|
XR Upper Extremity Infant Right
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
CPT 73092 TC,RT
|
| Hospital Charge Code |
2980000
|
|
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 Right
|
Facility
|
OP
|
$508.00
|
|
|
Service Code
|
CPT 73092 RT,TC
|
| Hospital Charge Code |
1537437
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$147.93 |
| Max. Negotiated Rate |
$486.05 |
| Rate for Payer: Aetna Commercial |
$475.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.36
|
| Rate for Payer: Aetna Managed Medicare |
$147.93
|
| 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 |
$280.01
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$486.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$295.66
|
| Rate for Payer: Health EOS Commercial |
$470.20
|
| Rate for Payer: HFN Commercial |
$486.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$396.24
|
| Rate for Payer: Multiplan Commercial |
$422.66
|
| Rate for Payer: NAPHCARE Commercial |
$316.99
|
| Rate for Payer: Preferred Network Access Commercial |
$486.05
|
| Rate for Payer: Quartz Beloit One Network |
$258.88
|
| Rate for Payer: Quartz Commercial |
$343.41
|
| Rate for Payer: Quartz Medicare Advantage |
$316.99
|
| Rate for Payer: The Alliance Commercial |
$264.16
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$290.58
|
| Rate for Payer: WPS Commercial |
$391.31
|
|
|
XR Upper Extremity Infant Right
|
Professional
|
Both
|
$508.00
|
|
|
Service Code
|
CPT 73092 RT,TC
|
| Hospital Charge Code |
1537437
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$232.46 |
| Max. Negotiated Rate |
$501.90 |
| Rate for Payer: Aetna Commercial |
$501.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.36
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$501.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$264.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$316.99
|
| Rate for Payer: Health EOS Commercial |
$480.77
|
| Rate for Payer: HFN Commercial |
$501.90
|
| Rate for Payer: Multiplan Commercial |
$422.66
|
| Rate for Payer: Preferred Network Access Commercial |
$501.90
|
| Rate for Payer: Quartz Beloit One Network |
$232.46
|
| Rate for Payer: Quartz Commercial |
$301.14
|
| Rate for Payer: The Alliance Commercial |
$264.16
|
| Rate for Payer: WEA Trust Commercial |
$290.58
|
| Rate for Payer: WPS Commercial |
$391.31
|
|
|
XR Upper Extremity Infant Right
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
CPT 73092 TC,RT
|
| Hospital Charge Code |
2980000
|
|
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 Right
|
Facility
|
OP
|
$479.00
|
|
|
Service Code
|
CPT 73092 TC,RT
|
| Hospital Charge Code |
2980000
|
|
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 Right
|
Facility
|
IP
|
$508.00
|
|
|
Service Code
|
CPT 73092 RT,TC
|
| Hospital Charge Code |
1537437
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$258.88 |
| Max. Negotiated Rate |
$486.05 |
| Rate for Payer: Aetna Commercial |
$475.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$280.01
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$486.05
|
| Rate for Payer: Health EOS Commercial |
$470.20
|
| Rate for Payer: HFN Commercial |
$486.05
|
| Rate for Payer: Multiplan Commercial |
$422.66
|
| Rate for Payer: Preferred Network Access Commercial |
$486.05
|
| Rate for Payer: Quartz Beloit One Network |
$258.88
|
| Rate for Payer: Quartz Commercial |
$316.99
|
| Rate for Payer: WEA Trust Commercial |
$290.58
|
| Rate for Payer: WPS Commercial |
$391.31
|
|
|
XR Upper GI
|
Facility
|
OP
|
$1,156.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537439
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$184.59 |
| Max. Negotiated Rate |
$1,106.06 |
| Rate for Payer: Aetna Commercial |
$1,082.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,033.93
|
| Rate for Payer: Aetna Managed Medicare |
$184.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$708.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.26
|
| Rate for Payer: Anthem Medicare Advantage |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$637.19
|
| 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 |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,106.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$184.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$672.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$184.59
|
| Rate for Payer: Health EOS Commercial |
$1,069.99
|
| Rate for Payer: HFN Commercial |
$1,106.06
|
| 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 |
$961.79
|
| Rate for Payer: NAPHCARE Commercial |
$276.88
|
| Rate for Payer: Preferred Network Access Commercial |
$1,106.06
|
| Rate for Payer: Quartz Beloit One Network |
$589.10
|
| Rate for Payer: Quartz Commercial |
$781.46
|
| 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: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$661.23
|
| Rate for Payer: Wellcare Medicare |
$184.59
|
| Rate for Payer: WPS Commercial |
$890.47
|
|
|
XR Upper GI
|
Facility
|
IP
|
$1,156.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537439
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$589.10 |
| Max. Negotiated Rate |
$1,106.06 |
| Rate for Payer: Aetna Commercial |
$1,082.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,033.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$637.19
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,106.06
|
| Rate for Payer: Health EOS Commercial |
$1,069.99
|
| Rate for Payer: HFN Commercial |
$1,106.06
|
| Rate for Payer: Multiplan Commercial |
$961.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,106.06
|
| Rate for Payer: Quartz Beloit One Network |
$589.10
|
| Rate for Payer: Quartz Commercial |
$721.34
|
| Rate for Payer: WEA Trust Commercial |
$661.23
|
| Rate for Payer: WPS Commercial |
$890.47
|
|
|
XR Upper GI
|
Professional
|
Both
|
$1,092.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
613594
|
| Min. Negotiated Rate |
$121.47 |
| Max. Negotiated Rate |
$1,078.90 |
| Rate for Payer: Aetna Commercial |
$1,078.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.68
|
| Rate for Payer: Aetna Managed Medicare |
$121.47
|
| Rate for Payer: Anthem Medicare Advantage |
$121.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$121.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$121.47
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,078.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$567.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.47
|
| Rate for Payer: Health EOS Commercial |
$1,033.47
|
| Rate for Payer: HFN Commercial |
$1,078.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$121.47
|
| Rate for Payer: Multiplan Commercial |
$908.54
|
| Rate for Payer: NAPHCARE Commercial |
$182.21
|
| Rate for Payer: Preferred Network Access Commercial |
$1,078.90
|
| Rate for Payer: Quartz Beloit One Network |
$499.70
|
| Rate for Payer: Quartz Commercial |
$647.34
|
| Rate for Payer: Quartz Medicare Advantage |
$121.47
|
| Rate for Payer: The Alliance Commercial |
$461.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$121.47
|
| Rate for Payer: WEA Trust Commercial |
$624.62
|
| Rate for Payer: WPS Commercial |
$607.36
|
|
|
XR Upper GI
|
Facility
|
OP
|
$1,092.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
613594
|
| Min. Negotiated Rate |
$184.59 |
| Max. Negotiated Rate |
$1,044.83 |
| Rate for Payer: Aetna Commercial |
$1,022.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.68
|
| Rate for Payer: Aetna Managed Medicare |
$184.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$738.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$567.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$545.13
|
| Rate for Payer: Anthem Medicare Advantage |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$601.91
|
| 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 |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,044.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$184.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$635.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$184.59
|
| Rate for Payer: Health EOS Commercial |
$1,010.76
|
| Rate for Payer: HFN Commercial |
$1,044.83
|
| 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 |
$908.54
|
| Rate for Payer: NAPHCARE Commercial |
$276.88
|
| Rate for Payer: Preferred Network Access Commercial |
$1,044.83
|
| Rate for Payer: Quartz Beloit One Network |
$556.48
|
| Rate for Payer: Quartz Commercial |
$738.19
|
| 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 |
$624.62
|
| Rate for Payer: Wellcare Medicare |
$184.59
|
| Rate for Payer: WPS Commercial |
$841.17
|
|
|
XR Upper GI
|
Facility
|
IP
|
$1,092.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
613594
|
| Min. Negotiated Rate |
$556.48 |
| Max. Negotiated Rate |
$1,044.83 |
| Rate for Payer: Aetna Commercial |
$1,022.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$601.91
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,044.83
|
| Rate for Payer: Health EOS Commercial |
$1,010.76
|
| Rate for Payer: HFN Commercial |
$1,044.83
|
| Rate for Payer: Multiplan Commercial |
$908.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,044.83
|
| Rate for Payer: Quartz Beloit One Network |
$556.48
|
| Rate for Payer: Quartz Commercial |
$681.41
|
| Rate for Payer: WEA Trust Commercial |
$624.62
|
| Rate for Payer: WPS Commercial |
$841.17
|
|
|
XR Upper GI
|
Professional
|
Both
|
$1,156.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537439
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$121.47 |
| Max. Negotiated Rate |
$1,142.13 |
| Rate for Payer: Aetna Commercial |
$1,142.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,033.93
|
| Rate for Payer: Aetna Managed Medicare |
$121.47
|
| Rate for Payer: Anthem Medicare Advantage |
$121.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$121.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$121.47
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,142.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$601.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.47
|
| Rate for Payer: Health EOS Commercial |
$1,094.04
|
| Rate for Payer: HFN Commercial |
$1,142.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$121.47
|
| Rate for Payer: Multiplan Commercial |
$961.79
|
| Rate for Payer: NAPHCARE Commercial |
$182.21
|
| Rate for Payer: Preferred Network Access Commercial |
$1,142.13
|
| Rate for Payer: Quartz Beloit One Network |
$528.99
|
| Rate for Payer: Quartz Commercial |
$685.28
|
| Rate for Payer: Quartz Medicare Advantage |
$121.47
|
| Rate for Payer: The Alliance Commercial |
$461.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$121.47
|
| Rate for Payer: WEA Trust Commercial |
$661.23
|
| Rate for Payer: WPS Commercial |
$607.36
|
|
|
XR Upper GI + KUB
|
Professional
|
Both
|
$1,147.00
|
|
|
Service Code
|
CPT 74240 TC
|
| Hospital Charge Code |
1537441
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.64 |
| Max. Negotiated Rate |
$1,133.24 |
| Rate for Payer: Aetna Commercial |
$1,133.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.88
|
| Rate for Payer: Aetna Managed Medicare |
$83.64
|
| Rate for Payer: Anthem Medicare Advantage |
$83.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$83.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$83.64
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cigna Commercial |
$1,133.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$596.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.64
|
| Rate for Payer: Health EOS Commercial |
$1,085.52
|
| Rate for Payer: HFN Commercial |
$1,133.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$83.64
|
| Rate for Payer: Multiplan Commercial |
$954.30
|
| Rate for Payer: NAPHCARE Commercial |
$125.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,133.24
|
| Rate for Payer: Quartz Beloit One Network |
$524.87
|
| Rate for Payer: Quartz Commercial |
$679.94
|
| Rate for Payer: Quartz Medicare Advantage |
$83.64
|
| Rate for Payer: The Alliance Commercial |
$317.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$83.64
|
| Rate for Payer: WEA Trust Commercial |
$656.08
|
| Rate for Payer: WPS Commercial |
$418.18
|
|
|
XR Upper GI + KUB
|
Professional
|
Both
|
$1,103.00
|
|
| Hospital Charge Code |
613596
|
| Min. Negotiated Rate |
$504.73 |
| Max. Negotiated Rate |
$1,089.76 |
| Rate for Payer: Aetna Commercial |
$1,089.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$986.52
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,089.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$573.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$688.27
|
| Rate for Payer: Health EOS Commercial |
$1,043.88
|
| Rate for Payer: HFN Commercial |
$1,089.76
|
| Rate for Payer: Multiplan Commercial |
$917.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,089.76
|
| Rate for Payer: Quartz Beloit One Network |
$504.73
|
| Rate for Payer: Quartz Commercial |
$653.86
|
| Rate for Payer: The Alliance Commercial |
$573.56
|
| Rate for Payer: WEA Trust Commercial |
$630.92
|
| Rate for Payer: WPS Commercial |
$849.64
|
|
|
XR Upper GI + KUB
|
Facility
|
OP
|
$1,103.00
|
|
| Hospital Charge Code |
613596
|
| Min. Negotiated Rate |
$321.19 |
| Max. Negotiated Rate |
$1,055.35 |
| Rate for Payer: Aetna Commercial |
$1,032.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$986.52
|
| Rate for Payer: Aetna Managed Medicare |
$321.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$745.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$573.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$550.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$607.97
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,055.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$641.95
|
| Rate for Payer: Health EOS Commercial |
$1,020.94
|
| Rate for Payer: HFN Commercial |
$1,055.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$860.34
|
| Rate for Payer: Multiplan Commercial |
$917.70
|
| Rate for Payer: NAPHCARE Commercial |
$688.27
|
| Rate for Payer: Preferred Network Access Commercial |
$1,055.35
|
| Rate for Payer: Quartz Beloit One Network |
$562.09
|
| Rate for Payer: Quartz Commercial |
$745.63
|
| Rate for Payer: Quartz Medicare Advantage |
$688.27
|
| Rate for Payer: The Alliance Commercial |
$573.56
|
| Rate for Payer: WEA Trust Commercial |
$630.92
|
| Rate for Payer: WPS Commercial |
$849.64
|
|
|
XR Upper GI + KUB
|
Facility
|
IP
|
$1,103.00
|
|
| Hospital Charge Code |
613596
|
| Min. Negotiated Rate |
$562.09 |
| Max. Negotiated Rate |
$1,055.35 |
| Rate for Payer: Aetna Commercial |
$1,032.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$986.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$607.97
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,055.35
|
| Rate for Payer: Health EOS Commercial |
$1,020.94
|
| Rate for Payer: HFN Commercial |
$1,055.35
|
| Rate for Payer: Multiplan Commercial |
$917.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,055.35
|
| Rate for Payer: Quartz Beloit One Network |
$562.09
|
| Rate for Payer: Quartz Commercial |
$688.27
|
| Rate for Payer: WEA Trust Commercial |
$630.92
|
| Rate for Payer: WPS Commercial |
$849.64
|
|
|
XR Upper GI + KUB
|
Facility
|
IP
|
$1,147.00
|
|
|
Service Code
|
CPT 74240 TC
|
| Hospital Charge Code |
1537441
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$584.51 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Aetna Commercial |
$1,073.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$632.23
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cigna Commercial |
$1,097.45
|
| Rate for Payer: Health EOS Commercial |
$1,061.66
|
| Rate for Payer: HFN Commercial |
$1,097.45
|
| Rate for Payer: Multiplan Commercial |
$954.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,097.45
|
| Rate for Payer: Quartz Beloit One Network |
$584.51
|
| Rate for Payer: Quartz Commercial |
$715.73
|
| Rate for Payer: WEA Trust Commercial |
$656.08
|
| Rate for Payer: WPS Commercial |
$883.53
|
|
|
XR Upper GI + KUB
|
Facility
|
OP
|
$1,147.00
|
|
|
Service Code
|
CPT 74240 TC
|
| Hospital Charge Code |
1537441
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Aetna Commercial |
$1,073.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.88
|
| Rate for Payer: Aetna Managed Medicare |
$334.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$708.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$632.23
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cigna Commercial |
$1,097.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$667.55
|
| Rate for Payer: Health EOS Commercial |
$1,061.66
|
| Rate for Payer: HFN Commercial |
$1,097.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$894.66
|
| Rate for Payer: Multiplan Commercial |
$954.30
|
| Rate for Payer: NAPHCARE Commercial |
$715.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,097.45
|
| Rate for Payer: Quartz Beloit One Network |
$584.51
|
| Rate for Payer: Quartz Commercial |
$775.37
|
| Rate for Payer: Quartz Medicare Advantage |
$715.73
|
| Rate for Payer: The Alliance Commercial |
$334.55
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$656.08
|
| Rate for Payer: WPS Commercial |
$883.53
|
|
|
XR Upper GI w/ Air
|
Facility
|
IP
|
$1,221.00
|
|
|
Service Code
|
CPT 74246 TC
|
| Hospital Charge Code |
5597616
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$622.22 |
| Max. Negotiated Rate |
$1,168.25 |
| Rate for Payer: Aetna Commercial |
$1,142.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,092.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$673.02
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,168.25
|
| Rate for Payer: Health EOS Commercial |
$1,130.16
|
| Rate for Payer: HFN Commercial |
$1,168.25
|
| Rate for Payer: Multiplan Commercial |
$1,015.87
|
| Rate for Payer: Preferred Network Access Commercial |
$1,168.25
|
| Rate for Payer: Quartz Beloit One Network |
$622.22
|
| Rate for Payer: Quartz Commercial |
$761.90
|
| Rate for Payer: WEA Trust Commercial |
$698.41
|
| Rate for Payer: WPS Commercial |
$940.54
|
|
|
XR Upper GI w/ Air
|
Facility
|
OP
|
$1,221.00
|
|
|
Service Code
|
CPT 74246 TC
|
| Hospital Charge Code |
5597616
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$1,168.25 |
| Rate for Payer: Aetna Commercial |
$1,142.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,092.06
|
| Rate for Payer: Aetna Managed Medicare |
$355.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$708.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$673.02
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,168.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$710.62
|
| Rate for Payer: Health EOS Commercial |
$1,130.16
|
| Rate for Payer: HFN Commercial |
$1,168.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$952.38
|
| Rate for Payer: Multiplan Commercial |
$1,015.87
|
| Rate for Payer: NAPHCARE Commercial |
$761.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,168.25
|
| Rate for Payer: Quartz Beloit One Network |
$622.22
|
| Rate for Payer: Quartz Commercial |
$825.40
|
| Rate for Payer: Quartz Medicare Advantage |
$761.90
|
| Rate for Payer: The Alliance Commercial |
$369.16
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$698.41
|
| Rate for Payer: WPS Commercial |
$940.54
|
|
|
XR Upper GI w/ Air
|
Professional
|
Both
|
$1,221.00
|
|
|
Service Code
|
CPT 74246 TC
|
| Hospital Charge Code |
5597616
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$92.29 |
| Max. Negotiated Rate |
$1,206.35 |
| Rate for Payer: Aetna Commercial |
$1,206.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,092.06
|
| Rate for Payer: Aetna Managed Medicare |
$92.29
|
| Rate for Payer: Anthem Medicare Advantage |
$92.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$92.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$92.29
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,206.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$634.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.29
|
| Rate for Payer: Health EOS Commercial |
$1,155.55
|
| Rate for Payer: HFN Commercial |
$1,206.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$92.29
|
| Rate for Payer: Multiplan Commercial |
$1,015.87
|
| Rate for Payer: NAPHCARE Commercial |
$138.43
|
| Rate for Payer: Preferred Network Access Commercial |
$1,206.35
|
| Rate for Payer: Quartz Beloit One Network |
$558.73
|
| Rate for Payer: Quartz Commercial |
$723.81
|
| Rate for Payer: Quartz Medicare Advantage |
$92.29
|
| Rate for Payer: The Alliance Commercial |
$350.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$92.29
|
| Rate for Payer: WEA Trust Commercial |
$698.41
|
| Rate for Payer: WPS Commercial |
$461.45
|
|
|
XR Upper GI w/ Air Contrast
|
Facility
|
IP
|
$1,269.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
1537443
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$646.68 |
| Max. Negotiated Rate |
$1,214.18 |
| Rate for Payer: Aetna Commercial |
$1,187.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,134.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$699.47
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cigna Commercial |
$1,214.18
|
| Rate for Payer: Health EOS Commercial |
$1,174.59
|
| Rate for Payer: HFN Commercial |
$1,214.18
|
| Rate for Payer: Multiplan Commercial |
$1,055.81
|
| Rate for Payer: Preferred Network Access Commercial |
$1,214.18
|
| Rate for Payer: Quartz Beloit One Network |
$646.68
|
| Rate for Payer: Quartz Commercial |
$791.86
|
| Rate for Payer: WEA Trust Commercial |
$725.87
|
| Rate for Payer: WPS Commercial |
$977.51
|
|
|
XR Upper GI w/ Air Contrast
|
Professional
|
Both
|
$1,269.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
1537443
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$134.04 |
| Max. Negotiated Rate |
$1,253.77 |
| Rate for Payer: Aetna Commercial |
$1,253.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,134.99
|
| Rate for Payer: Aetna Managed Medicare |
$134.04
|
| Rate for Payer: Anthem Medicare Advantage |
$134.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$134.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$134.04
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cigna Commercial |
$1,253.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$659.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.04
|
| Rate for Payer: Health EOS Commercial |
$1,200.98
|
| Rate for Payer: HFN Commercial |
$1,253.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$134.04
|
| Rate for Payer: Multiplan Commercial |
$1,055.81
|
| Rate for Payer: NAPHCARE Commercial |
$201.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,253.77
|
| Rate for Payer: Quartz Beloit One Network |
$580.69
|
| Rate for Payer: Quartz Commercial |
$752.26
|
| Rate for Payer: Quartz Medicare Advantage |
$134.04
|
| Rate for Payer: The Alliance Commercial |
$509.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$134.04
|
| Rate for Payer: WEA Trust Commercial |
$725.87
|
| Rate for Payer: WPS Commercial |
$670.18
|
|
|
XR Upper GI w/ Air Contrast
|
Facility
|
OP
|
$1,269.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
1537443
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$184.59 |
| Max. Negotiated Rate |
$1,214.18 |
| Rate for Payer: Aetna Commercial |
$1,187.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,134.99
|
| Rate for Payer: Aetna Managed Medicare |
$184.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$708.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.26
|
| Rate for Payer: Anthem Medicare Advantage |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$699.47
|
| 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 |
$380.70
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cigna Commercial |
$1,214.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$184.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$738.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$184.59
|
| Rate for Payer: Health EOS Commercial |
$1,174.59
|
| Rate for Payer: HFN Commercial |
$1,214.18
|
| 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 |
$1,055.81
|
| Rate for Payer: NAPHCARE Commercial |
$276.88
|
| Rate for Payer: Preferred Network Access Commercial |
$1,214.18
|
| Rate for Payer: Quartz Beloit One Network |
$646.68
|
| Rate for Payer: Quartz Commercial |
$857.84
|
| 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: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$725.87
|
| Rate for Payer: Wellcare Medicare |
$184.59
|
| Rate for Payer: WPS Commercial |
$977.51
|
|
|
XR Upper GI w/ Air Contrast
|
Professional
|
Both
|
$1,174.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
613598
|
| Min. Negotiated Rate |
$134.04 |
| Max. Negotiated Rate |
$1,159.91 |
| Rate for Payer: Aetna Commercial |
$1,159.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.03
|
| Rate for Payer: Aetna Managed Medicare |
$134.04
|
| Rate for Payer: Anthem Medicare Advantage |
$134.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$134.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$134.04
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cigna Commercial |
$1,159.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$610.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.04
|
| Rate for Payer: Health EOS Commercial |
$1,111.07
|
| Rate for Payer: HFN Commercial |
$1,159.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$134.04
|
| Rate for Payer: Multiplan Commercial |
$976.77
|
| Rate for Payer: NAPHCARE Commercial |
$201.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.91
|
| Rate for Payer: Quartz Beloit One Network |
$537.22
|
| Rate for Payer: Quartz Commercial |
$695.95
|
| Rate for Payer: Quartz Medicare Advantage |
$134.04
|
| Rate for Payer: The Alliance Commercial |
$509.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$134.04
|
| Rate for Payer: WEA Trust Commercial |
$671.53
|
| Rate for Payer: WPS Commercial |
$670.18
|
|
