|
XR Upper GI w/ Small Bowel
|
Professional
|
Both
|
$1,867.00
|
|
| Hospital Charge Code |
613604
|
| Min. Negotiated Rate |
$854.34 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,844.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,669.84
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$970.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,165.01
|
| Rate for Payer: Health EOS Commercial |
$1,766.93
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,553.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$854.34
|
| Rate for Payer: Quartz Commercial |
$1,106.76
|
| Rate for Payer: The Alliance Commercial |
$970.84
|
| Rate for Payer: WEA Trust Commercial |
$1,067.92
|
| Rate for Payer: WPS Commercial |
$1,438.15
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Professional
|
Both
|
$1,867.00
|
|
| Hospital Charge Code |
1537453
|
| Min. Negotiated Rate |
$854.34 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,844.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,669.84
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$970.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,165.01
|
| Rate for Payer: Health EOS Commercial |
$1,766.93
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,553.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$854.34
|
| Rate for Payer: Quartz Commercial |
$1,106.76
|
| Rate for Payer: The Alliance Commercial |
$970.84
|
| Rate for Payer: WEA Trust Commercial |
$1,067.92
|
| Rate for Payer: WPS Commercial |
$1,438.15
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Facility
|
IP
|
$1,867.00
|
|
| Hospital Charge Code |
675805
|
| Min. Negotiated Rate |
$951.42 |
| Max. Negotiated Rate |
$1,786.35 |
| Rate for Payer: Aetna Commercial |
$1,747.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,669.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,029.09
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,786.35
|
| Rate for Payer: Health EOS Commercial |
$1,728.10
|
| Rate for Payer: HFN Commercial |
$1,786.35
|
| Rate for Payer: Multiplan Commercial |
$1,553.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,786.35
|
| Rate for Payer: Quartz Beloit One Network |
$951.42
|
| Rate for Payer: Quartz Commercial |
$1,165.01
|
| Rate for Payer: WEA Trust Commercial |
$1,067.92
|
| Rate for Payer: WPS Commercial |
$1,438.15
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Facility
|
IP
|
$1,867.00
|
|
| Hospital Charge Code |
1537453
|
| Min. Negotiated Rate |
$951.42 |
| Max. Negotiated Rate |
$1,786.35 |
| Rate for Payer: Aetna Commercial |
$1,747.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,669.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,029.09
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,786.35
|
| Rate for Payer: Health EOS Commercial |
$1,728.10
|
| Rate for Payer: HFN Commercial |
$1,786.35
|
| Rate for Payer: Multiplan Commercial |
$1,553.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,786.35
|
| Rate for Payer: Quartz Beloit One Network |
$951.42
|
| Rate for Payer: Quartz Commercial |
$1,165.01
|
| Rate for Payer: WEA Trust Commercial |
$1,067.92
|
| Rate for Payer: WPS Commercial |
$1,438.15
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Facility
|
OP
|
$1,867.00
|
|
| Hospital Charge Code |
1537453
|
| Min. Negotiated Rate |
$543.67 |
| Max. Negotiated Rate |
$1,786.35 |
| Rate for Payer: Aetna Commercial |
$1,747.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,669.84
|
| Rate for Payer: Aetna Managed Medicare |
$543.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,262.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$970.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$932.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,029.09
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,786.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,086.59
|
| Rate for Payer: Health EOS Commercial |
$1,728.10
|
| Rate for Payer: HFN Commercial |
$1,786.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,456.26
|
| Rate for Payer: Multiplan Commercial |
$1,553.34
|
| Rate for Payer: NAPHCARE Commercial |
$1,165.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,786.35
|
| Rate for Payer: Quartz Beloit One Network |
$951.42
|
| Rate for Payer: Quartz Commercial |
$1,262.09
|
| Rate for Payer: Quartz Medicare Advantage |
$1,165.01
|
| Rate for Payer: The Alliance Commercial |
$970.84
|
| Rate for Payer: WEA Trust Commercial |
$1,067.92
|
| Rate for Payer: WPS Commercial |
$1,438.15
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Facility
|
OP
|
$1,867.00
|
|
| Hospital Charge Code |
675805
|
| Min. Negotiated Rate |
$543.67 |
| Max. Negotiated Rate |
$1,786.35 |
| Rate for Payer: Aetna Commercial |
$1,747.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,669.84
|
| Rate for Payer: Aetna Managed Medicare |
$543.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,262.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$970.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$932.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,029.09
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,786.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,086.59
|
| Rate for Payer: Health EOS Commercial |
$1,728.10
|
| Rate for Payer: HFN Commercial |
$1,786.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,456.26
|
| Rate for Payer: Multiplan Commercial |
$1,553.34
|
| Rate for Payer: NAPHCARE Commercial |
$1,165.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,786.35
|
| Rate for Payer: Quartz Beloit One Network |
$951.42
|
| Rate for Payer: Quartz Commercial |
$1,262.09
|
| Rate for Payer: Quartz Medicare Advantage |
$1,165.01
|
| Rate for Payer: The Alliance Commercial |
$970.84
|
| Rate for Payer: WEA Trust Commercial |
$1,067.92
|
| Rate for Payer: WPS Commercial |
$1,438.15
|
|
|
XR Upper GI w/ Small Bowel Gastrografin
|
Professional
|
Both
|
$1,867.00
|
|
| Hospital Charge Code |
675805
|
| Min. Negotiated Rate |
$854.34 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Health EOS Commercial |
$1,766.93
|
| Rate for Payer: Aetna Commercial |
$1,844.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,669.84
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$970.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,165.01
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,553.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$854.34
|
| Rate for Payer: Quartz Commercial |
$1,106.76
|
| Rate for Payer: The Alliance Commercial |
$970.84
|
| Rate for Payer: WEA Trust Commercial |
$1,067.92
|
| Rate for Payer: WPS Commercial |
$1,438.15
|
|
|
XR Ureteral Cath/Stent Place Left
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587322
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$310.86 |
| Max. Negotiated Rate |
$583.65 |
| Rate for Payer: Aetna Commercial |
$570.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$545.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$336.23
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$583.65
|
| Rate for Payer: Health EOS Commercial |
$564.62
|
| Rate for Payer: HFN Commercial |
$583.65
|
| Rate for Payer: Multiplan Commercial |
$507.52
|
| Rate for Payer: Preferred Network Access Commercial |
$583.65
|
| Rate for Payer: Quartz Beloit One Network |
$310.86
|
| Rate for Payer: Quartz Commercial |
$380.64
|
| Rate for Payer: WEA Trust Commercial |
$348.92
|
| Rate for Payer: WPS Commercial |
$469.88
|
|
|
XR Ureteral Cath/Stent Place Left
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587322
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$41.86 |
| Max. Negotiated Rate |
$602.68 |
| Rate for Payer: Aetna Commercial |
$602.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$545.58
|
| Rate for Payer: Aetna Managed Medicare |
$41.86
|
| Rate for Payer: Anthem Medicare Advantage |
$41.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.86
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$602.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$317.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.86
|
| Rate for Payer: Health EOS Commercial |
$577.30
|
| Rate for Payer: HFN Commercial |
$602.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.86
|
| Rate for Payer: Multiplan Commercial |
$507.52
|
| Rate for Payer: NAPHCARE Commercial |
$62.79
|
| Rate for Payer: Preferred Network Access Commercial |
$602.68
|
| Rate for Payer: Quartz Beloit One Network |
$279.14
|
| Rate for Payer: Quartz Commercial |
$361.61
|
| Rate for Payer: Quartz Medicare Advantage |
$41.86
|
| Rate for Payer: The Alliance Commercial |
$159.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.86
|
| Rate for Payer: WEA Trust Commercial |
$348.92
|
| Rate for Payer: WPS Commercial |
$209.30
|
|
|
XR Ureteral Cath/Stent Place Left
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587322
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$583.65 |
| Rate for Payer: Aetna Commercial |
$570.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$545.58
|
| Rate for Payer: Aetna Managed Medicare |
$110.02
|
| 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: Anthem Medicare Advantage |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$336.23
|
| 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 |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$583.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$110.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$355.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$110.02
|
| Rate for Payer: Health EOS Commercial |
$564.62
|
| Rate for Payer: HFN Commercial |
$583.65
|
| 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 |
$507.52
|
| Rate for Payer: NAPHCARE Commercial |
$165.03
|
| Rate for Payer: Preferred Network Access Commercial |
$583.65
|
| Rate for Payer: Quartz Beloit One Network |
$310.86
|
| Rate for Payer: Quartz Commercial |
$412.36
|
| 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: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$348.92
|
| Rate for Payer: Wellcare Medicare |
$110.02
|
| Rate for Payer: WPS Commercial |
$469.88
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
|
OP
|
$565.00
|
|
|
Service Code
|
CPT 74020
|
| Hospital Charge Code |
2448819
|
| Min. Negotiated Rate |
$164.53 |
| Max. Negotiated Rate |
$540.59 |
| Rate for Payer: Aetna Commercial |
$528.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$505.34
|
| Rate for Payer: Aetna Managed Medicare |
$164.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$381.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$293.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.43
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$540.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$328.83
|
| Rate for Payer: Health EOS Commercial |
$522.96
|
| Rate for Payer: HFN Commercial |
$540.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$440.70
|
| Rate for Payer: Multiplan Commercial |
$470.08
|
| Rate for Payer: NAPHCARE Commercial |
$352.56
|
| Rate for Payer: Preferred Network Access Commercial |
$540.59
|
| Rate for Payer: Quartz Beloit One Network |
$287.92
|
| Rate for Payer: Quartz Commercial |
$381.94
|
| Rate for Payer: Quartz Medicare Advantage |
$352.56
|
| Rate for Payer: The Alliance Commercial |
$293.80
|
| Rate for Payer: WEA Trust Commercial |
$323.18
|
| Rate for Payer: WPS Commercial |
$435.22
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
|
IP
|
$565.00
|
|
|
Service Code
|
CPT 74020
|
| Hospital Charge Code |
2448819
|
| Min. Negotiated Rate |
$287.92 |
| Max. Negotiated Rate |
$540.59 |
| Rate for Payer: Aetna Commercial |
$528.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$505.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.43
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$540.59
|
| Rate for Payer: Health EOS Commercial |
$522.96
|
| Rate for Payer: HFN Commercial |
$540.59
|
| Rate for Payer: Multiplan Commercial |
$470.08
|
| Rate for Payer: Preferred Network Access Commercial |
$540.59
|
| Rate for Payer: Quartz Beloit One Network |
$287.92
|
| Rate for Payer: Quartz Commercial |
$352.56
|
| Rate for Payer: WEA Trust Commercial |
$323.18
|
| Rate for Payer: WPS Commercial |
$435.22
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587325
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$583.65 |
| Rate for Payer: Aetna Commercial |
$570.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$545.58
|
| Rate for Payer: Aetna Managed Medicare |
$110.02
|
| 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: Anthem Medicare Advantage |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$336.23
|
| 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 |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$583.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$110.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$355.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$110.02
|
| Rate for Payer: Health EOS Commercial |
$564.62
|
| Rate for Payer: HFN Commercial |
$583.65
|
| 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 |
$507.52
|
| Rate for Payer: NAPHCARE Commercial |
$165.03
|
| Rate for Payer: Preferred Network Access Commercial |
$583.65
|
| Rate for Payer: Quartz Beloit One Network |
$310.86
|
| Rate for Payer: Quartz Commercial |
$412.36
|
| 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: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$348.92
|
| Rate for Payer: Wellcare Medicare |
$110.02
|
| Rate for Payer: WPS Commercial |
$469.88
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587325
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$310.86 |
| Max. Negotiated Rate |
$583.65 |
| Rate for Payer: Aetna Commercial |
$570.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$545.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$336.23
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$583.65
|
| Rate for Payer: Health EOS Commercial |
$564.62
|
| Rate for Payer: HFN Commercial |
$583.65
|
| Rate for Payer: Multiplan Commercial |
$507.52
|
| Rate for Payer: Preferred Network Access Commercial |
$583.65
|
| Rate for Payer: Quartz Beloit One Network |
$310.86
|
| Rate for Payer: Quartz Commercial |
$380.64
|
| Rate for Payer: WEA Trust Commercial |
$348.92
|
| Rate for Payer: WPS Commercial |
$469.88
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
|
OP
|
$588.00
|
|
|
Service Code
|
CPT 74021 TC,RT
|
| Hospital Charge Code |
5577652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$171.23 |
| Max. Negotiated Rate |
$562.60 |
| Rate for Payer: Aetna Commercial |
$550.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.91
|
| Rate for Payer: Aetna Managed Medicare |
$171.23
|
| 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 |
$324.11
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$562.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$342.22
|
| Rate for Payer: Health EOS Commercial |
$544.25
|
| Rate for Payer: HFN Commercial |
$562.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$458.64
|
| Rate for Payer: Multiplan Commercial |
$489.22
|
| Rate for Payer: NAPHCARE Commercial |
$366.91
|
| Rate for Payer: Preferred Network Access Commercial |
$562.60
|
| Rate for Payer: Quartz Beloit One Network |
$299.64
|
| Rate for Payer: Quartz Commercial |
$397.49
|
| Rate for Payer: Quartz Medicare Advantage |
$366.91
|
| Rate for Payer: The Alliance Commercial |
$305.76
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$336.34
|
| Rate for Payer: WPS Commercial |
$452.94
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
|
IP
|
$588.00
|
|
|
Service Code
|
CPT 74021 TC,RT
|
| Hospital Charge Code |
5577652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$299.64 |
| Max. Negotiated Rate |
$562.60 |
| Rate for Payer: Aetna Commercial |
$550.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$324.11
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$562.60
|
| Rate for Payer: Health EOS Commercial |
$544.25
|
| Rate for Payer: HFN Commercial |
$562.60
|
| Rate for Payer: Multiplan Commercial |
$489.22
|
| Rate for Payer: Preferred Network Access Commercial |
$562.60
|
| Rate for Payer: Quartz Beloit One Network |
$299.64
|
| Rate for Payer: Quartz Commercial |
$366.91
|
| Rate for Payer: WEA Trust Commercial |
$336.34
|
| Rate for Payer: WPS Commercial |
$452.94
|
|
|
XR Ureteral Cath/Stent Place Right
|
Professional
|
Both
|
$588.00
|
|
|
Service Code
|
CPT 74021 TC,RT
|
| Hospital Charge Code |
5577652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$269.07 |
| Max. Negotiated Rate |
$580.94 |
| Rate for Payer: Aetna Commercial |
$580.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.91
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$580.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$305.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$366.91
|
| Rate for Payer: Health EOS Commercial |
$556.48
|
| Rate for Payer: HFN Commercial |
$580.94
|
| Rate for Payer: Multiplan Commercial |
$489.22
|
| Rate for Payer: Preferred Network Access Commercial |
$580.94
|
| Rate for Payer: Quartz Beloit One Network |
$269.07
|
| Rate for Payer: Quartz Commercial |
$348.57
|
| Rate for Payer: The Alliance Commercial |
$305.76
|
| Rate for Payer: WEA Trust Commercial |
$336.34
|
| Rate for Payer: WPS Commercial |
$452.94
|
|
|
XR Urethrocystography Retrograde
|
Professional
|
Both
|
$683.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
613606
|
| Min. Negotiated Rate |
$312.54 |
| Max. Negotiated Rate |
$674.80 |
| Rate for Payer: Aetna Commercial |
$674.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$610.88
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cigna Commercial |
$674.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$355.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$426.19
|
| Rate for Payer: Health EOS Commercial |
$646.39
|
| Rate for Payer: HFN Commercial |
$674.80
|
| Rate for Payer: Multiplan Commercial |
$568.26
|
| Rate for Payer: Preferred Network Access Commercial |
$674.80
|
| Rate for Payer: Quartz Beloit One Network |
$312.54
|
| Rate for Payer: Quartz Commercial |
$404.88
|
| Rate for Payer: The Alliance Commercial |
$355.16
|
| Rate for Payer: WEA Trust Commercial |
$390.68
|
| Rate for Payer: WPS Commercial |
$526.11
|
|
|
XR Urethrocystography Retrograde
|
Facility
|
OP
|
$683.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
613606
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$1,004.39 |
| Rate for Payer: Aetna Commercial |
$639.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$610.88
|
| Rate for Payer: Aetna Managed Medicare |
$251.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$461.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$355.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$340.95
|
| Rate for Payer: Anthem Medicare Advantage |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$376.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$251.10
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cigna Commercial |
$653.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$251.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$397.51
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$251.10
|
| Rate for Payer: Health EOS Commercial |
$632.18
|
| Rate for Payer: HFN Commercial |
$653.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$934.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$251.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$251.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$251.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$251.10
|
| Rate for Payer: Multiplan Commercial |
$568.26
|
| Rate for Payer: NAPHCARE Commercial |
$376.65
|
| Rate for Payer: Preferred Network Access Commercial |
$653.49
|
| Rate for Payer: Quartz Beloit One Network |
$348.06
|
| Rate for Payer: Quartz Commercial |
$461.71
|
| Rate for Payer: Quartz Medicare Advantage |
$251.10
|
| Rate for Payer: The Alliance Commercial |
$1,004.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$251.10
|
| Rate for Payer: WEA Trust Commercial |
$390.68
|
| Rate for Payer: Wellcare Medicare |
$251.10
|
| Rate for Payer: WPS Commercial |
$526.11
|
|
|
XR Urethrocystography Retrograde
|
Professional
|
Both
|
$720.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1537455
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$329.47 |
| Max. Negotiated Rate |
$711.36 |
| Rate for Payer: Aetna Commercial |
$711.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$711.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$374.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$449.28
|
| Rate for Payer: Health EOS Commercial |
$681.41
|
| Rate for Payer: HFN Commercial |
$711.36
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: Preferred Network Access Commercial |
$711.36
|
| Rate for Payer: Quartz Beloit One Network |
$329.47
|
| Rate for Payer: Quartz Commercial |
$426.82
|
| Rate for Payer: The Alliance Commercial |
$374.40
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
XR Urethrocystography Retrograde
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1537455
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$1,004.39 |
| Rate for Payer: Aetna Commercial |
$673.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Aetna Managed Medicare |
$251.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$944.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$755.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$717.88
|
| Rate for Payer: Anthem Medicare Advantage |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$251.10
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$688.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$251.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$419.04
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$251.10
|
| Rate for Payer: Health EOS Commercial |
$666.43
|
| Rate for Payer: HFN Commercial |
$688.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$934.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$251.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$251.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$251.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$251.10
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: NAPHCARE Commercial |
$376.65
|
| Rate for Payer: Preferred Network Access Commercial |
$688.90
|
| Rate for Payer: Quartz Beloit One Network |
$366.91
|
| Rate for Payer: Quartz Commercial |
$486.72
|
| Rate for Payer: Quartz Medicare Advantage |
$251.10
|
| Rate for Payer: The Alliance Commercial |
$1,004.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$251.10
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: Wellcare Medicare |
$251.10
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
XR Urethrocystography Retrograde
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1537455
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$366.91 |
| Max. Negotiated Rate |
$688.90 |
| Rate for Payer: Aetna Commercial |
$673.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.86
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$688.90
|
| Rate for Payer: Health EOS Commercial |
$666.43
|
| Rate for Payer: HFN Commercial |
$688.90
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: Preferred Network Access Commercial |
$688.90
|
| Rate for Payer: Quartz Beloit One Network |
$366.91
|
| Rate for Payer: Quartz Commercial |
$449.28
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
XR Urethrocystography Retrograde
|
Facility
|
IP
|
$683.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
613606
|
| Min. Negotiated Rate |
$348.06 |
| Max. Negotiated Rate |
$653.49 |
| Rate for Payer: Aetna Commercial |
$639.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$610.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$376.47
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cigna Commercial |
$653.49
|
| Rate for Payer: Health EOS Commercial |
$632.18
|
| Rate for Payer: HFN Commercial |
$653.49
|
| Rate for Payer: Multiplan Commercial |
$568.26
|
| Rate for Payer: Preferred Network Access Commercial |
$653.49
|
| Rate for Payer: Quartz Beloit One Network |
$348.06
|
| Rate for Payer: Quartz Commercial |
$426.19
|
| Rate for Payer: WEA Trust Commercial |
$390.68
|
| Rate for Payer: WPS Commercial |
$526.11
|
|
|
XR Urethrocystography Voiding
|
Facility
|
IP
|
$1,161.00
|
|
|
Service Code
|
CPT 74455 TC
|
| Hospital Charge Code |
3072720
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$591.65 |
| Max. Negotiated Rate |
$1,110.84 |
| Rate for Payer: Aetna Commercial |
$1,086.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,038.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$639.94
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cigna Commercial |
$1,110.84
|
| Rate for Payer: Health EOS Commercial |
$1,074.62
|
| Rate for Payer: HFN Commercial |
$1,110.84
|
| Rate for Payer: Multiplan Commercial |
$965.95
|
| Rate for Payer: Preferred Network Access Commercial |
$1,110.84
|
| Rate for Payer: Quartz Beloit One Network |
$591.65
|
| Rate for Payer: Quartz Commercial |
$724.46
|
| Rate for Payer: WEA Trust Commercial |
$664.09
|
| Rate for Payer: WPS Commercial |
$894.32
|
|
|
XR Urethrocystography Voiding
|
Professional
|
Both
|
$1,161.00
|
|
|
Service Code
|
CPT 74455 TC
|
| Hospital Charge Code |
3072720
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.29 |
| Max. Negotiated Rate |
$1,147.07 |
| Rate for Payer: Aetna Commercial |
$1,147.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,038.40
|
| Rate for Payer: Aetna Managed Medicare |
$89.29
|
| Rate for Payer: Anthem Medicare Advantage |
$89.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.29
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cigna Commercial |
$1,147.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$603.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.29
|
| Rate for Payer: Health EOS Commercial |
$1,098.77
|
| Rate for Payer: HFN Commercial |
$1,147.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.29
|
| Rate for Payer: Multiplan Commercial |
$965.95
|
| Rate for Payer: NAPHCARE Commercial |
$133.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,147.07
|
| Rate for Payer: Quartz Beloit One Network |
$531.27
|
| Rate for Payer: Quartz Commercial |
$688.24
|
| Rate for Payer: Quartz Medicare Advantage |
$89.29
|
| Rate for Payer: The Alliance Commercial |
$339.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.29
|
| Rate for Payer: WEA Trust Commercial |
$664.09
|
| Rate for Payer: WPS Commercial |
$446.47
|
|
