|
BCE XR Nephrostomy Dilation Bilateral
|
Facility
IP
|
$5,405.00
|
|
|
Service Code
|
CPT 50432 TC
|
| Hospital Charge Code |
5430695
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$2,648.45 |
| Max. Negotiated Rate |
$4,972.60 |
| Rate for Payer: Aetna Commercial |
$4,864.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,864.65
|
| Rate for Payer: Cash Price |
$1,621.50
|
| Rate for Payer: Cigna Commercial |
$4,972.60
|
| Rate for Payer: Health EOS Commercial |
$4,810.45
|
| Rate for Payer: HFN Commercial |
$4,972.60
|
| Rate for Payer: Multiplan Commercial |
$4,324.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,972.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,648.45
|
| Rate for Payer: Quartz Commercial |
$3,243.00
|
| Rate for Payer: WEA Trust Commercial |
$2,972.75
|
| Rate for Payer: WPS Commercial |
$4,003.48
|
|
|
BCE XR Neph Tube Exchange Percutaneous
|
Professional
|
$3,505.00
|
|
|
Service Code
|
CPT 50435 TC
|
| Hospital Charge Code |
4616667
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,542.20 |
| Max. Negotiated Rate |
$3,329.75 |
| Rate for Payer: Aetna Commercial |
$3,329.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,014.30
|
| Rate for Payer: Cash Price |
$1,051.50
|
| Rate for Payer: Cash Price |
$1,051.50
|
| Rate for Payer: Cigna Commercial |
$3,329.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,752.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,103.00
|
| Rate for Payer: Health EOS Commercial |
$3,189.55
|
| Rate for Payer: Multiplan Commercial |
$2,804.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,329.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,542.20
|
| Rate for Payer: Quartz Commercial |
$1,997.85
|
| Rate for Payer: The Alliance Commercial |
$1,752.50
|
| Rate for Payer: WEA Trust Commercial |
$1,927.75
|
| Rate for Payer: WPS Commercial |
$2,596.15
|
|
|
BCE XR Neph Tube Exchange Percutaneous
|
Facility
OP
|
$3,505.00
|
|
|
Service Code
|
CPT 50435 TC
|
| Hospital Charge Code |
4616667
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$14,020.00 |
| Rate for Payer: Aetna Commercial |
$3,154.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,014.30
|
| Rate for Payer: Aetna Managed Medicare |
$981.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,278.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,752.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,682.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,857.65
|
| Rate for Payer: Cash Price |
$1,051.50
|
| Rate for Payer: Cash Price |
$1,051.50
|
| Rate for Payer: Cigna Commercial |
$3,224.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,961.40
|
| Rate for Payer: Health EOS Commercial |
$3,119.45
|
| Rate for Payer: HFN Commercial |
$3,224.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,628.75
|
| Rate for Payer: Multiplan Commercial |
$2,804.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,103.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,224.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,717.45
|
| Rate for Payer: Quartz Commercial |
$2,278.25
|
| Rate for Payer: Quartz Medicare Advantage |
$2,103.00
|
| Rate for Payer: The Alliance Commercial |
$14,020.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$1,927.75
|
| Rate for Payer: WPS Commercial |
$2,596.15
|
|
|
BCE XR Neph Tube Exchange Percutaneous
|
Facility
IP
|
$3,505.00
|
|
|
Service Code
|
CPT 50435 TC
|
| Hospital Charge Code |
4616667
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,717.45 |
| Max. Negotiated Rate |
$3,224.60 |
| Rate for Payer: Aetna Commercial |
$3,154.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,857.65
|
| Rate for Payer: Cash Price |
$1,051.50
|
| Rate for Payer: Cigna Commercial |
$3,224.60
|
| Rate for Payer: Health EOS Commercial |
$3,119.45
|
| Rate for Payer: HFN Commercial |
$3,224.60
|
| Rate for Payer: Multiplan Commercial |
$2,804.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,103.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,224.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,717.45
|
| Rate for Payer: Quartz Commercial |
$2,103.00
|
| Rate for Payer: WEA Trust Commercial |
$1,927.75
|
| Rate for Payer: WPS Commercial |
$2,596.15
|
|
|
BCE XR Pelvis 1 or 2 Views
|
Facility
IP
|
$556.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
3925398
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$272.44 |
| Max. Negotiated Rate |
$511.52 |
| Rate for Payer: Aetna Commercial |
$500.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.68
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$511.52
|
| Rate for Payer: Health EOS Commercial |
$494.84
|
| Rate for Payer: HFN Commercial |
$511.52
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: NAPHCARE Commercial |
$333.60
|
| Rate for Payer: Preferred Network Access Commercial |
$511.52
|
| Rate for Payer: Quartz Beloit One Network |
$272.44
|
| Rate for Payer: Quartz Commercial |
$333.60
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$411.83
|
|
|
BCE XR Pelvis 1 or 2 Views
|
Facility
OP
|
$556.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
3925398
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$155.68 |
| Max. Negotiated Rate |
$2,224.00 |
| Rate for Payer: Aetna Commercial |
$500.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.16
|
| Rate for Payer: Aetna Managed Medicare |
$155.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$361.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$278.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.68
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$511.52
|
| Rate for Payer: Health EOS Commercial |
$494.84
|
| Rate for Payer: HFN Commercial |
$511.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$417.00
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: NAPHCARE Commercial |
$333.60
|
| Rate for Payer: Preferred Network Access Commercial |
$511.52
|
| Rate for Payer: Quartz Beloit One Network |
$272.44
|
| Rate for Payer: Quartz Commercial |
$361.40
|
| Rate for Payer: Quartz Medicare Advantage |
$333.60
|
| Rate for Payer: The Alliance Commercial |
$2,224.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$411.83
|
|
|
BCE XR Pelvis 1 or 2 Views
|
Professional
|
$556.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
3925398
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$18.78 |
| Max. Negotiated Rate |
$528.20 |
| Rate for Payer: Aetna Commercial |
$528.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.16
|
| Rate for Payer: Aetna Managed Medicare |
$18.78
|
| Rate for Payer: Anthem Medicare Advantage |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.78
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$528.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$278.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.78
|
| Rate for Payer: Health EOS Commercial |
$505.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.78
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$528.20
|
| Rate for Payer: Quartz Beloit One Network |
$244.64
|
| Rate for Payer: Quartz Commercial |
$316.92
|
| Rate for Payer: Quartz Medicare Advantage |
$18.78
|
| Rate for Payer: The Alliance Commercial |
$71.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.78
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$93.90
|
|
|
BCE XR Ribs w/PA Chest Left
|
Facility
OP
|
$787.00
|
|
|
Service Code
|
CPT 71101 TC,LT
|
| Hospital Charge Code |
5280646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$220.36 |
| Max. Negotiated Rate |
$3,148.00 |
| Rate for Payer: Aetna Commercial |
$708.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$676.82
|
| Rate for Payer: Aetna Managed Medicare |
$220.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$511.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$393.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$377.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$417.11
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cigna Commercial |
$724.04
|
| Rate for Payer: Health EOS Commercial |
$700.43
|
| Rate for Payer: HFN Commercial |
$724.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$590.25
|
| Rate for Payer: Multiplan Commercial |
$629.60
|
| Rate for Payer: NAPHCARE Commercial |
$472.20
|
| Rate for Payer: Preferred Network Access Commercial |
$724.04
|
| Rate for Payer: Quartz Beloit One Network |
$385.63
|
| Rate for Payer: Quartz Commercial |
$511.55
|
| Rate for Payer: Quartz Medicare Advantage |
$472.20
|
| Rate for Payer: The Alliance Commercial |
$3,148.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$432.85
|
| Rate for Payer: WPS Commercial |
$582.93
|
|
|
BCE XR Ribs w/PA Chest Left
|
Facility
IP
|
$787.00
|
|
|
Service Code
|
CPT 71101 TC,LT
|
| Hospital Charge Code |
5280646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$385.63 |
| Max. Negotiated Rate |
$724.04 |
| Rate for Payer: Aetna Commercial |
$708.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$417.11
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cigna Commercial |
$724.04
|
| Rate for Payer: Health EOS Commercial |
$700.43
|
| Rate for Payer: HFN Commercial |
$724.04
|
| Rate for Payer: Multiplan Commercial |
$629.60
|
| Rate for Payer: NAPHCARE Commercial |
$472.20
|
| Rate for Payer: Preferred Network Access Commercial |
$724.04
|
| Rate for Payer: Quartz Beloit One Network |
$385.63
|
| Rate for Payer: Quartz Commercial |
$472.20
|
| Rate for Payer: WEA Trust Commercial |
$432.85
|
| Rate for Payer: WPS Commercial |
$582.93
|
|
|
BCE XR Ribs w/PA Chest Left
|
Professional
|
$787.00
|
|
|
Service Code
|
CPT 71101 TC,LT
|
| Hospital Charge Code |
5280646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$346.28 |
| Max. Negotiated Rate |
$747.65 |
| Rate for Payer: Aetna Commercial |
$747.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$676.82
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cigna Commercial |
$747.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$393.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$472.20
|
| Rate for Payer: Health EOS Commercial |
$716.17
|
| Rate for Payer: Multiplan Commercial |
$629.60
|
| Rate for Payer: Preferred Network Access Commercial |
$747.65
|
| Rate for Payer: Quartz Beloit One Network |
$346.28
|
| Rate for Payer: Quartz Commercial |
$448.59
|
| Rate for Payer: The Alliance Commercial |
$393.50
|
| Rate for Payer: WEA Trust Commercial |
$432.85
|
| Rate for Payer: WPS Commercial |
$582.93
|
|
|
BCE XR Shoulder Complete Left
|
Facility
IP
|
$646.00
|
|
|
Service Code
|
CPT 73030 TC,LT
|
| Hospital Charge Code |
3925371
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$316.54 |
| Max. Negotiated Rate |
$594.32 |
| Rate for Payer: Aetna Commercial |
$581.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.38
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$594.32
|
| Rate for Payer: Health EOS Commercial |
$574.94
|
| Rate for Payer: HFN Commercial |
$594.32
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: NAPHCARE Commercial |
$387.60
|
| Rate for Payer: Preferred Network Access Commercial |
$594.32
|
| Rate for Payer: Quartz Beloit One Network |
$316.54
|
| Rate for Payer: Quartz Commercial |
$387.60
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$478.49
|
|
|
BCE XR Shoulder Complete Left
|
Facility
OP
|
$646.00
|
|
|
Service Code
|
CPT 73030 TC,LT
|
| Hospital Charge Code |
3925371
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$180.88 |
| Max. Negotiated Rate |
$2,584.00 |
| Rate for Payer: Aetna Commercial |
$581.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.56
|
| Rate for Payer: Aetna Managed Medicare |
$180.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$419.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$323.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$310.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.38
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$594.32
|
| Rate for Payer: Health EOS Commercial |
$574.94
|
| Rate for Payer: HFN Commercial |
$594.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$484.50
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: NAPHCARE Commercial |
$387.60
|
| Rate for Payer: Preferred Network Access Commercial |
$594.32
|
| Rate for Payer: Quartz Beloit One Network |
$316.54
|
| Rate for Payer: Quartz Commercial |
$419.90
|
| Rate for Payer: Quartz Medicare Advantage |
$387.60
|
| Rate for Payer: The Alliance Commercial |
$2,584.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$478.49
|
|
|
BCE XR Shoulder Complete Left
|
Professional
|
$646.00
|
|
|
Service Code
|
CPT 73030 TC,LT
|
| Hospital Charge Code |
3925371
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$284.24 |
| Max. Negotiated Rate |
$613.70 |
| Rate for Payer: Aetna Commercial |
$613.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.56
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$613.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$323.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$387.60
|
| Rate for Payer: Health EOS Commercial |
$587.86
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: Preferred Network Access Commercial |
$613.70
|
| Rate for Payer: Quartz Beloit One Network |
$284.24
|
| Rate for Payer: Quartz Commercial |
$368.22
|
| Rate for Payer: The Alliance Commercial |
$323.00
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$478.49
|
|
|
BCE XR Shoulder Complete Right
|
Professional
|
$671.00
|
|
|
Service Code
|
CPT 73030 TC,RT
|
| Hospital Charge Code |
3091466
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$295.24 |
| Max. Negotiated Rate |
$637.45 |
| Rate for Payer: Aetna Commercial |
$637.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.06
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$637.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$335.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$402.60
|
| Rate for Payer: Health EOS Commercial |
$610.61
|
| Rate for Payer: Multiplan Commercial |
$536.80
|
| Rate for Payer: Preferred Network Access Commercial |
$637.45
|
| Rate for Payer: Quartz Beloit One Network |
$295.24
|
| Rate for Payer: Quartz Commercial |
$382.47
|
| Rate for Payer: The Alliance Commercial |
$335.50
|
| Rate for Payer: WEA Trust Commercial |
$369.05
|
| Rate for Payer: WPS Commercial |
$497.01
|
|
|
BCE XR Shoulder Complete Right
|
Facility
OP
|
$671.00
|
|
|
Service Code
|
CPT 73030 TC,RT
|
| Hospital Charge Code |
3091466
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$187.88 |
| Max. Negotiated Rate |
$2,684.00 |
| Rate for Payer: Aetna Commercial |
$603.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.06
|
| Rate for Payer: Aetna Managed Medicare |
$187.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$436.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$335.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$355.63
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$617.32
|
| Rate for Payer: Health EOS Commercial |
$597.19
|
| Rate for Payer: HFN Commercial |
$617.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$503.25
|
| Rate for Payer: Multiplan Commercial |
$536.80
|
| Rate for Payer: NAPHCARE Commercial |
$402.60
|
| Rate for Payer: Preferred Network Access Commercial |
$617.32
|
| Rate for Payer: Quartz Beloit One Network |
$328.79
|
| Rate for Payer: Quartz Commercial |
$436.15
|
| Rate for Payer: Quartz Medicare Advantage |
$402.60
|
| Rate for Payer: The Alliance Commercial |
$2,684.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$369.05
|
| Rate for Payer: WPS Commercial |
$497.01
|
|
|
BCE XR Shoulder Complete Right
|
Facility
IP
|
$671.00
|
|
|
Service Code
|
CPT 73030 TC,RT
|
| Hospital Charge Code |
3091466
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$328.79 |
| Max. Negotiated Rate |
$617.32 |
| Rate for Payer: Aetna Commercial |
$603.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$355.63
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$617.32
|
| Rate for Payer: Health EOS Commercial |
$597.19
|
| Rate for Payer: HFN Commercial |
$617.32
|
| Rate for Payer: Multiplan Commercial |
$536.80
|
| Rate for Payer: NAPHCARE Commercial |
$402.60
|
| Rate for Payer: Preferred Network Access Commercial |
$617.32
|
| Rate for Payer: Quartz Beloit One Network |
$328.79
|
| Rate for Payer: Quartz Commercial |
$402.60
|
| Rate for Payer: WEA Trust Commercial |
$369.05
|
| Rate for Payer: WPS Commercial |
$497.01
|
|
|
BCE XR Spine, C,T,L incl Skull 2 or 3 Views
|
Professional
|
$625.00
|
|
|
Service Code
|
CPT 72082 TC
|
| Hospital Charge Code |
4598708
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.22 |
| Max. Negotiated Rate |
$593.75 |
| Rate for Payer: Aetna Commercial |
$593.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$537.50
|
| Rate for Payer: Aetna Managed Medicare |
$53.22
|
| Rate for Payer: Anthem Medicare Advantage |
$53.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.22
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$593.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$312.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.22
|
| Rate for Payer: Health EOS Commercial |
$568.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$184.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$184.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.22
|
| Rate for Payer: Multiplan Commercial |
$500.00
|
| Rate for Payer: Preferred Network Access Commercial |
$593.75
|
| Rate for Payer: Quartz Beloit One Network |
$275.00
|
| Rate for Payer: Quartz Commercial |
$356.25
|
| Rate for Payer: Quartz Medicare Advantage |
$53.22
|
| Rate for Payer: The Alliance Commercial |
$202.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.22
|
| Rate for Payer: WEA Trust Commercial |
$343.75
|
| Rate for Payer: WPS Commercial |
$266.10
|
|
|
BCE XR Spine, C,T,L incl Skull 2 or 3 Views
|
Facility
OP
|
$625.00
|
|
|
Service Code
|
CPT 72082 TC
|
| Hospital Charge Code |
4598708
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$2,500.00 |
| Rate for Payer: Aetna Commercial |
$562.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$537.50
|
| Rate for Payer: Aetna Managed Medicare |
$175.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$406.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$312.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$300.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.25
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$575.00
|
| Rate for Payer: Health EOS Commercial |
$556.25
|
| Rate for Payer: HFN Commercial |
$575.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$468.75
|
| Rate for Payer: Multiplan Commercial |
$500.00
|
| Rate for Payer: NAPHCARE Commercial |
$375.00
|
| Rate for Payer: Preferred Network Access Commercial |
$575.00
|
| Rate for Payer: Quartz Beloit One Network |
$306.25
|
| Rate for Payer: Quartz Commercial |
$406.25
|
| Rate for Payer: Quartz Medicare Advantage |
$375.00
|
| Rate for Payer: The Alliance Commercial |
$2,500.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$343.75
|
| Rate for Payer: WPS Commercial |
$462.94
|
|
|
BCE XR Spine, C,T,L incl Skull 2 or 3 Views
|
Facility
IP
|
$625.00
|
|
|
Service Code
|
CPT 72082 TC
|
| Hospital Charge Code |
4598708
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$306.25 |
| Max. Negotiated Rate |
$575.00 |
| Rate for Payer: Aetna Commercial |
$562.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.25
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$575.00
|
| Rate for Payer: Health EOS Commercial |
$556.25
|
| Rate for Payer: HFN Commercial |
$575.00
|
| Rate for Payer: Multiplan Commercial |
$500.00
|
| Rate for Payer: NAPHCARE Commercial |
$375.00
|
| Rate for Payer: Preferred Network Access Commercial |
$575.00
|
| Rate for Payer: Quartz Beloit One Network |
$306.25
|
| Rate for Payer: Quartz Commercial |
$375.00
|
| Rate for Payer: WEA Trust Commercial |
$343.75
|
| Rate for Payer: WPS Commercial |
$462.94
|
|
|
BCE XR Spine Lumbosacral 2 or 3 View
|
Professional
|
$705.00
|
|
|
Service Code
|
CPT 72100 TC
|
| Hospital Charge Code |
3925416
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$28.11 |
| Max. Negotiated Rate |
$669.75 |
| Rate for Payer: Aetna Commercial |
$669.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.30
|
| Rate for Payer: Aetna Managed Medicare |
$28.11
|
| Rate for Payer: Anthem Medicare Advantage |
$28.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.11
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$669.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$352.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.11
|
| Rate for Payer: Health EOS Commercial |
$641.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$96.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.11
|
| Rate for Payer: Multiplan Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$669.75
|
| Rate for Payer: Quartz Beloit One Network |
$310.20
|
| Rate for Payer: Quartz Commercial |
$401.85
|
| Rate for Payer: Quartz Medicare Advantage |
$28.11
|
| Rate for Payer: The Alliance Commercial |
$106.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.11
|
| Rate for Payer: WEA Trust Commercial |
$387.75
|
| Rate for Payer: WPS Commercial |
$140.55
|
|
|
BCE XR Spine Lumbosacral 2 or 3 View
|
Facility
IP
|
$705.00
|
|
|
Service Code
|
CPT 72100 TC
|
| Hospital Charge Code |
3925416
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$345.45 |
| Max. Negotiated Rate |
$648.60 |
| Rate for Payer: Aetna Commercial |
$634.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.65
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$648.60
|
| Rate for Payer: Health EOS Commercial |
$627.45
|
| Rate for Payer: HFN Commercial |
$648.60
|
| Rate for Payer: Multiplan Commercial |
$564.00
|
| Rate for Payer: NAPHCARE Commercial |
$423.00
|
| Rate for Payer: Preferred Network Access Commercial |
$648.60
|
| Rate for Payer: Quartz Beloit One Network |
$345.45
|
| Rate for Payer: Quartz Commercial |
$423.00
|
| Rate for Payer: WEA Trust Commercial |
$387.75
|
| Rate for Payer: WPS Commercial |
$522.19
|
|
|
BCE XR Spine Lumbosacral 2 or 3 View
|
Facility
OP
|
$705.00
|
|
|
Service Code
|
CPT 72100 TC
|
| Hospital Charge Code |
3925416
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$197.40 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$634.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.30
|
| Rate for Payer: Aetna Managed Medicare |
$197.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$458.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$352.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$338.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.65
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$648.60
|
| Rate for Payer: Health EOS Commercial |
$627.45
|
| Rate for Payer: HFN Commercial |
$648.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$528.75
|
| Rate for Payer: Multiplan Commercial |
$564.00
|
| Rate for Payer: NAPHCARE Commercial |
$423.00
|
| Rate for Payer: Preferred Network Access Commercial |
$648.60
|
| Rate for Payer: Quartz Beloit One Network |
$345.45
|
| Rate for Payer: Quartz Commercial |
$458.25
|
| Rate for Payer: Quartz Medicare Advantage |
$423.00
|
| Rate for Payer: The Alliance Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$387.75
|
| Rate for Payer: WPS Commercial |
$522.19
|
|
|
BCE XR Tibia/Fibula Left
|
Facility
IP
|
$584.00
|
|
|
Service Code
|
CPT 73590 TC,LT
|
| Hospital Charge Code |
3091471
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$286.16 |
| Max. Negotiated Rate |
$537.28 |
| Rate for Payer: Aetna Commercial |
$525.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.52
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cigna Commercial |
$537.28
|
| Rate for Payer: Health EOS Commercial |
$519.76
|
| Rate for Payer: HFN Commercial |
$537.28
|
| Rate for Payer: Multiplan Commercial |
$467.20
|
| Rate for Payer: NAPHCARE Commercial |
$350.40
|
| Rate for Payer: Preferred Network Access Commercial |
$537.28
|
| Rate for Payer: Quartz Beloit One Network |
$286.16
|
| Rate for Payer: Quartz Commercial |
$350.40
|
| Rate for Payer: WEA Trust Commercial |
$321.20
|
| Rate for Payer: WPS Commercial |
$432.57
|
|
|
BCE XR Tibia/Fibula Left
|
Facility
OP
|
$584.00
|
|
|
Service Code
|
CPT 73590 TC,LT
|
| Hospital Charge Code |
3091471
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$163.52 |
| Max. Negotiated Rate |
$2,336.00 |
| Rate for Payer: Aetna Commercial |
$525.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.24
|
| Rate for Payer: Aetna Managed Medicare |
$163.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$379.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$292.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.52
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cigna Commercial |
$537.28
|
| Rate for Payer: Health EOS Commercial |
$519.76
|
| Rate for Payer: HFN Commercial |
$537.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$438.00
|
| Rate for Payer: Multiplan Commercial |
$467.20
|
| Rate for Payer: NAPHCARE Commercial |
$350.40
|
| Rate for Payer: Preferred Network Access Commercial |
$537.28
|
| Rate for Payer: Quartz Beloit One Network |
$286.16
|
| Rate for Payer: Quartz Commercial |
$379.60
|
| Rate for Payer: Quartz Medicare Advantage |
$350.40
|
| Rate for Payer: The Alliance Commercial |
$2,336.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$321.20
|
| Rate for Payer: WPS Commercial |
$432.57
|
|
|
BCE XR Tibia/Fibula Left
|
Professional
|
$584.00
|
|
|
Service Code
|
CPT 73590 TC,LT
|
| Hospital Charge Code |
3091471
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$256.96 |
| Max. Negotiated Rate |
$554.80 |
| Rate for Payer: Aetna Commercial |
$554.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.24
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cigna Commercial |
$554.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$292.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$350.40
|
| Rate for Payer: Health EOS Commercial |
$531.44
|
| Rate for Payer: Multiplan Commercial |
$467.20
|
| Rate for Payer: Preferred Network Access Commercial |
$554.80
|
| Rate for Payer: Quartz Beloit One Network |
$256.96
|
| Rate for Payer: Quartz Commercial |
$332.88
|
| Rate for Payer: The Alliance Commercial |
$292.00
|
| Rate for Payer: WEA Trust Commercial |
$321.20
|
| Rate for Payer: WPS Commercial |
$432.57
|
|
