|
XR Urethrocystography Voiding
|
Facility
|
OP
|
$1,161.00
|
|
|
Service Code
|
CPT 74455 TC
|
| Hospital Charge Code |
3072720
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.04 |
| 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: Aetna Managed Medicare |
$338.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$944.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$755.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$717.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$639.94
|
| 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 |
$1,110.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$675.70
|
| Rate for Payer: Health EOS Commercial |
$1,074.62
|
| Rate for Payer: HFN Commercial |
$1,110.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$905.58
|
| Rate for Payer: Multiplan Commercial |
$965.95
|
| Rate for Payer: NAPHCARE Commercial |
$724.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,110.84
|
| Rate for Payer: Quartz Beloit One Network |
$591.65
|
| Rate for Payer: Quartz Commercial |
$784.84
|
| Rate for Payer: Quartz Medicare Advantage |
$724.46
|
| Rate for Payer: The Alliance Commercial |
$357.18
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$664.09
|
| Rate for Payer: WPS Commercial |
$894.32
|
|
|
XR Urography Retrograde
|
Facility
|
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 LT
|
| Hospital Charge Code |
1537459
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$1,482.47 |
| Rate for Payer: Aetna Commercial |
$1,171.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Aetna Managed Medicare |
$364.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,185.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,126.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.10
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,197.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$728.66
|
| Rate for Payer: Health EOS Commercial |
$1,158.85
|
| Rate for Payer: HFN Commercial |
$1,197.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$976.56
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: NAPHCARE Commercial |
$781.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,197.91
|
| Rate for Payer: Quartz Beloit One Network |
$638.02
|
| Rate for Payer: Quartz Commercial |
$846.35
|
| Rate for Payer: Quartz Medicare Advantage |
$781.25
|
| Rate for Payer: The Alliance Commercial |
$651.04
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$964.42
|
|
|
XR Urography Retrograde
|
Professional
|
Both
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 LT
|
| Hospital Charge Code |
1537459
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$572.92 |
| Max. Negotiated Rate |
$1,236.98 |
| Rate for Payer: Aetna Commercial |
$1,236.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,236.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$651.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$781.25
|
| Rate for Payer: Health EOS Commercial |
$1,184.89
|
| Rate for Payer: HFN Commercial |
$1,236.98
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,236.98
|
| Rate for Payer: Quartz Beloit One Network |
$572.92
|
| Rate for Payer: Quartz Commercial |
$742.19
|
| Rate for Payer: The Alliance Commercial |
$651.04
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$964.42
|
|
|
XR Urography Retrograde
|
Facility
|
IP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 LT
|
| Hospital Charge Code |
1537459
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$638.02 |
| Max. Negotiated Rate |
$1,197.91 |
| Rate for Payer: Aetna Commercial |
$1,171.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.10
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,197.91
|
| Rate for Payer: Health EOS Commercial |
$1,158.85
|
| Rate for Payer: HFN Commercial |
$1,197.91
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,197.91
|
| Rate for Payer: Quartz Beloit One Network |
$638.02
|
| Rate for Payer: Quartz Commercial |
$781.25
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$964.42
|
|
|
XR Urography Retrograde LT
|
Facility
|
OP
|
$1,002.00
|
|
|
Service Code
|
CPT 74420 TC,LT
|
| Hospital Charge Code |
3072645
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$291.78 |
| Max. Negotiated Rate |
$1,482.47 |
| Rate for Payer: Aetna Commercial |
$937.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.19
|
| Rate for Payer: Aetna Managed Medicare |
$291.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,185.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,126.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.30
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$958.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$583.16
|
| Rate for Payer: Health EOS Commercial |
$927.45
|
| Rate for Payer: HFN Commercial |
$958.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$781.56
|
| Rate for Payer: Multiplan Commercial |
$833.66
|
| Rate for Payer: NAPHCARE Commercial |
$625.25
|
| Rate for Payer: Preferred Network Access Commercial |
$958.71
|
| Rate for Payer: Quartz Beloit One Network |
$510.62
|
| Rate for Payer: Quartz Commercial |
$677.35
|
| Rate for Payer: Quartz Medicare Advantage |
$625.25
|
| Rate for Payer: The Alliance Commercial |
$521.04
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$573.14
|
| Rate for Payer: WPS Commercial |
$771.84
|
|
|
XR Urography Retrograde LT
|
Facility
|
IP
|
$1,002.00
|
|
|
Service Code
|
CPT 74420 TC,LT
|
| Hospital Charge Code |
3072645
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$510.62 |
| Max. Negotiated Rate |
$958.71 |
| Rate for Payer: Aetna Commercial |
$937.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.30
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$958.71
|
| Rate for Payer: Health EOS Commercial |
$927.45
|
| Rate for Payer: HFN Commercial |
$958.71
|
| Rate for Payer: Multiplan Commercial |
$833.66
|
| Rate for Payer: Preferred Network Access Commercial |
$958.71
|
| Rate for Payer: Quartz Beloit One Network |
$510.62
|
| Rate for Payer: Quartz Commercial |
$625.25
|
| Rate for Payer: WEA Trust Commercial |
$573.14
|
| Rate for Payer: WPS Commercial |
$771.84
|
|
|
XR Urography Retrograde LT
|
Professional
|
Both
|
$1,002.00
|
|
|
Service Code
|
CPT 74420 TC,LT
|
| Hospital Charge Code |
3072645
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$458.52 |
| Max. Negotiated Rate |
$989.98 |
| Rate for Payer: Aetna Commercial |
$989.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.19
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$989.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$521.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$625.25
|
| Rate for Payer: Health EOS Commercial |
$948.29
|
| Rate for Payer: HFN Commercial |
$989.98
|
| Rate for Payer: Multiplan Commercial |
$833.66
|
| Rate for Payer: Preferred Network Access Commercial |
$989.98
|
| Rate for Payer: Quartz Beloit One Network |
$458.52
|
| Rate for Payer: Quartz Commercial |
$593.99
|
| Rate for Payer: The Alliance Commercial |
$521.04
|
| Rate for Payer: WEA Trust Commercial |
$573.14
|
| Rate for Payer: WPS Commercial |
$771.84
|
|
|
XR Urography Retrograde RT
|
Facility
|
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC,RT
|
| Hospital Charge Code |
3072646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$1,482.47 |
| Rate for Payer: Aetna Commercial |
$1,171.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Aetna Managed Medicare |
$364.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,185.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,126.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.10
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,197.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$728.66
|
| Rate for Payer: Health EOS Commercial |
$1,158.85
|
| Rate for Payer: HFN Commercial |
$1,197.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$976.56
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: NAPHCARE Commercial |
$781.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,197.91
|
| Rate for Payer: Quartz Beloit One Network |
$638.02
|
| Rate for Payer: Quartz Commercial |
$846.35
|
| Rate for Payer: Quartz Medicare Advantage |
$781.25
|
| Rate for Payer: The Alliance Commercial |
$651.04
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$964.42
|
|
|
XR Urography Retrograde RT
|
Professional
|
Both
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC,RT
|
| Hospital Charge Code |
3072646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$572.92 |
| Max. Negotiated Rate |
$1,236.98 |
| Rate for Payer: Aetna Commercial |
$1,236.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,236.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$651.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$781.25
|
| Rate for Payer: Health EOS Commercial |
$1,184.89
|
| Rate for Payer: HFN Commercial |
$1,236.98
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,236.98
|
| Rate for Payer: Quartz Beloit One Network |
$572.92
|
| Rate for Payer: Quartz Commercial |
$742.19
|
| Rate for Payer: The Alliance Commercial |
$651.04
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$964.42
|
|
|
XR Urography Retrograde RT
|
Facility
|
IP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC,RT
|
| Hospital Charge Code |
3072646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$638.02 |
| Max. Negotiated Rate |
$1,197.91 |
| Rate for Payer: Aetna Commercial |
$1,171.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.10
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,197.91
|
| Rate for Payer: Health EOS Commercial |
$1,158.85
|
| Rate for Payer: HFN Commercial |
$1,197.91
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,197.91
|
| Rate for Payer: Quartz Beloit One Network |
$638.02
|
| Rate for Payer: Quartz Commercial |
$781.25
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$964.42
|
|
|
XR Urography Retro Lt
|
Facility
|
IP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596968
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$638.02 |
| Max. Negotiated Rate |
$1,197.91 |
| Rate for Payer: Aetna Commercial |
$1,171.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.10
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,197.91
|
| Rate for Payer: Health EOS Commercial |
$1,158.85
|
| Rate for Payer: HFN Commercial |
$1,197.91
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,197.91
|
| Rate for Payer: Quartz Beloit One Network |
$638.02
|
| Rate for Payer: Quartz Commercial |
$781.25
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$964.42
|
|
|
XR Urography Retro Lt
|
Professional
|
Both
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596968
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$56.01 |
| Max. Negotiated Rate |
$1,236.98 |
| Rate for Payer: Aetna Commercial |
$1,236.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Aetna Managed Medicare |
$56.01
|
| Rate for Payer: Anthem Medicare Advantage |
$56.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$56.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$56.01
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,236.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$651.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.01
|
| Rate for Payer: Health EOS Commercial |
$1,184.89
|
| Rate for Payer: HFN Commercial |
$1,236.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$56.01
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: NAPHCARE Commercial |
$84.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,236.98
|
| Rate for Payer: Quartz Beloit One Network |
$572.92
|
| Rate for Payer: Quartz Commercial |
$742.19
|
| Rate for Payer: Quartz Medicare Advantage |
$56.01
|
| Rate for Payer: The Alliance Commercial |
$212.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.01
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$280.07
|
|
|
XR Urography Retro Lt
|
Facility
|
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596968
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$224.06 |
| Max. Negotiated Rate |
$1,482.47 |
| Rate for Payer: Aetna Commercial |
$1,171.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Aetna Managed Medicare |
$364.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,185.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,126.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.10
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,197.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$728.66
|
| Rate for Payer: Health EOS Commercial |
$1,158.85
|
| Rate for Payer: HFN Commercial |
$1,197.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$976.56
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: NAPHCARE Commercial |
$781.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,197.91
|
| Rate for Payer: Quartz Beloit One Network |
$638.02
|
| Rate for Payer: Quartz Commercial |
$846.35
|
| Rate for Payer: Quartz Medicare Advantage |
$781.25
|
| Rate for Payer: The Alliance Commercial |
$224.06
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$964.42
|
|
|
XR Urography Retro Rt
|
Professional
|
Both
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596965
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$56.01 |
| Max. Negotiated Rate |
$1,236.98 |
| Rate for Payer: Aetna Commercial |
$1,236.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Aetna Managed Medicare |
$56.01
|
| Rate for Payer: Anthem Medicare Advantage |
$56.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$56.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$56.01
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,236.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$651.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.01
|
| Rate for Payer: Health EOS Commercial |
$1,184.89
|
| Rate for Payer: HFN Commercial |
$1,236.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$56.01
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: NAPHCARE Commercial |
$84.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,236.98
|
| Rate for Payer: Quartz Beloit One Network |
$572.92
|
| Rate for Payer: Quartz Commercial |
$742.19
|
| Rate for Payer: Quartz Medicare Advantage |
$56.01
|
| Rate for Payer: The Alliance Commercial |
$212.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.01
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$280.07
|
|
|
XR Urography Retro Rt
|
Facility
|
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596965
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$224.06 |
| Max. Negotiated Rate |
$1,482.47 |
| Rate for Payer: Aetna Commercial |
$1,171.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Aetna Managed Medicare |
$364.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,185.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,126.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.10
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,197.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$728.66
|
| Rate for Payer: Health EOS Commercial |
$1,158.85
|
| Rate for Payer: HFN Commercial |
$1,197.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$976.56
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: NAPHCARE Commercial |
$781.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,197.91
|
| Rate for Payer: Quartz Beloit One Network |
$638.02
|
| Rate for Payer: Quartz Commercial |
$846.35
|
| Rate for Payer: Quartz Medicare Advantage |
$781.25
|
| Rate for Payer: The Alliance Commercial |
$224.06
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$964.42
|
|
|
XR Urography Retro Rt
|
Facility
|
IP
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC
|
| Hospital Charge Code |
4596965
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$638.02 |
| Max. Negotiated Rate |
$1,197.91 |
| Rate for Payer: Aetna Commercial |
$1,171.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.10
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$1,197.91
|
| Rate for Payer: Health EOS Commercial |
$1,158.85
|
| Rate for Payer: HFN Commercial |
$1,197.91
|
| Rate for Payer: Multiplan Commercial |
$1,041.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,197.91
|
| Rate for Payer: Quartz Beloit One Network |
$638.02
|
| Rate for Payer: Quartz Commercial |
$781.25
|
| Rate for Payer: WEA Trust Commercial |
$716.14
|
| Rate for Payer: WPS Commercial |
$964.42
|
|
|
XR US Guidance
|
Facility
|
OP
|
$454.00
|
|
|
Service Code
|
CPT 76937
|
| Hospital Charge Code |
3242195
|
| Min. Negotiated Rate |
$132.20 |
| Max. Negotiated Rate |
$434.39 |
| Rate for Payer: Aetna Commercial |
$424.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$406.06
|
| Rate for Payer: Aetna Managed Medicare |
$132.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$306.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$236.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$226.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$250.24
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$434.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$264.23
|
| Rate for Payer: Health EOS Commercial |
$420.22
|
| Rate for Payer: HFN Commercial |
$434.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$354.12
|
| Rate for Payer: Multiplan Commercial |
$377.73
|
| Rate for Payer: NAPHCARE Commercial |
$283.30
|
| Rate for Payer: Preferred Network Access Commercial |
$434.39
|
| Rate for Payer: Quartz Beloit One Network |
$231.36
|
| Rate for Payer: Quartz Commercial |
$306.90
|
| Rate for Payer: Quartz Medicare Advantage |
$283.30
|
| Rate for Payer: The Alliance Commercial |
$159.16
|
| Rate for Payer: WEA Trust Commercial |
$259.69
|
| Rate for Payer: WPS Commercial |
$349.72
|
|
|
XR US Guidance
|
Facility
|
IP
|
$454.00
|
|
|
Service Code
|
CPT 76937
|
| Hospital Charge Code |
3242195
|
| Min. Negotiated Rate |
$231.36 |
| Max. Negotiated Rate |
$434.39 |
| Rate for Payer: Aetna Commercial |
$424.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$406.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$250.24
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$434.39
|
| Rate for Payer: Health EOS Commercial |
$420.22
|
| Rate for Payer: HFN Commercial |
$434.39
|
| Rate for Payer: Multiplan Commercial |
$377.73
|
| Rate for Payer: Preferred Network Access Commercial |
$434.39
|
| Rate for Payer: Quartz Beloit One Network |
$231.36
|
| Rate for Payer: Quartz Commercial |
$283.30
|
| Rate for Payer: WEA Trust Commercial |
$259.69
|
| Rate for Payer: WPS Commercial |
$349.72
|
|
|
XR US Guidance
|
Professional
|
Both
|
$454.00
|
|
|
Service Code
|
CPT 76937
|
| Hospital Charge Code |
3242195
|
| Min. Negotiated Rate |
$39.79 |
| Max. Negotiated Rate |
$448.55 |
| Rate for Payer: Aetna Commercial |
$448.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$406.06
|
| Rate for Payer: Aetna Managed Medicare |
$39.79
|
| Rate for Payer: Anthem Medicare Advantage |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.79
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$448.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$236.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.79
|
| Rate for Payer: Health EOS Commercial |
$429.67
|
| Rate for Payer: HFN Commercial |
$448.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.79
|
| Rate for Payer: Multiplan Commercial |
$377.73
|
| Rate for Payer: NAPHCARE Commercial |
$59.69
|
| Rate for Payer: Preferred Network Access Commercial |
$448.55
|
| Rate for Payer: Quartz Beloit One Network |
$207.75
|
| Rate for Payer: Quartz Commercial |
$269.13
|
| Rate for Payer: Quartz Medicare Advantage |
$39.79
|
| Rate for Payer: The Alliance Commercial |
$151.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.79
|
| Rate for Payer: WEA Trust Commercial |
$259.69
|
| Rate for Payer: WPS Commercial |
$198.95
|
|
|
XR US Guided Midline
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552128
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$105.58 |
| Max. Negotiated Rate |
$848.64 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Aetna Managed Medicare |
$129.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$848.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$681.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.28
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$425.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.99
|
| Rate for Payer: Health EOS Commercial |
$411.89
|
| Rate for Payer: HFN Commercial |
$425.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.10
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: NAPHCARE Commercial |
$277.68
|
| Rate for Payer: Preferred Network Access Commercial |
$425.78
|
| Rate for Payer: Quartz Beloit One Network |
$226.77
|
| Rate for Payer: Quartz Commercial |
$300.82
|
| Rate for Payer: Quartz Medicare Advantage |
$277.68
|
| Rate for Payer: The Alliance Commercial |
$105.58
|
| Rate for Payer: United Healthcare PPO |
$596.96
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$342.78
|
|
|
XR US Guided Midline
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552128
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$226.77 |
| Max. Negotiated Rate |
$425.78 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.28
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$425.78
|
| Rate for Payer: Health EOS Commercial |
$411.89
|
| Rate for Payer: HFN Commercial |
$425.78
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: Preferred Network Access Commercial |
$425.78
|
| Rate for Payer: Quartz Beloit One Network |
$226.77
|
| Rate for Payer: Quartz Commercial |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$342.78
|
|
|
XR US Guided Midline
|
Professional
|
Both
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552128
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$439.66 |
| Rate for Payer: Aetna Commercial |
$439.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Aetna Managed Medicare |
$26.40
|
| Rate for Payer: Anthem Medicare Advantage |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26.40
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$439.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$231.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.40
|
| Rate for Payer: Health EOS Commercial |
$421.15
|
| Rate for Payer: HFN Commercial |
$439.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: NAPHCARE Commercial |
$39.59
|
| Rate for Payer: Preferred Network Access Commercial |
$439.66
|
| Rate for Payer: Quartz Beloit One Network |
$203.63
|
| Rate for Payer: Quartz Commercial |
$263.80
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$100.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$131.98
|
|
|
XR Venogram Lower Extremity Bilateral
|
Facility
|
IP
|
$1,723.00
|
|
|
Service Code
|
CPT 75822 TC
|
| Hospital Charge Code |
3072721
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$878.04 |
| Max. Negotiated Rate |
$1,648.57 |
| Rate for Payer: Aetna Commercial |
$1,612.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$949.72
|
| Rate for Payer: Cash Price |
$516.90
|
| Rate for Payer: Cigna Commercial |
$1,648.57
|
| Rate for Payer: Health EOS Commercial |
$1,594.81
|
| Rate for Payer: HFN Commercial |
$1,648.57
|
| Rate for Payer: Multiplan Commercial |
$1,433.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,648.57
|
| Rate for Payer: Quartz Beloit One Network |
$878.04
|
| Rate for Payer: Quartz Commercial |
$1,075.15
|
| Rate for Payer: WEA Trust Commercial |
$985.56
|
| Rate for Payer: WPS Commercial |
$1,327.23
|
|
|
XR Venogram Lower Extremity Bilateral
|
Facility
|
OP
|
$1,723.00
|
|
|
Service Code
|
CPT 75822 TC
|
| Hospital Charge Code |
3072721
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$261.33 |
| Max. Negotiated Rate |
$1,648.57 |
| Rate for Payer: Aetna Commercial |
$1,612.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.05
|
| Rate for Payer: Aetna Managed Medicare |
$501.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,164.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$895.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$860.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$949.72
|
| Rate for Payer: Cash Price |
$516.90
|
| Rate for Payer: Cash Price |
$516.90
|
| Rate for Payer: Cigna Commercial |
$1,648.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,002.79
|
| Rate for Payer: Health EOS Commercial |
$1,594.81
|
| Rate for Payer: HFN Commercial |
$1,648.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,343.94
|
| Rate for Payer: Multiplan Commercial |
$1,433.54
|
| Rate for Payer: NAPHCARE Commercial |
$1,075.15
|
| Rate for Payer: Preferred Network Access Commercial |
$1,648.57
|
| Rate for Payer: Quartz Beloit One Network |
$878.04
|
| Rate for Payer: Quartz Commercial |
$1,164.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,075.15
|
| Rate for Payer: The Alliance Commercial |
$261.33
|
| Rate for Payer: WEA Trust Commercial |
$985.56
|
| Rate for Payer: WPS Commercial |
$1,327.23
|
|
|
XR Venogram Lower Extremity Bilateral
|
Professional
|
Both
|
$1,723.00
|
|
|
Service Code
|
CPT 75822 TC
|
| Hospital Charge Code |
3072721
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$65.33 |
| Max. Negotiated Rate |
$1,702.32 |
| Rate for Payer: Aetna Commercial |
$1,702.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.05
|
| Rate for Payer: Aetna Managed Medicare |
$65.33
|
| Rate for Payer: Anthem Medicare Advantage |
$65.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$65.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$65.33
|
| Rate for Payer: Cash Price |
$516.90
|
| Rate for Payer: Cash Price |
$516.90
|
| Rate for Payer: Cash Price |
$516.90
|
| Rate for Payer: Cigna Commercial |
$1,702.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$895.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.33
|
| Rate for Payer: Health EOS Commercial |
$1,630.65
|
| Rate for Payer: HFN Commercial |
$1,702.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$65.33
|
| Rate for Payer: Multiplan Commercial |
$1,433.54
|
| Rate for Payer: NAPHCARE Commercial |
$98.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,702.32
|
| Rate for Payer: Quartz Beloit One Network |
$788.44
|
| Rate for Payer: Quartz Commercial |
$1,021.39
|
| Rate for Payer: Quartz Medicare Advantage |
$65.33
|
| Rate for Payer: The Alliance Commercial |
$248.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$65.33
|
| Rate for Payer: WEA Trust Commercial |
$985.56
|
| Rate for Payer: WPS Commercial |
$326.66
|
|
