|
XR Toes Great Left
|
Facility
|
OP
|
$402.00
|
|
|
Service Code
|
CPT 73660 TA,TC
|
| Hospital Charge Code |
1537413
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$117.06 |
| Max. Negotiated Rate |
$384.63 |
| Rate for Payer: Aetna Commercial |
$376.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.55
|
| Rate for Payer: Aetna Managed Medicare |
$117.06
|
| 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 |
$221.58
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$384.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.96
|
| Rate for Payer: Health EOS Commercial |
$372.09
|
| Rate for Payer: HFN Commercial |
$384.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$313.56
|
| Rate for Payer: Multiplan Commercial |
$334.46
|
| Rate for Payer: NAPHCARE Commercial |
$250.85
|
| Rate for Payer: Preferred Network Access Commercial |
$384.63
|
| Rate for Payer: Quartz Beloit One Network |
$204.86
|
| Rate for Payer: Quartz Commercial |
$271.75
|
| Rate for Payer: Quartz Medicare Advantage |
$250.85
|
| Rate for Payer: The Alliance Commercial |
$209.04
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$229.94
|
| Rate for Payer: WPS Commercial |
$309.66
|
|
|
XR Toes Great Right
|
Facility
|
OP
|
$402.00
|
|
|
Service Code
|
CPT 73660 TC,T5
|
| Hospital Charge Code |
1537415
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$117.06 |
| Max. Negotiated Rate |
$384.63 |
| Rate for Payer: Aetna Commercial |
$376.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.55
|
| Rate for Payer: Aetna Managed Medicare |
$117.06
|
| 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 |
$221.58
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$384.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.96
|
| Rate for Payer: Health EOS Commercial |
$372.09
|
| Rate for Payer: HFN Commercial |
$384.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$313.56
|
| Rate for Payer: Multiplan Commercial |
$334.46
|
| Rate for Payer: NAPHCARE Commercial |
$250.85
|
| Rate for Payer: Preferred Network Access Commercial |
$384.63
|
| Rate for Payer: Quartz Beloit One Network |
$204.86
|
| Rate for Payer: Quartz Commercial |
$271.75
|
| Rate for Payer: Quartz Medicare Advantage |
$250.85
|
| Rate for Payer: The Alliance Commercial |
$209.04
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$229.94
|
| Rate for Payer: WPS Commercial |
$309.66
|
|
|
XR Toes Great Right
|
Facility
|
IP
|
$402.00
|
|
|
Service Code
|
CPT 73660 TC,T5
|
| Hospital Charge Code |
1537415
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$204.86 |
| Max. Negotiated Rate |
$384.63 |
| Rate for Payer: Aetna Commercial |
$376.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.58
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$384.63
|
| Rate for Payer: Health EOS Commercial |
$372.09
|
| Rate for Payer: HFN Commercial |
$384.63
|
| Rate for Payer: Multiplan Commercial |
$334.46
|
| Rate for Payer: Preferred Network Access Commercial |
$384.63
|
| Rate for Payer: Quartz Beloit One Network |
$204.86
|
| Rate for Payer: Quartz Commercial |
$250.85
|
| Rate for Payer: WEA Trust Commercial |
$229.94
|
| Rate for Payer: WPS Commercial |
$309.66
|
|
|
XR Toes Great Right
|
Professional
|
Both
|
$402.00
|
|
|
Service Code
|
CPT 73660 TC,T5
|
| Hospital Charge Code |
1537415
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$183.96 |
| Max. Negotiated Rate |
$397.18 |
| Rate for Payer: Aetna Commercial |
$397.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.55
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$397.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$209.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.85
|
| Rate for Payer: Health EOS Commercial |
$380.45
|
| Rate for Payer: HFN Commercial |
$397.18
|
| Rate for Payer: Multiplan Commercial |
$334.46
|
| Rate for Payer: Preferred Network Access Commercial |
$397.18
|
| Rate for Payer: Quartz Beloit One Network |
$183.96
|
| Rate for Payer: Quartz Commercial |
$238.31
|
| Rate for Payer: The Alliance Commercial |
$209.04
|
| Rate for Payer: WEA Trust Commercial |
$229.94
|
| Rate for Payer: WPS Commercial |
$309.66
|
|
|
XR Toes Great Right
|
Facility
|
OP
|
$391.00
|
|
|
Service Code
|
CPT 73660
|
| Hospital Charge Code |
629858
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$374.11 |
| Rate for Payer: Aetna Commercial |
$365.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.71
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$264.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$203.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$195.19
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.52
|
| 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 |
$117.30
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$374.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$227.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$361.91
|
| Rate for Payer: HFN Commercial |
$374.11
|
| 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 |
$325.31
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$374.11
|
| Rate for Payer: Quartz Beloit One Network |
$199.25
|
| Rate for Payer: Quartz Commercial |
$264.32
|
| 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 |
$223.65
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$301.19
|
|
|
XR Toes Great Right
|
Facility
|
IP
|
$391.00
|
|
|
Service Code
|
CPT 73660
|
| Hospital Charge Code |
629858
|
| Min. Negotiated Rate |
$199.25 |
| Max. Negotiated Rate |
$374.11 |
| Rate for Payer: Aetna Commercial |
$365.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.52
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$374.11
|
| Rate for Payer: Health EOS Commercial |
$361.91
|
| Rate for Payer: HFN Commercial |
$374.11
|
| Rate for Payer: Multiplan Commercial |
$325.31
|
| Rate for Payer: Preferred Network Access Commercial |
$374.11
|
| Rate for Payer: Quartz Beloit One Network |
$199.25
|
| Rate for Payer: Quartz Commercial |
$243.98
|
| Rate for Payer: WEA Trust Commercial |
$223.65
|
| Rate for Payer: WPS Commercial |
$301.19
|
|
|
XR Toes Great Right
|
Professional
|
Both
|
$391.00
|
|
|
Service Code
|
CPT 73660
|
| Hospital Charge Code |
629858
|
| Min. Negotiated Rate |
$28.36 |
| Max. Negotiated Rate |
$386.31 |
| Rate for Payer: Aetna Commercial |
$386.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.71
|
| Rate for Payer: Aetna Managed Medicare |
$28.36
|
| Rate for Payer: Anthem Medicare Advantage |
$28.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.36
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$386.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$203.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.36
|
| Rate for Payer: Health EOS Commercial |
$370.04
|
| Rate for Payer: HFN Commercial |
$386.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.36
|
| Rate for Payer: Multiplan Commercial |
$325.31
|
| Rate for Payer: NAPHCARE Commercial |
$42.54
|
| Rate for Payer: Preferred Network Access Commercial |
$386.31
|
| Rate for Payer: Quartz Beloit One Network |
$178.92
|
| Rate for Payer: Quartz Commercial |
$231.78
|
| Rate for Payer: Quartz Medicare Advantage |
$28.36
|
| Rate for Payer: The Alliance Commercial |
$107.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.36
|
| Rate for Payer: WEA Trust Commercial |
$223.65
|
| Rate for Payer: WPS Commercial |
$141.80
|
|
|
XR Trauma Chest 1 View, Pelvis 1 View
|
Facility
|
OP
|
$484.00
|
|
|
Service Code
|
CPT 71045 TC
|
| Hospital Charge Code |
6182034
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$66.98 |
| Max. Negotiated Rate |
$463.09 |
| Rate for Payer: Aetna Commercial |
$453.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$432.89
|
| Rate for Payer: Aetna Managed Medicare |
$140.94
|
| 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 |
$266.78
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$463.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$281.69
|
| Rate for Payer: Health EOS Commercial |
$447.99
|
| Rate for Payer: HFN Commercial |
$463.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$377.52
|
| Rate for Payer: Multiplan Commercial |
$402.69
|
| Rate for Payer: NAPHCARE Commercial |
$302.02
|
| Rate for Payer: Preferred Network Access Commercial |
$463.09
|
| Rate for Payer: Quartz Beloit One Network |
$246.65
|
| Rate for Payer: Quartz Commercial |
$327.18
|
| Rate for Payer: Quartz Medicare Advantage |
$302.02
|
| Rate for Payer: The Alliance Commercial |
$66.98
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$276.85
|
| Rate for Payer: WPS Commercial |
$372.83
|
|
|
XR Trauma Chest 1 View, Pelvis 1 View
|
Professional
|
Both
|
$484.00
|
|
|
Service Code
|
CPT 71045 TC
|
| Hospital Charge Code |
6182034
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$16.74 |
| Max. Negotiated Rate |
$478.19 |
| Rate for Payer: Aetna Commercial |
$478.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$432.89
|
| Rate for Payer: Aetna Managed Medicare |
$16.74
|
| Rate for Payer: Anthem Medicare Advantage |
$16.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.74
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$478.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$251.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.74
|
| Rate for Payer: Health EOS Commercial |
$458.06
|
| Rate for Payer: HFN Commercial |
$478.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.74
|
| Rate for Payer: Multiplan Commercial |
$402.69
|
| Rate for Payer: NAPHCARE Commercial |
$25.12
|
| Rate for Payer: Preferred Network Access Commercial |
$478.19
|
| Rate for Payer: Quartz Beloit One Network |
$221.48
|
| Rate for Payer: Quartz Commercial |
$286.92
|
| Rate for Payer: Quartz Medicare Advantage |
$16.74
|
| Rate for Payer: The Alliance Commercial |
$63.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.74
|
| Rate for Payer: WEA Trust Commercial |
$276.85
|
| Rate for Payer: WPS Commercial |
$83.72
|
|
|
XR Trauma Chest 1 View, Pelvis 1 View
|
Facility
|
IP
|
$484.00
|
|
|
Service Code
|
CPT 71045 TC
|
| Hospital Charge Code |
6182034
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$246.65 |
| Max. Negotiated Rate |
$463.09 |
| Rate for Payer: Aetna Commercial |
$453.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$432.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$266.78
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$463.09
|
| Rate for Payer: Health EOS Commercial |
$447.99
|
| Rate for Payer: HFN Commercial |
$463.09
|
| Rate for Payer: Multiplan Commercial |
$402.69
|
| Rate for Payer: Preferred Network Access Commercial |
$463.09
|
| Rate for Payer: Quartz Beloit One Network |
$246.65
|
| Rate for Payer: Quartz Commercial |
$302.02
|
| Rate for Payer: WEA Trust Commercial |
$276.85
|
| Rate for Payer: WPS Commercial |
$372.83
|
|
|
XR Upper Extremity Infant Bilateral
|
Facility
|
IP
|
$922.00
|
|
|
Service Code
|
CPT 73092
|
| Hospital Charge Code |
613588
|
| Min. Negotiated Rate |
$469.85 |
| Max. Negotiated Rate |
$882.17 |
| Rate for Payer: Aetna Commercial |
$862.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.21
|
| Rate for Payer: Cash Price |
$276.60
|
| Rate for Payer: Cigna Commercial |
$882.17
|
| Rate for Payer: Health EOS Commercial |
$853.40
|
| Rate for Payer: HFN Commercial |
$882.17
|
| Rate for Payer: Multiplan Commercial |
$767.10
|
| Rate for Payer: Preferred Network Access Commercial |
$882.17
|
| Rate for Payer: Quartz Beloit One Network |
$469.85
|
| Rate for Payer: Quartz Commercial |
$575.33
|
| Rate for Payer: WEA Trust Commercial |
$527.38
|
| Rate for Payer: WPS Commercial |
$710.22
|
|
|
XR Upper Extremity Infant Bilateral
|
Facility
|
OP
|
$922.00
|
|
|
Service Code
|
CPT 73092
|
| Hospital Charge Code |
613588
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$882.17 |
| Rate for Payer: Aetna Commercial |
$862.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.64
|
| Rate for Payer: Aetna Managed Medicare |
$110.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$623.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$479.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$460.26
|
| Rate for Payer: Anthem Medicare Advantage |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$110.02
|
| Rate for Payer: Cash Price |
$276.60
|
| Rate for Payer: Cash Price |
$276.60
|
| Rate for Payer: Cigna Commercial |
$882.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$110.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$536.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$110.02
|
| Rate for Payer: Health EOS Commercial |
$853.40
|
| Rate for Payer: HFN Commercial |
$882.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$409.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$110.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$110.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$110.02
|
| Rate for Payer: Multiplan Commercial |
$767.10
|
| Rate for Payer: NAPHCARE Commercial |
$165.03
|
| Rate for Payer: Preferred Network Access Commercial |
$882.17
|
| Rate for Payer: Quartz Beloit One Network |
$469.85
|
| Rate for Payer: Quartz Commercial |
$623.27
|
| Rate for Payer: Quartz Medicare Advantage |
$110.02
|
| Rate for Payer: The Alliance Commercial |
$440.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.02
|
| Rate for Payer: WEA Trust Commercial |
$527.38
|
| Rate for Payer: Wellcare Medicare |
$110.02
|
| Rate for Payer: WPS Commercial |
$710.22
|
|
|
XR Upper Extremity Infant Bilateral
|
Professional
|
Both
|
$922.00
|
|
|
Service Code
|
CPT 73092
|
| Hospital Charge Code |
613588
|
| Min. Negotiated Rate |
$30.40 |
| Max. Negotiated Rate |
$910.94 |
| Rate for Payer: Aetna Commercial |
$910.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.64
|
| Rate for Payer: Aetna Managed Medicare |
$30.40
|
| Rate for Payer: Anthem Medicare Advantage |
$30.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.40
|
| Rate for Payer: Cash Price |
$276.60
|
| Rate for Payer: Cash Price |
$276.60
|
| Rate for Payer: Cash Price |
$276.60
|
| Rate for Payer: Cigna Commercial |
$910.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$479.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.40
|
| Rate for Payer: Health EOS Commercial |
$872.58
|
| Rate for Payer: HFN Commercial |
$910.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.40
|
| Rate for Payer: Multiplan Commercial |
$767.10
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$910.94
|
| Rate for Payer: Quartz Beloit One Network |
$421.91
|
| Rate for Payer: Quartz Commercial |
$546.56
|
| Rate for Payer: Quartz Medicare Advantage |
$30.40
|
| Rate for Payer: The Alliance Commercial |
$115.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.40
|
| Rate for Payer: WEA Trust Commercial |
$527.38
|
| Rate for Payer: WPS Commercial |
$152.00
|
|
|
XR Upper Extremity Infant Bilateral
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
CPT 73092 LT,TC
|
| Hospital Charge Code |
1537433
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$219.19 |
| Max. Negotiated Rate |
$473.25 |
| Rate for Payer: Aetna Commercial |
$473.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$473.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$249.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$298.90
|
| Rate for Payer: Health EOS Commercial |
$453.33
|
| Rate for Payer: HFN Commercial |
$473.25
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: Preferred Network Access Commercial |
$473.25
|
| Rate for Payer: Quartz Beloit One Network |
$219.19
|
| Rate for Payer: Quartz Commercial |
$283.95
|
| Rate for Payer: The Alliance Commercial |
$249.08
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
XR Upper Extremity Infant Bilateral
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
CPT 73092 LT,TC
|
| Hospital Charge Code |
1537433
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$244.10 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$298.90
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
XR Upper Extremity Infant Bilateral
|
Facility
|
OP
|
$479.00
|
|
|
Service Code
|
CPT 73092 LT,TC
|
| Hospital Charge Code |
1537433
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$139.48 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Aetna Managed Medicare |
$139.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.78
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$373.62
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: NAPHCARE Commercial |
$298.90
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$323.80
|
| Rate for Payer: Quartz Medicare Advantage |
$298.90
|
| Rate for Payer: The Alliance Commercial |
$249.08
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
XR Upper Extremity Infant Left
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
CPT 73092 LT,TC
|
| Hospital Charge Code |
1537435
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$219.19 |
| Max. Negotiated Rate |
$473.25 |
| Rate for Payer: Aetna Commercial |
$473.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$473.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$249.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$298.90
|
| Rate for Payer: Health EOS Commercial |
$453.33
|
| Rate for Payer: HFN Commercial |
$473.25
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: Preferred Network Access Commercial |
$473.25
|
| Rate for Payer: Quartz Beloit One Network |
$219.19
|
| Rate for Payer: Quartz Commercial |
$283.95
|
| Rate for Payer: The Alliance Commercial |
$249.08
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
XR Upper Extremity Infant Left
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
CPT 73092 LT,TC
|
| Hospital Charge Code |
1537435
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$244.10 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$298.90
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
XR Upper Extremity Infant Left
|
Facility
|
OP
|
$479.00
|
|
|
Service Code
|
CPT 73092 LT,TC
|
| Hospital Charge Code |
1537435
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$139.48 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Aetna Managed Medicare |
$139.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.78
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$373.62
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: NAPHCARE Commercial |
$298.90
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$323.80
|
| Rate for Payer: Quartz Medicare Advantage |
$298.90
|
| Rate for Payer: The Alliance Commercial |
$249.08
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
XR Upper Extremity Infant Left
|
Facility
|
OP
|
$461.00
|
|
|
Service Code
|
CPT 73092
|
| Hospital Charge Code |
613590
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$441.08 |
| Rate for Payer: Aetna Commercial |
$431.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.32
|
| Rate for Payer: Aetna Managed Medicare |
$110.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$311.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$230.13
|
| Rate for Payer: Anthem Medicare Advantage |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$110.02
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$441.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$110.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$110.02
|
| Rate for Payer: Health EOS Commercial |
$426.70
|
| Rate for Payer: HFN Commercial |
$441.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$409.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$110.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$110.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$110.02
|
| Rate for Payer: Multiplan Commercial |
$383.55
|
| Rate for Payer: NAPHCARE Commercial |
$165.03
|
| Rate for Payer: Preferred Network Access Commercial |
$441.08
|
| Rate for Payer: Quartz Beloit One Network |
$234.93
|
| Rate for Payer: Quartz Commercial |
$311.64
|
| Rate for Payer: Quartz Medicare Advantage |
$110.02
|
| Rate for Payer: The Alliance Commercial |
$440.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.02
|
| Rate for Payer: WEA Trust Commercial |
$263.69
|
| Rate for Payer: Wellcare Medicare |
$110.02
|
| Rate for Payer: WPS Commercial |
$355.11
|
|
|
XR Upper Extremity Infant Left
|
Professional
|
Both
|
$461.00
|
|
|
Service Code
|
CPT 73092
|
| Hospital Charge Code |
613590
|
| Min. Negotiated Rate |
$30.40 |
| Max. Negotiated Rate |
$455.47 |
| Rate for Payer: Aetna Commercial |
$455.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.32
|
| Rate for Payer: Aetna Managed Medicare |
$30.40
|
| Rate for Payer: Anthem Medicare Advantage |
$30.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.40
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$455.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$239.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.40
|
| Rate for Payer: Health EOS Commercial |
$436.29
|
| Rate for Payer: HFN Commercial |
$455.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.40
|
| Rate for Payer: Multiplan Commercial |
$383.55
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$455.47
|
| Rate for Payer: Quartz Beloit One Network |
$210.95
|
| Rate for Payer: Quartz Commercial |
$273.28
|
| Rate for Payer: Quartz Medicare Advantage |
$30.40
|
| Rate for Payer: The Alliance Commercial |
$115.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.40
|
| Rate for Payer: WEA Trust Commercial |
$263.69
|
| Rate for Payer: WPS Commercial |
$152.00
|
|
|
XR Upper Extremity Infant Left
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
CPT 73092
|
| Hospital Charge Code |
613590
|
| Min. Negotiated Rate |
$234.93 |
| Max. Negotiated Rate |
$441.08 |
| Rate for Payer: Aetna Commercial |
$431.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.10
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$441.08
|
| Rate for Payer: Health EOS Commercial |
$426.70
|
| Rate for Payer: HFN Commercial |
$441.08
|
| Rate for Payer: Multiplan Commercial |
$383.55
|
| Rate for Payer: Preferred Network Access Commercial |
$441.08
|
| Rate for Payer: Quartz Beloit One Network |
$234.93
|
| Rate for Payer: Quartz Commercial |
$287.66
|
| Rate for Payer: WEA Trust Commercial |
$263.69
|
| Rate for Payer: WPS Commercial |
$355.11
|
|
|
XR Upper Extremity Infant Right
|
Facility
|
IP
|
$470.00
|
|
|
Service Code
|
CPT 73092
|
| Hospital Charge Code |
613592
|
| Min. Negotiated Rate |
$239.51 |
| Max. Negotiated Rate |
$449.70 |
| Rate for Payer: Aetna Commercial |
$439.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$259.06
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$449.70
|
| Rate for Payer: Health EOS Commercial |
$435.03
|
| Rate for Payer: HFN Commercial |
$449.70
|
| Rate for Payer: Multiplan Commercial |
$391.04
|
| Rate for Payer: Preferred Network Access Commercial |
$449.70
|
| Rate for Payer: Quartz Beloit One Network |
$239.51
|
| Rate for Payer: Quartz Commercial |
$293.28
|
| Rate for Payer: WEA Trust Commercial |
$268.84
|
| Rate for Payer: WPS Commercial |
$362.04
|
|
|
XR Upper Extremity Infant Right
|
Professional
|
Both
|
$470.00
|
|
|
Service Code
|
CPT 73092
|
| Hospital Charge Code |
613592
|
| Min. Negotiated Rate |
$30.40 |
| Max. Negotiated Rate |
$464.36 |
| Rate for Payer: Aetna Commercial |
$464.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.37
|
| Rate for Payer: Aetna Managed Medicare |
$30.40
|
| Rate for Payer: Anthem Medicare Advantage |
$30.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.40
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$464.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$244.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.40
|
| Rate for Payer: Health EOS Commercial |
$444.81
|
| Rate for Payer: HFN Commercial |
$464.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.40
|
| Rate for Payer: Multiplan Commercial |
$391.04
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$464.36
|
| Rate for Payer: Quartz Beloit One Network |
$215.07
|
| Rate for Payer: Quartz Commercial |
$278.62
|
| Rate for Payer: Quartz Medicare Advantage |
$30.40
|
| Rate for Payer: The Alliance Commercial |
$115.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.40
|
| Rate for Payer: WEA Trust Commercial |
$268.84
|
| Rate for Payer: WPS Commercial |
$152.00
|
|
|
XR Upper Extremity Infant Right
|
Facility
|
OP
|
$470.00
|
|
|
Service Code
|
CPT 73092
|
| Hospital Charge Code |
613592
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$449.70 |
| Rate for Payer: Aetna Commercial |
$439.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.37
|
| Rate for Payer: Aetna Managed Medicare |
$110.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$317.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$244.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$234.62
|
| Rate for Payer: Anthem Medicare Advantage |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$259.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$110.02
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$449.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$110.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$273.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$110.02
|
| Rate for Payer: Health EOS Commercial |
$435.03
|
| Rate for Payer: HFN Commercial |
$449.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$409.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$110.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$110.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$110.02
|
| Rate for Payer: Multiplan Commercial |
$391.04
|
| Rate for Payer: NAPHCARE Commercial |
$165.03
|
| Rate for Payer: Preferred Network Access Commercial |
$449.70
|
| Rate for Payer: Quartz Beloit One Network |
$239.51
|
| Rate for Payer: Quartz Commercial |
$317.72
|
| Rate for Payer: Quartz Medicare Advantage |
$110.02
|
| Rate for Payer: The Alliance Commercial |
$440.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.02
|
| Rate for Payer: WEA Trust Commercial |
$268.84
|
| Rate for Payer: Wellcare Medicare |
$110.02
|
| Rate for Payer: WPS Commercial |
$362.04
|
|
