|
XR Humerus Bilateral
|
Professional
|
Both
|
$557.00
|
|
|
Service Code
|
CPT 73060 LT,TC
|
| Hospital Charge Code |
1537120
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$112.96 |
| Max. Negotiated Rate |
$550.32 |
| Rate for Payer: Aetna Commercial |
$550.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$498.18
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$550.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$289.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$347.57
|
| Rate for Payer: Health EOS Commercial |
$527.14
|
| Rate for Payer: HFN Commercial |
$550.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.96
|
| Rate for Payer: Multiplan Commercial |
$463.42
|
| Rate for Payer: Preferred Network Access Commercial |
$550.32
|
| Rate for Payer: Quartz Beloit One Network |
$254.88
|
| Rate for Payer: Quartz Commercial |
$330.19
|
| Rate for Payer: The Alliance Commercial |
$289.64
|
| Rate for Payer: WEA Trust Commercial |
$318.60
|
| Rate for Payer: WPS Commercial |
$429.06
|
|
|
XR Humerus Bilateral
|
Facility
|
IP
|
$557.00
|
|
|
Service Code
|
CPT 73060 LT,TC
|
| Hospital Charge Code |
1537120
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$283.85 |
| Max. Negotiated Rate |
$532.94 |
| Rate for Payer: Aetna Commercial |
$521.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$498.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.02
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$532.94
|
| Rate for Payer: Health EOS Commercial |
$515.56
|
| Rate for Payer: HFN Commercial |
$532.94
|
| Rate for Payer: Multiplan Commercial |
$463.42
|
| Rate for Payer: Preferred Network Access Commercial |
$532.94
|
| Rate for Payer: Quartz Beloit One Network |
$283.85
|
| Rate for Payer: Quartz Commercial |
$347.57
|
| Rate for Payer: WEA Trust Commercial |
$318.60
|
| Rate for Payer: WPS Commercial |
$429.06
|
|
|
XR Humerus Left
|
Facility
|
OP
|
$515.00
|
|
|
Service Code
|
CPT 73060
|
| Hospital Charge Code |
630429
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$492.75 |
| Rate for Payer: Aetna Commercial |
$482.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.62
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$348.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$267.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$257.09
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.87
|
| 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 |
$154.50
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$492.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$299.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$476.68
|
| Rate for Payer: HFN Commercial |
$492.75
|
| 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 |
$428.48
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$492.75
|
| Rate for Payer: Quartz Beloit One Network |
$262.44
|
| Rate for Payer: Quartz Commercial |
$348.14
|
| 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 |
$294.58
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$396.70
|
|
|
XR Humerus Left
|
Facility
|
IP
|
$515.00
|
|
|
Service Code
|
CPT 73060
|
| Hospital Charge Code |
630429
|
| Min. Negotiated Rate |
$262.44 |
| Max. Negotiated Rate |
$492.75 |
| Rate for Payer: Aetna Commercial |
$482.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.87
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$492.75
|
| Rate for Payer: Health EOS Commercial |
$476.68
|
| Rate for Payer: HFN Commercial |
$492.75
|
| Rate for Payer: Multiplan Commercial |
$428.48
|
| Rate for Payer: Preferred Network Access Commercial |
$492.75
|
| Rate for Payer: Quartz Beloit One Network |
$262.44
|
| Rate for Payer: Quartz Commercial |
$321.36
|
| Rate for Payer: WEA Trust Commercial |
$294.58
|
| Rate for Payer: WPS Commercial |
$396.70
|
|
|
XR Humerus Left
|
Facility
|
IP
|
$557.00
|
|
|
Service Code
|
CPT 73060 LT,TC
|
| Hospital Charge Code |
1537122
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$283.85 |
| Max. Negotiated Rate |
$532.94 |
| Rate for Payer: Aetna Commercial |
$521.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$498.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.02
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$532.94
|
| Rate for Payer: Health EOS Commercial |
$515.56
|
| Rate for Payer: HFN Commercial |
$532.94
|
| Rate for Payer: Multiplan Commercial |
$463.42
|
| Rate for Payer: Preferred Network Access Commercial |
$532.94
|
| Rate for Payer: Quartz Beloit One Network |
$283.85
|
| Rate for Payer: Quartz Commercial |
$347.57
|
| Rate for Payer: WEA Trust Commercial |
$318.60
|
| Rate for Payer: WPS Commercial |
$429.06
|
|
|
XR Humerus Left
|
Facility
|
OP
|
$557.00
|
|
|
Service Code
|
CPT 73060 LT,TC
|
| Hospital Charge Code |
1537122
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$162.20 |
| Max. Negotiated Rate |
$532.94 |
| Rate for Payer: Aetna Commercial |
$521.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$498.18
|
| Rate for Payer: Aetna Managed Medicare |
$162.20
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.02
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$532.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$324.17
|
| Rate for Payer: Health EOS Commercial |
$515.56
|
| Rate for Payer: HFN Commercial |
$532.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$434.46
|
| Rate for Payer: Multiplan Commercial |
$463.42
|
| Rate for Payer: NAPHCARE Commercial |
$347.57
|
| Rate for Payer: Preferred Network Access Commercial |
$532.94
|
| Rate for Payer: Quartz Beloit One Network |
$283.85
|
| Rate for Payer: Quartz Commercial |
$376.53
|
| Rate for Payer: Quartz Medicare Advantage |
$347.57
|
| Rate for Payer: The Alliance Commercial |
$289.64
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$318.60
|
| Rate for Payer: WPS Commercial |
$429.06
|
|
|
XR Humerus Left
|
Professional
|
Both
|
$557.00
|
|
|
Service Code
|
CPT 73060 LT,TC
|
| Hospital Charge Code |
1537122
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$112.96 |
| Max. Negotiated Rate |
$550.32 |
| Rate for Payer: Aetna Commercial |
$550.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$498.18
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$550.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$289.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$347.57
|
| Rate for Payer: Health EOS Commercial |
$527.14
|
| Rate for Payer: HFN Commercial |
$550.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.96
|
| Rate for Payer: Multiplan Commercial |
$463.42
|
| Rate for Payer: Preferred Network Access Commercial |
$550.32
|
| Rate for Payer: Quartz Beloit One Network |
$254.88
|
| Rate for Payer: Quartz Commercial |
$330.19
|
| Rate for Payer: The Alliance Commercial |
$289.64
|
| Rate for Payer: WEA Trust Commercial |
$318.60
|
| Rate for Payer: WPS Commercial |
$429.06
|
|
|
XR Humerus Left
|
Professional
|
Both
|
$515.00
|
|
|
Service Code
|
CPT 73060
|
| Hospital Charge Code |
630429
|
| Min. Negotiated Rate |
$31.73 |
| Max. Negotiated Rate |
$508.82 |
| Rate for Payer: Aetna Commercial |
$508.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.62
|
| Rate for Payer: Aetna Managed Medicare |
$31.73
|
| Rate for Payer: Anthem Medicare Advantage |
$31.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$31.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$31.73
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$508.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$267.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.73
|
| Rate for Payer: Health EOS Commercial |
$487.40
|
| Rate for Payer: HFN Commercial |
$508.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$31.73
|
| Rate for Payer: Multiplan Commercial |
$428.48
|
| Rate for Payer: NAPHCARE Commercial |
$47.60
|
| Rate for Payer: Preferred Network Access Commercial |
$508.82
|
| Rate for Payer: Quartz Beloit One Network |
$235.66
|
| Rate for Payer: Quartz Commercial |
$305.29
|
| Rate for Payer: Quartz Medicare Advantage |
$31.73
|
| Rate for Payer: The Alliance Commercial |
$120.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31.73
|
| Rate for Payer: WEA Trust Commercial |
$294.58
|
| Rate for Payer: WPS Commercial |
$158.65
|
|
|
XR Humerus Right
|
Facility
|
OP
|
$515.00
|
|
|
Service Code
|
CPT 73060
|
| Hospital Charge Code |
630427
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$492.75 |
| Rate for Payer: Aetna Commercial |
$482.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.62
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$348.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$267.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$257.09
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.87
|
| 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 |
$154.50
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$492.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$299.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$476.68
|
| Rate for Payer: HFN Commercial |
$492.75
|
| 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 |
$428.48
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$492.75
|
| Rate for Payer: Quartz Beloit One Network |
$262.44
|
| Rate for Payer: Quartz Commercial |
$348.14
|
| 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 |
$294.58
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$396.70
|
|
|
XR Humerus Right
|
Facility
|
OP
|
$557.00
|
|
|
Service Code
|
CPT 73060 RT,TC
|
| Hospital Charge Code |
1537124
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$162.20 |
| Max. Negotiated Rate |
$532.94 |
| Rate for Payer: Aetna Commercial |
$521.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$498.18
|
| Rate for Payer: Aetna Managed Medicare |
$162.20
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.02
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$532.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$324.17
|
| Rate for Payer: Health EOS Commercial |
$515.56
|
| Rate for Payer: HFN Commercial |
$532.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$434.46
|
| Rate for Payer: Multiplan Commercial |
$463.42
|
| Rate for Payer: NAPHCARE Commercial |
$347.57
|
| Rate for Payer: Preferred Network Access Commercial |
$532.94
|
| Rate for Payer: Quartz Beloit One Network |
$283.85
|
| Rate for Payer: Quartz Commercial |
$376.53
|
| Rate for Payer: Quartz Medicare Advantage |
$347.57
|
| Rate for Payer: The Alliance Commercial |
$289.64
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$318.60
|
| Rate for Payer: WPS Commercial |
$429.06
|
|
|
XR Humerus Right
|
Professional
|
Both
|
$536.00
|
|
|
Service Code
|
CPT 73060 TC,RT
|
| Hospital Charge Code |
2979996
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$112.96 |
| Max. Negotiated Rate |
$529.57 |
| Rate for Payer: Aetna Commercial |
$529.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.40
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cigna Commercial |
$529.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$278.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$334.46
|
| Rate for Payer: Health EOS Commercial |
$507.27
|
| Rate for Payer: HFN Commercial |
$529.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.96
|
| Rate for Payer: Multiplan Commercial |
$445.95
|
| Rate for Payer: Preferred Network Access Commercial |
$529.57
|
| Rate for Payer: Quartz Beloit One Network |
$245.27
|
| Rate for Payer: Quartz Commercial |
$317.74
|
| Rate for Payer: The Alliance Commercial |
$278.72
|
| Rate for Payer: WEA Trust Commercial |
$306.59
|
| Rate for Payer: WPS Commercial |
$412.88
|
|
|
XR Humerus Right
|
Facility
|
IP
|
$515.00
|
|
|
Service Code
|
CPT 73060
|
| Hospital Charge Code |
630427
|
| Min. Negotiated Rate |
$262.44 |
| Max. Negotiated Rate |
$492.75 |
| Rate for Payer: Aetna Commercial |
$482.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.87
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$492.75
|
| Rate for Payer: Health EOS Commercial |
$476.68
|
| Rate for Payer: HFN Commercial |
$492.75
|
| Rate for Payer: Multiplan Commercial |
$428.48
|
| Rate for Payer: Preferred Network Access Commercial |
$492.75
|
| Rate for Payer: Quartz Beloit One Network |
$262.44
|
| Rate for Payer: Quartz Commercial |
$321.36
|
| Rate for Payer: WEA Trust Commercial |
$294.58
|
| Rate for Payer: WPS Commercial |
$396.70
|
|
|
XR Humerus Right
|
Professional
|
Both
|
$515.00
|
|
|
Service Code
|
CPT 73060
|
| Hospital Charge Code |
630427
|
| Min. Negotiated Rate |
$31.73 |
| Max. Negotiated Rate |
$508.82 |
| Rate for Payer: Aetna Commercial |
$508.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.62
|
| Rate for Payer: Aetna Managed Medicare |
$31.73
|
| Rate for Payer: Anthem Medicare Advantage |
$31.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$31.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$31.73
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$508.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$267.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.73
|
| Rate for Payer: Health EOS Commercial |
$487.40
|
| Rate for Payer: HFN Commercial |
$508.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$31.73
|
| Rate for Payer: Multiplan Commercial |
$428.48
|
| Rate for Payer: NAPHCARE Commercial |
$47.60
|
| Rate for Payer: Preferred Network Access Commercial |
$508.82
|
| Rate for Payer: Quartz Beloit One Network |
$235.66
|
| Rate for Payer: Quartz Commercial |
$305.29
|
| Rate for Payer: Quartz Medicare Advantage |
$31.73
|
| Rate for Payer: The Alliance Commercial |
$120.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31.73
|
| Rate for Payer: WEA Trust Commercial |
$294.58
|
| Rate for Payer: WPS Commercial |
$158.65
|
|
|
XR Humerus Right
|
Facility
|
IP
|
$557.00
|
|
|
Service Code
|
CPT 73060 RT,TC
|
| Hospital Charge Code |
1537124
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$283.85 |
| Max. Negotiated Rate |
$532.94 |
| Rate for Payer: Aetna Commercial |
$521.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$498.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.02
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$532.94
|
| Rate for Payer: Health EOS Commercial |
$515.56
|
| Rate for Payer: HFN Commercial |
$532.94
|
| Rate for Payer: Multiplan Commercial |
$463.42
|
| Rate for Payer: Preferred Network Access Commercial |
$532.94
|
| Rate for Payer: Quartz Beloit One Network |
$283.85
|
| Rate for Payer: Quartz Commercial |
$347.57
|
| Rate for Payer: WEA Trust Commercial |
$318.60
|
| Rate for Payer: WPS Commercial |
$429.06
|
|
|
XR Humerus Right
|
Facility
|
OP
|
$536.00
|
|
|
Service Code
|
CPT 73060 TC,RT
|
| Hospital Charge Code |
2979996
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$156.08 |
| Max. Negotiated Rate |
$512.84 |
| Rate for Payer: Aetna Commercial |
$501.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.40
|
| Rate for Payer: Aetna Managed Medicare |
$156.08
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.44
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cigna Commercial |
$512.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$311.95
|
| Rate for Payer: Health EOS Commercial |
$496.12
|
| Rate for Payer: HFN Commercial |
$512.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$418.08
|
| Rate for Payer: Multiplan Commercial |
$445.95
|
| Rate for Payer: NAPHCARE Commercial |
$334.46
|
| Rate for Payer: Preferred Network Access Commercial |
$512.84
|
| Rate for Payer: Quartz Beloit One Network |
$273.15
|
| Rate for Payer: Quartz Commercial |
$362.34
|
| Rate for Payer: Quartz Medicare Advantage |
$334.46
|
| Rate for Payer: The Alliance Commercial |
$278.72
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$306.59
|
| Rate for Payer: WPS Commercial |
$412.88
|
|
|
XR Humerus Right
|
Facility
|
IP
|
$536.00
|
|
|
Service Code
|
CPT 73060 TC,RT
|
| Hospital Charge Code |
2979996
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$273.15 |
| Max. Negotiated Rate |
$512.84 |
| Rate for Payer: Aetna Commercial |
$501.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.44
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cigna Commercial |
$512.84
|
| Rate for Payer: Health EOS Commercial |
$496.12
|
| Rate for Payer: HFN Commercial |
$512.84
|
| Rate for Payer: Multiplan Commercial |
$445.95
|
| Rate for Payer: Preferred Network Access Commercial |
$512.84
|
| Rate for Payer: Quartz Beloit One Network |
$273.15
|
| Rate for Payer: Quartz Commercial |
$334.46
|
| Rate for Payer: WEA Trust Commercial |
$306.59
|
| Rate for Payer: WPS Commercial |
$412.88
|
|
|
XR Humerus Right
|
Professional
|
Both
|
$557.00
|
|
|
Service Code
|
CPT 73060 RT,TC
|
| Hospital Charge Code |
1537124
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$112.96 |
| Max. Negotiated Rate |
$550.32 |
| Rate for Payer: Aetna Commercial |
$550.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$498.18
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$550.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$289.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$347.57
|
| Rate for Payer: Health EOS Commercial |
$527.14
|
| Rate for Payer: HFN Commercial |
$550.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.96
|
| Rate for Payer: Multiplan Commercial |
$463.42
|
| Rate for Payer: Preferred Network Access Commercial |
$550.32
|
| Rate for Payer: Quartz Beloit One Network |
$254.88
|
| Rate for Payer: Quartz Commercial |
$330.19
|
| Rate for Payer: The Alliance Commercial |
$289.64
|
| Rate for Payer: WEA Trust Commercial |
$318.60
|
| Rate for Payer: WPS Commercial |
$429.06
|
|
|
XR Hysterosalpingography
|
Facility
|
OP
|
$1,017.00
|
|
|
Service Code
|
CPT 74740 TC
|
| Hospital Charge Code |
3072714
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$287.96 |
| Max. Negotiated Rate |
$973.07 |
| Rate for Payer: Aetna Commercial |
$951.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$909.60
|
| Rate for Payer: Aetna Managed Medicare |
$296.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$944.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$755.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$717.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$560.57
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cigna Commercial |
$973.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$591.89
|
| Rate for Payer: Health EOS Commercial |
$941.34
|
| Rate for Payer: HFN Commercial |
$973.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$793.26
|
| Rate for Payer: Multiplan Commercial |
$846.14
|
| Rate for Payer: NAPHCARE Commercial |
$634.61
|
| Rate for Payer: Preferred Network Access Commercial |
$973.07
|
| Rate for Payer: Quartz Beloit One Network |
$518.26
|
| Rate for Payer: Quartz Commercial |
$687.49
|
| Rate for Payer: Quartz Medicare Advantage |
$634.61
|
| Rate for Payer: The Alliance Commercial |
$287.96
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$581.72
|
| Rate for Payer: WPS Commercial |
$783.40
|
|
|
XR Hysterosalpingography
|
Facility
|
IP
|
$1,017.00
|
|
|
Service Code
|
CPT 74740 TC
|
| Hospital Charge Code |
3072714
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$518.26 |
| Max. Negotiated Rate |
$973.07 |
| Rate for Payer: Aetna Commercial |
$951.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$909.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$560.57
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cigna Commercial |
$973.07
|
| Rate for Payer: Health EOS Commercial |
$941.34
|
| Rate for Payer: HFN Commercial |
$973.07
|
| Rate for Payer: Multiplan Commercial |
$846.14
|
| Rate for Payer: Preferred Network Access Commercial |
$973.07
|
| Rate for Payer: Quartz Beloit One Network |
$518.26
|
| Rate for Payer: Quartz Commercial |
$634.61
|
| Rate for Payer: WEA Trust Commercial |
$581.72
|
| Rate for Payer: WPS Commercial |
$783.40
|
|
|
XR Hysterosalpingography
|
Professional
|
Both
|
$1,017.00
|
|
|
Service Code
|
CPT 74740 TC
|
| Hospital Charge Code |
3072714
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$71.99 |
| Max. Negotiated Rate |
$1,004.80 |
| Rate for Payer: Aetna Commercial |
$1,004.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$909.60
|
| Rate for Payer: Aetna Managed Medicare |
$71.99
|
| Rate for Payer: Anthem Medicare Advantage |
$71.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$71.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$71.99
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cigna Commercial |
$1,004.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$528.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.99
|
| Rate for Payer: Health EOS Commercial |
$962.49
|
| Rate for Payer: HFN Commercial |
$1,004.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$279.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$279.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$71.99
|
| Rate for Payer: Multiplan Commercial |
$846.14
|
| Rate for Payer: NAPHCARE Commercial |
$107.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,004.80
|
| Rate for Payer: Quartz Beloit One Network |
$465.38
|
| Rate for Payer: Quartz Commercial |
$602.88
|
| Rate for Payer: Quartz Medicare Advantage |
$71.99
|
| Rate for Payer: The Alliance Commercial |
$273.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$71.99
|
| Rate for Payer: WEA Trust Commercial |
$581.72
|
| Rate for Payer: WPS Commercial |
$359.94
|
|
|
XR Intro Of Intra Cath Into Renal Pelvis
|
Professional
|
Both
|
$2,972.00
|
|
|
Service Code
|
CPT 74475 TC
|
| Hospital Charge Code |
3072723
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,359.99 |
| Max. Negotiated Rate |
$2,936.34 |
| Rate for Payer: Aetna Commercial |
$2,936.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,658.16
|
| Rate for Payer: Cash Price |
$891.60
|
| Rate for Payer: Cigna Commercial |
$2,936.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,545.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,854.53
|
| Rate for Payer: Health EOS Commercial |
$2,812.70
|
| Rate for Payer: HFN Commercial |
$2,936.34
|
| Rate for Payer: Multiplan Commercial |
$2,472.70
|
| Rate for Payer: Preferred Network Access Commercial |
$2,936.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,359.99
|
| Rate for Payer: Quartz Commercial |
$1,761.80
|
| Rate for Payer: The Alliance Commercial |
$1,545.44
|
| Rate for Payer: WEA Trust Commercial |
$1,699.98
|
| Rate for Payer: WPS Commercial |
$2,289.33
|
|
|
XR Intro Of Intra Cath Into Renal Pelvis
|
Facility
|
IP
|
$2,972.00
|
|
|
Service Code
|
CPT 74475 TC
|
| Hospital Charge Code |
3072723
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,514.53 |
| Max. Negotiated Rate |
$2,843.61 |
| Rate for Payer: Aetna Commercial |
$2,781.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,658.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,638.17
|
| Rate for Payer: Cash Price |
$891.60
|
| Rate for Payer: Cigna Commercial |
$2,843.61
|
| Rate for Payer: Health EOS Commercial |
$2,750.88
|
| Rate for Payer: HFN Commercial |
$2,843.61
|
| Rate for Payer: Multiplan Commercial |
$2,472.70
|
| Rate for Payer: Preferred Network Access Commercial |
$2,843.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,514.53
|
| Rate for Payer: Quartz Commercial |
$1,854.53
|
| Rate for Payer: WEA Trust Commercial |
$1,699.98
|
| Rate for Payer: WPS Commercial |
$2,289.33
|
|
|
XR Intro Of Intra Cath Into Renal Pelvis
|
Facility
|
OP
|
$2,972.00
|
|
|
Service Code
|
CPT 74475 TC
|
| Hospital Charge Code |
3072723
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$865.45 |
| Max. Negotiated Rate |
$2,843.61 |
| Rate for Payer: Aetna Commercial |
$2,781.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,658.16
|
| Rate for Payer: Aetna Managed Medicare |
$865.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,009.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,545.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,483.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,638.17
|
| Rate for Payer: Cash Price |
$891.60
|
| Rate for Payer: Cigna Commercial |
$2,843.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,729.70
|
| Rate for Payer: Health EOS Commercial |
$2,750.88
|
| Rate for Payer: HFN Commercial |
$2,843.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,318.16
|
| Rate for Payer: Multiplan Commercial |
$2,472.70
|
| Rate for Payer: NAPHCARE Commercial |
$1,854.53
|
| Rate for Payer: Preferred Network Access Commercial |
$2,843.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,514.53
|
| Rate for Payer: Quartz Commercial |
$2,009.07
|
| Rate for Payer: Quartz Medicare Advantage |
$1,854.53
|
| Rate for Payer: The Alliance Commercial |
$1,545.44
|
| Rate for Payer: WEA Trust Commercial |
$1,699.98
|
| Rate for Payer: WPS Commercial |
$2,289.33
|
|
|
XR IVP
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
CPT 74400
|
| Hospital Charge Code |
1537128
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$777.14 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
XR IVP
|
Facility
|
OP
|
$1,412.00
|
|
|
Service Code
|
CPT 74400
|
| Hospital Charge Code |
630417
|
| Min. Negotiated Rate |
$184.59 |
| Max. Negotiated Rate |
$1,351.00 |
| Rate for Payer: Aetna Commercial |
$1,321.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,262.89
|
| Rate for Payer: Aetna Managed Medicare |
$184.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$954.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$734.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$704.87
|
| Rate for Payer: Anthem Medicare Advantage |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$778.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$184.59
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cigna Commercial |
$1,351.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$184.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$821.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$184.59
|
| Rate for Payer: Health EOS Commercial |
$1,306.95
|
| Rate for Payer: HFN Commercial |
$1,351.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$184.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$184.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$184.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$184.59
|
| Rate for Payer: Multiplan Commercial |
$1,174.78
|
| Rate for Payer: NAPHCARE Commercial |
$276.88
|
| Rate for Payer: Preferred Network Access Commercial |
$1,351.00
|
| Rate for Payer: Quartz Beloit One Network |
$719.56
|
| Rate for Payer: Quartz Commercial |
$954.51
|
| Rate for Payer: Quartz Medicare Advantage |
$184.59
|
| Rate for Payer: The Alliance Commercial |
$738.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$184.59
|
| Rate for Payer: WEA Trust Commercial |
$807.66
|
| Rate for Payer: Wellcare Medicare |
$184.59
|
| Rate for Payer: WPS Commercial |
$1,087.66
|
|
