercial |
$1,076.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,076.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$566.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$679.80
|
| Rate for Payer: Health EOS Commercial |
$1,031.03
|
| Rate for Payer: HFN Commercial |
$1,076.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$395.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$395.54
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,076.35
|
| Rate for Payer: Quartz Beloit One Network |
$498.52
|
| Rate for Payer: Quartz Commercial |
$645.81
|
| Rate for Payer: The Alliance Commercial |
$566.50
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
XR PAIN Fluoro Guided Joint
|
Facility
|
OP
|
$1,133.00
|
|
|
Service Code
|
CPT 77002
|
| Hospital Charge Code |
5963664
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$4,532.00 |
| Rate for Payer: Aetna Commercial |
$1,019.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Aetna Managed Medicare |
$317.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$736.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$543.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$600.49
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,042.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$634.03
|
| Rate for Payer: Health EOS Commercial |
$1,008.37
|
| Rate for Payer: HFN Commercial |
$1,042.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$849.75
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: NAPHCARE Commercial |
$679.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,042.36
|
| Rate for Payer: Quartz Beloit One Network |
$555.17
|
| Rate for Payer: Quartz Commercial |
$736.45
|
| Rate for Payer: Quartz Medicare Advantage |
$679.80
|
| Rate for Payer: The Alliance Commercial |
$4,532.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
XR Panorex/Orthopantogram
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
630293
|
| Min. Negotiated Rate |
$234.71 |
| Max. Negotiated Rate |
$440.68 |
| Rate for Payer: Aetna Commercial |
$431.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.87
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$440.68
|
| Rate for Payer: Health EOS Commercial |
$426.31
|
| Rate for Payer: HFN Commercial |
$440.68
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: NAPHCARE Commercial |
$287.40
|
| Rate for Payer: Preferred Network Access Commercial |
$440.68
|
| Rate for Payer: Quartz Beloit One Network |
$234.71
|
| Rate for Payer: Quartz Commercial |
$287.40
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
XR Panorex/Orthopantogram
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
630293
|
| Min. Negotiated Rate |
$62.48 |
| Max. Negotiated Rate |
$455.05 |
| Rate for Payer: Aetna Commercial |
$455.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$455.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$239.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$287.40
|
| Rate for Payer: Health EOS Commercial |
$435.89
|
| Rate for Payer: HFN Commercial |
$455.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.48
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: Preferred Network Access Commercial |
$455.05
|
| Rate for Payer: Quartz Beloit One Network |
$210.76
|
| Rate for Payer: Quartz Commercial |
$273.03
|
| Rate for Payer: The Alliance Commercial |
$239.50
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
