|
XR Upper Extremity Infant Right
|
Facility
|
IP
|
$470.00
|
|
|
Service Code
|
CPT 73092
|
| Hospital Charge Code |
613592
|
| Min. Negotiated Rate |
$230.30 |
| Max. Negotiated Rate |
$432.40 |
| Rate for Payer: Aetna Commercial |
$423.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.10
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$432.40
|
| Rate for Payer: Health EOS Commercial |
$418.30
|
| Rate for Payer: HFN Commercial |
$432.40
|
| Rate for Payer: Multiplan Commercial |
$376.00
|
| Rate for Payer: NAPHCARE Commercial |
$282.00
|
| Rate for Payer: Preferred Network Access Commercial |
$432.40
|
| Rate for Payer: Quartz Beloit One Network |
$230.30
|
| Rate for Payer: Quartz Commercial |
$282.00
|
| Rate for Payer: WEA Trust Commercial |
$258.50
|
| Rate for Payer: WPS Commercial |
$348.13
|
|
|
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 |
$248.92 |
| Max. Negotiated Rate |
$467.36 |
| Rate for Payer: Aetna Commercial |
$457.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$269.24
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$467.36
|
| Rate for Payer: Health EOS Commercial |
$452.12
|
| Rate for Payer: HFN Commercial |
$467.36
|
| Rate for Payer: Multiplan Commercial |
$406.40
|
| Rate for Payer: NAPHCARE Commercial |
$304.80
|
| Rate for Payer: Preferred Network Access Commercial |
$467.36
|
| Rate for Payer: Quartz Beloit One Network |
$248.92
|
| Rate for Payer: Quartz Commercial |
$304.80
|
| Rate for Payer: WEA Trust Commercial |
$279.40
|
| Rate for Payer: WPS Commercial |
$376.28
|
|
|
XR Upper Extremity Infant Right
|
Professional
|
Both
|
$470.00
|
|
|
Service Code
|
CPT 73092
|
| Hospital Charge Code |
613592
|
| Min. Negotiated Rate |
$106.29 |
| Max. Negotiated Rate |
$446.50 |
| Rate for Payer: Aetna Commercial |
$446.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.20
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$446.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$235.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$282.00
|
| Rate for Payer: Health EOS Commercial |
$427.70
|
| Rate for Payer: HFN Commercial |
$446.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$106.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$106.29
|
| Rate for Payer: Multiplan Commercial |
$376.00
|
| Rate for Payer: Preferred Network Access Commercial |
$446.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.80
|
| Rate for Payer: Quartz Commercial |
$267.90
|
| Rate for Payer: The Alliance Commercial |
$235.00
|
| Rate for Payer: WEA Trust Commercial |
$258.50
|
| Rate for Payer: WPS Commercial |
$348.13
|
|
|
XR Upper GI
|
Facility
|
IP
|
$1,092.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
613594
|
| Min. Negotiated Rate |
$535.08 |
| Max. Negotiated Rate |
$1,004.64 |
| Rate for Payer: Aetna Commercial |
$982.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$939.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$578.76
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,004.64
|
| Rate for Payer: Health EOS Commercial |
$971.88
|
| Rate for Payer: HFN Commercial |
$1,004.64
|
| Rate for Payer: Multiplan Commercial |
$873.60
|
| Rate for Payer: NAPHCARE Commercial |
$655.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,004.64
|
| Rate for Payer: Quartz Beloit One Network |
$535.08
|
| Rate for Payer: Quartz Commercial |
$655.20
|
| Rate for Payer: WEA Trust Commercial |
$600.60
|
| Rate for Payer: WPS Commercial |
$808.84
|
|
|
XR Upper GI
|
Facility
|
OP
|
$1,092.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
613594
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$1,004.64 |
| Rate for Payer: Aetna Commercial |
$982.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$939.12
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$709.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$546.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$524.16
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$578.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,004.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$611.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$971.88
|
| Rate for Payer: HFN Commercial |
$1,004.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$873.60
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,004.64
|
| Rate for Payer: Quartz Beloit One Network |
$535.08
|
| Rate for Payer: Quartz Commercial |
$709.80
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$726.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: WEA Trust Commercial |
$600.60
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$808.84
|
|
|
XR Upper GI
|
Professional
|
Both
|
$1,156.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537439
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$427.55 |
| Max. Negotiated Rate |
$1,098.20 |
| Rate for Payer: Aetna Commercial |
$1,098.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$994.16
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,098.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$578.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$693.60
|
| Rate for Payer: Health EOS Commercial |
$1,051.96
|
| Rate for Payer: HFN Commercial |
$1,098.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$427.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$427.55
|
| Rate for Payer: Multiplan Commercial |
$924.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,098.20
|
| Rate for Payer: Quartz Beloit One Network |
$508.64
|
| Rate for Payer: Quartz Commercial |
$658.92
|
| Rate for Payer: The Alliance Commercial |
$578.00
|
| Rate for Payer: WEA Trust Commercial |
$635.80
|
| Rate for Payer: WPS Commercial |
$856.25
|
|
|
XR Upper GI
|
Facility
|
IP
|
$1,156.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537439
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$566.44 |
| Max. Negotiated Rate |
$1,063.52 |
| Rate for Payer: Aetna Commercial |
$1,040.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$994.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$612.68
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,063.52
|
| Rate for Payer: Health EOS Commercial |
$1,028.84
|
| Rate for Payer: HFN Commercial |
$1,063.52
|
| Rate for Payer: Multiplan Commercial |
$924.80
|
| Rate for Payer: NAPHCARE Commercial |
$693.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,063.52
|
| Rate for Payer: Quartz Beloit One Network |
$566.44
|
| Rate for Payer: Quartz Commercial |
$693.60
|
| Rate for Payer: WEA Trust Commercial |
$635.80
|
| Rate for Payer: WPS Commercial |
$856.25
|
|
|
XR Upper GI
|
Professional
|
Both
|
$1,092.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
613594
|
| Min. Negotiated Rate |
$427.55 |
| Max. Negotiated Rate |
$1,037.40 |
| Rate for Payer: Aetna Commercial |
$1,037.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$939.12
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,037.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$546.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$655.20
|
| Rate for Payer: Health EOS Commercial |
$993.72
|
| Rate for Payer: HFN Commercial |
$1,037.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$427.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$427.55
|
| Rate for Payer: Multiplan Commercial |
$873.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.40
|
| Rate for Payer: Quartz Beloit One Network |
$480.48
|
| Rate for Payer: Quartz Commercial |
$622.44
|
| Rate for Payer: The Alliance Commercial |
$546.00
|
| Rate for Payer: WEA Trust Commercial |
$600.60
|
| Rate for Payer: WPS Commercial |
$808.84
|
|
|
XR Upper GI
|
Facility
|
OP
|
$1,156.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1537439
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$1,063.52 |
| Rate for Payer: Aetna Commercial |
$1,040.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$994.16
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$681.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$544.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$517.56
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$612.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| 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 |
$1,063.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$646.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$1,028.84
|
| Rate for Payer: HFN Commercial |
$1,063.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$924.80
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,063.52
|
| Rate for Payer: Quartz Beloit One Network |
$566.44
|
| Rate for Payer: Quartz Commercial |
$751.40
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$726.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$635.80
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$856.25
|
|
|
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 |
$293.91 |
| Max. Negotiated Rate |
$1,089.65 |
| Rate for Payer: Aetna Commercial |
$1,089.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$986.42
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cigna Commercial |
$1,089.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$573.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$688.20
|
| Rate for Payer: Health EOS Commercial |
$1,043.77
|
| Rate for Payer: HFN Commercial |
$1,089.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$293.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$293.91
|
| Rate for Payer: Multiplan Commercial |
$917.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,089.65
|
| Rate for Payer: Quartz Beloit One Network |
$504.68
|
| Rate for Payer: Quartz Commercial |
$653.79
|
| Rate for Payer: The Alliance Commercial |
$573.50
|
| Rate for Payer: WEA Trust Commercial |
$630.85
|
| Rate for Payer: WPS Commercial |
$849.58
|
|
|
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 |
$562.03 |
| Max. Negotiated Rate |
$1,055.24 |
| Rate for Payer: Aetna Commercial |
$1,032.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$986.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$607.91
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cigna Commercial |
$1,055.24
|
| Rate for Payer: Health EOS Commercial |
$1,020.83
|
| Rate for Payer: HFN Commercial |
$1,055.24
|
| Rate for Payer: Multiplan Commercial |
$917.60
|
| Rate for Payer: NAPHCARE Commercial |
$688.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,055.24
|
| Rate for Payer: Quartz Beloit One Network |
$562.03
|
| Rate for Payer: Quartz Commercial |
$688.20
|
| Rate for Payer: WEA Trust Commercial |
$630.85
|
| Rate for Payer: WPS Commercial |
$849.58
|
|
|
XR Upper GI + KUB
|
Facility
|
IP
|
$1,103.00
|
|
| Hospital Charge Code |
613596
|
| Min. Negotiated Rate |
$540.47 |
| Max. Negotiated Rate |
$1,014.76 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$661.80
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
XR Upper GI + KUB
|
Facility
|
OP
|
$1,103.00
|
|
| Hospital Charge Code |
613596
|
| Min. Negotiated Rate |
$308.84 |
| Max. Negotiated Rate |
$4,412.00 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Aetna Managed Medicare |
$308.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$716.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$551.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$529.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$617.24
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$827.25
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$716.95
|
| Rate for Payer: Quartz Medicare Advantage |
$661.80
|
| Rate for Payer: The Alliance Commercial |
$4,412.00
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
XR Upper GI + KUB
|
Professional
|
Both
|
$1,103.00
|
|
| Hospital Charge Code |
613596
|
| Min. Negotiated Rate |
$485.32 |
| Max. Negotiated Rate |
$1,047.85 |
| Rate for Payer: Aetna Commercial |
$1,047.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,047.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$551.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$661.80
|
| Rate for Payer: Health EOS Commercial |
$1,003.73
|
| Rate for Payer: HFN Commercial |
$1,047.85
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,047.85
|
| Rate for Payer: Quartz Beloit One Network |
$485.32
|
| Rate for Payer: Quartz Commercial |
$628.71
|
| Rate for Payer: The Alliance Commercial |
$551.50
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
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 |
$301.00 |
| Max. Negotiated Rate |
$4,588.00 |
| Rate for Payer: Aetna Commercial |
$1,032.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$986.42
|
| Rate for Payer: Aetna Managed Medicare |
$321.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$745.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$573.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$550.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$607.91
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cigna Commercial |
$1,055.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$641.86
|
| Rate for Payer: Health EOS Commercial |
$1,020.83
|
| Rate for Payer: HFN Commercial |
$1,055.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$860.25
|
| Rate for Payer: Multiplan Commercial |
$917.60
|
| Rate for Payer: NAPHCARE Commercial |
$688.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,055.24
|
| Rate for Payer: Quartz Beloit One Network |
$562.03
|
| Rate for Payer: Quartz Commercial |
$745.55
|
| Rate for Payer: Quartz Medicare Advantage |
$688.20
|
| Rate for Payer: The Alliance Commercial |
$4,588.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$630.85
|
| Rate for Payer: WPS Commercial |
$849.58
|
|
|
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 |
$598.29 |
| Max. Negotiated Rate |
$1,123.32 |
| Rate for Payer: Aetna Commercial |
$1,098.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$647.13
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,123.32
|
| Rate for Payer: Health EOS Commercial |
$1,086.69
|
| Rate for Payer: HFN Commercial |
$1,123.32
|
| Rate for Payer: Multiplan Commercial |
$976.80
|
| Rate for Payer: NAPHCARE Commercial |
$732.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,123.32
|
| Rate for Payer: Quartz Beloit One Network |
$598.29
|
| Rate for Payer: Quartz Commercial |
$732.60
|
| Rate for Payer: WEA Trust Commercial |
$671.55
|
| Rate for Payer: WPS Commercial |
$904.39
|
|
|
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 |
$301.00 |
| Max. Negotiated Rate |
$4,884.00 |
| Rate for Payer: Aetna Commercial |
$1,098.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.06
|
| Rate for Payer: Aetna Managed Medicare |
$341.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$793.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$610.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$586.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$647.13
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,123.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$683.27
|
| Rate for Payer: Health EOS Commercial |
$1,086.69
|
| Rate for Payer: HFN Commercial |
$1,123.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$915.75
|
| Rate for Payer: Multiplan Commercial |
$976.80
|
| Rate for Payer: NAPHCARE Commercial |
$732.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,123.32
|
| Rate for Payer: Quartz Beloit One Network |
$598.29
|
| Rate for Payer: Quartz Commercial |
$793.65
|
| Rate for Payer: Quartz Medicare Advantage |
$732.60
|
| Rate for Payer: The Alliance Commercial |
$4,884.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$671.55
|
| Rate for Payer: WPS Commercial |
$904.39
|
|
|
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 |
$341.46 |
| Max. Negotiated Rate |
$1,159.95 |
| Rate for Payer: Aetna Commercial |
$1,159.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.06
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,159.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$610.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$732.60
|
| Rate for Payer: Health EOS Commercial |
$1,111.11
|
| Rate for Payer: HFN Commercial |
$1,159.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$341.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$341.46
|
| Rate for Payer: Multiplan Commercial |
$976.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.95
|
| Rate for Payer: Quartz Beloit One Network |
$537.24
|
| Rate for Payer: Quartz Commercial |
$695.97
|
| Rate for Payer: The Alliance Commercial |
$610.50
|
| Rate for Payer: WEA Trust Commercial |
$671.55
|
| Rate for Payer: WPS Commercial |
$904.39
|
|
|
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 |
$181.60 |
| Max. Negotiated Rate |
$1,167.48 |
| Rate for Payer: Aetna Commercial |
$1,142.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,091.34
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$681.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$544.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$517.56
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$672.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| 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 |
$1,167.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$710.13
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$1,129.41
|
| Rate for Payer: HFN Commercial |
$1,167.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$1,015.20
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,167.48
|
| Rate for Payer: Quartz Beloit One Network |
$621.81
|
| Rate for Payer: Quartz Commercial |
$824.85
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$726.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$697.95
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$939.95
|
|
|
XR Upper GI w/ Air Contrast
|
Professional
|
Both
|
$1,174.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
613598
|
| Min. Negotiated Rate |
$490.92 |
| Max. Negotiated Rate |
$1,115.30 |
| Rate for Payer: Aetna Commercial |
$1,115.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,009.64
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cigna Commercial |
$1,115.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$587.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$704.40
|
| Rate for Payer: Health EOS Commercial |
$1,068.34
|
| Rate for Payer: HFN Commercial |
$1,115.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$490.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$490.92
|
| Rate for Payer: Multiplan Commercial |
$939.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.30
|
| Rate for Payer: Quartz Beloit One Network |
$516.56
|
| Rate for Payer: Quartz Commercial |
$669.18
|
| Rate for Payer: The Alliance Commercial |
$587.00
|
| Rate for Payer: WEA Trust Commercial |
$645.70
|
| Rate for Payer: WPS Commercial |
$869.58
|
|
|
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 |
$621.81 |
| Max. Negotiated Rate |
$1,167.48 |
| Rate for Payer: Aetna Commercial |
$1,142.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,091.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$672.57
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cigna Commercial |
$1,167.48
|
| Rate for Payer: Health EOS Commercial |
$1,129.41
|
| Rate for Payer: HFN Commercial |
$1,167.48
|
| Rate for Payer: Multiplan Commercial |
$1,015.20
|
| Rate for Payer: NAPHCARE Commercial |
$761.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,167.48
|
| Rate for Payer: Quartz Beloit One Network |
$621.81
|
| Rate for Payer: Quartz Commercial |
$761.40
|
| Rate for Payer: WEA Trust Commercial |
$697.95
|
| Rate for Payer: WPS Commercial |
$939.95
|
|
|
XR Upper GI w/ Air Contrast
|
Facility
|
IP
|
$1,174.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
613598
|
| Min. Negotiated Rate |
$575.26 |
| Max. Negotiated Rate |
$1,080.08 |
| Rate for Payer: Aetna Commercial |
$1,056.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,009.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$622.22
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cigna Commercial |
$1,080.08
|
| Rate for Payer: Health EOS Commercial |
$1,044.86
|
| Rate for Payer: HFN Commercial |
$1,080.08
|
| Rate for Payer: Multiplan Commercial |
$939.20
|
| Rate for Payer: NAPHCARE Commercial |
$704.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,080.08
|
| Rate for Payer: Quartz Beloit One Network |
$575.26
|
| Rate for Payer: Quartz Commercial |
$704.40
|
| Rate for Payer: WEA Trust Commercial |
$645.70
|
| Rate for Payer: WPS Commercial |
$869.58
|
|
|
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 |
$490.92 |
| Max. Negotiated Rate |
$1,205.55 |
| Rate for Payer: Aetna Commercial |
$1,205.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,091.34
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cigna Commercial |
$1,205.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$634.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$761.40
|
| Rate for Payer: Health EOS Commercial |
$1,154.79
|
| Rate for Payer: HFN Commercial |
$1,205.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$490.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$490.92
|
| Rate for Payer: Multiplan Commercial |
$1,015.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,205.55
|
| Rate for Payer: Quartz Beloit One Network |
$558.36
|
| Rate for Payer: Quartz Commercial |
$723.33
|
| Rate for Payer: The Alliance Commercial |
$634.50
|
| Rate for Payer: WEA Trust Commercial |
$697.95
|
| Rate for Payer: WPS Commercial |
$939.95
|
|
|
XR Upper GI w/ Air Contrast
|
Facility
|
OP
|
$1,174.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
613598
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$1,080.08 |
| Rate for Payer: Aetna Commercial |
$1,056.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,009.64
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$763.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$587.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$563.52
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$622.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cigna Commercial |
$1,080.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$656.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$1,044.86
|
| Rate for Payer: HFN Commercial |
$1,080.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$939.20
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,080.08
|
| Rate for Payer: Quartz Beloit One Network |
$575.26
|
| Rate for Payer: Quartz Commercial |
$763.10
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$726.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: WEA Trust Commercial |
$645.70
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$869.58
|
|
|
XR Upper GI w/ Air Contrast + KUB
|
Facility
|
IP
|
$1,278.00
|
|
|
Service Code
|
CPT 74246 TC
|
| Hospital Charge Code |
1537445
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$626.22 |
| Max. Negotiated Rate |
$1,175.76 |
| Rate for Payer: Aetna Commercial |
$1,150.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,099.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$677.34
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$1,175.76
|
| Rate for Payer: Health EOS Commercial |
$1,137.42
|
| Rate for Payer: HFN Commercial |
$1,175.76
|
| Rate for Payer: Multiplan Commercial |
$1,022.40
|
| Rate for Payer: NAPHCARE Commercial |
$766.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,175.76
|
| Rate for Payer: Quartz Beloit One Network |
$626.22
|
| Rate for Payer: Quartz Commercial |
$766.80
|
| Rate for Payer: WEA Trust Commercial |
$702.90
|
| Rate for Payer: WPS Commercial |
$946.61
|
|
