|
XR Upper GI + KUB
|
Facility
|
OP
|
$1,103.00
|
|
| Hospital Charge Code |
613596
|
| Min. Negotiated Rate |
$321.19 |
| Max. Negotiated Rate |
$1,055.35 |
| Rate for Payer: Aetna Commercial |
$1,032.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$986.52
|
| Rate for Payer: Aetna Managed Medicare |
$321.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$745.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$573.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$550.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$607.97
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,055.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$641.95
|
| Rate for Payer: Health EOS Commercial |
$1,020.94
|
| Rate for Payer: HFN Commercial |
$1,055.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$860.34
|
| Rate for Payer: Multiplan Commercial |
$917.70
|
| Rate for Payer: NAPHCARE Commercial |
$688.27
|
| Rate for Payer: Preferred Network Access Commercial |
$1,055.35
|
| Rate for Payer: Quartz Beloit One Network |
$562.09
|
| Rate for Payer: Quartz Commercial |
$745.63
|
| Rate for Payer: Quartz Medicare Advantage |
$688.27
|
| Rate for Payer: The Alliance Commercial |
$573.56
|
| Rate for Payer: WEA Trust Commercial |
$630.92
|
| Rate for Payer: WPS Commercial |
$849.64
|
|
|
XR Upper GI + KUB
|
Facility
|
IP
|
$1,103.00
|
|
| Hospital Charge Code |
613596
|
| Min. Negotiated Rate |
$562.09 |
| Max. Negotiated Rate |
$1,055.35 |
| Rate for Payer: Aetna Commercial |
$1,032.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$986.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$607.97
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,055.35
|
| Rate for Payer: Health EOS Commercial |
$1,020.94
|
| Rate for Payer: HFN Commercial |
$1,055.35
|
| Rate for Payer: Multiplan Commercial |
$917.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,055.35
|
| Rate for Payer: Quartz Beloit One Network |
$562.09
|
| Rate for Payer: Quartz Commercial |
$688.27
|
| Rate for Payer: WEA Trust Commercial |
$630.92
|
| Rate for Payer: WPS Commercial |
$849.64
|
|
|
XR Upper GI + KUB
|
Professional
|
Both
|
$1,147.00
|
|
|
Service Code
|
CPT 74240 TC
|
| Hospital Charge Code |
1537441
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.64 |
| Max. Negotiated Rate |
$1,133.24 |
| Rate for Payer: Aetna Commercial |
$1,133.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.88
|
| Rate for Payer: Aetna Managed Medicare |
$83.64
|
| Rate for Payer: Anthem Medicare Advantage |
$83.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$83.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$83.64
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cigna Commercial |
$1,133.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$596.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.64
|
| Rate for Payer: Health EOS Commercial |
$1,085.52
|
| Rate for Payer: HFN Commercial |
$1,133.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$305.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$305.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$83.64
|
| Rate for Payer: Multiplan Commercial |
$954.30
|
| Rate for Payer: NAPHCARE Commercial |
$125.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,133.24
|
| Rate for Payer: Quartz Beloit One Network |
$524.87
|
| Rate for Payer: Quartz Commercial |
$679.94
|
| Rate for Payer: Quartz Medicare Advantage |
$83.64
|
| Rate for Payer: The Alliance Commercial |
$317.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$83.64
|
| Rate for Payer: WEA Trust Commercial |
$656.08
|
| Rate for Payer: WPS Commercial |
$418.18
|
|
|
XR Upper GI + KUB
|
Facility
|
OP
|
$1,147.00
|
|
|
Service Code
|
CPT 74240 TC
|
| Hospital Charge Code |
1537441
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Aetna Commercial |
$1,073.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.88
|
| Rate for Payer: Aetna Managed Medicare |
$334.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$708.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$632.23
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cigna Commercial |
$1,097.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$667.55
|
| Rate for Payer: Health EOS Commercial |
$1,061.66
|
| Rate for Payer: HFN Commercial |
$1,097.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$894.66
|
| Rate for Payer: Multiplan Commercial |
$954.30
|
| Rate for Payer: NAPHCARE Commercial |
$715.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,097.45
|
| Rate for Payer: Quartz Beloit One Network |
$584.51
|
| Rate for Payer: Quartz Commercial |
$775.37
|
| Rate for Payer: Quartz Medicare Advantage |
$715.73
|
| Rate for Payer: The Alliance Commercial |
$334.55
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$656.08
|
| Rate for Payer: WPS Commercial |
$883.53
|
|
|
XR Upper GI + KUB
|
Professional
|
Both
|
$1,103.00
|
|
| Hospital Charge Code |
613596
|
| Min. Negotiated Rate |
$504.73 |
| Max. Negotiated Rate |
$1,089.76 |
| Rate for Payer: Aetna Commercial |
$1,089.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$986.52
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,089.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$573.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$688.27
|
| Rate for Payer: Health EOS Commercial |
$1,043.88
|
| Rate for Payer: HFN Commercial |
$1,089.76
|
| Rate for Payer: Multiplan Commercial |
$917.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,089.76
|
| Rate for Payer: Quartz Beloit One Network |
$504.73
|
| Rate for Payer: Quartz Commercial |
$653.86
|
| Rate for Payer: The Alliance Commercial |
$573.56
|
| Rate for Payer: WEA Trust Commercial |
$630.92
|
| Rate for Payer: WPS Commercial |
$849.64
|
|
|
XR Upper GI + KUB
|
Facility
|
IP
|
$1,147.00
|
|
|
Service Code
|
CPT 74240 TC
|
| Hospital Charge Code |
1537441
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$584.51 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Aetna Commercial |
$1,073.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$632.23
|
| Rate for Payer: Cash Price |
$344.10
|
| Rate for Payer: Cigna Commercial |
$1,097.45
|
| Rate for Payer: Health EOS Commercial |
$1,061.66
|
| Rate for Payer: HFN Commercial |
$1,097.45
|
| Rate for Payer: Multiplan Commercial |
$954.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,097.45
|
| Rate for Payer: Quartz Beloit One Network |
$584.51
|
| Rate for Payer: Quartz Commercial |
$715.73
|
| Rate for Payer: WEA Trust Commercial |
$656.08
|
| Rate for Payer: WPS Commercial |
$883.53
|
|
|
XR Upper GI w/ Air
|
Facility
|
IP
|
$1,221.00
|
|
|
Service Code
|
CPT 74246 TC
|
| Hospital Charge Code |
5597616
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$622.22 |
| Max. Negotiated Rate |
$1,168.25 |
| Rate for Payer: Aetna Commercial |
$1,142.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,092.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$673.02
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,168.25
|
| Rate for Payer: Health EOS Commercial |
$1,130.16
|
| Rate for Payer: HFN Commercial |
$1,168.25
|
| Rate for Payer: Multiplan Commercial |
$1,015.87
|
| Rate for Payer: Preferred Network Access Commercial |
$1,168.25
|
| Rate for Payer: Quartz Beloit One Network |
$622.22
|
| Rate for Payer: Quartz Commercial |
$761.90
|
| Rate for Payer: WEA Trust Commercial |
$698.41
|
| Rate for Payer: WPS Commercial |
$940.54
|
|
|
XR Upper GI w/ Air
|
Facility
|
OP
|
$1,221.00
|
|
|
Service Code
|
CPT 74246 TC
|
| Hospital Charge Code |
5597616
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$1,168.25 |
| Rate for Payer: Aetna Commercial |
$1,142.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,092.06
|
| Rate for Payer: Aetna Managed Medicare |
$355.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$708.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$673.02
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,168.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$710.62
|
| Rate for Payer: Health EOS Commercial |
$1,130.16
|
| Rate for Payer: HFN Commercial |
$1,168.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$952.38
|
| Rate for Payer: Multiplan Commercial |
$1,015.87
|
| Rate for Payer: NAPHCARE Commercial |
$761.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,168.25
|
| Rate for Payer: Quartz Beloit One Network |
$622.22
|
| Rate for Payer: Quartz Commercial |
$825.40
|
| Rate for Payer: Quartz Medicare Advantage |
$761.90
|
| Rate for Payer: The Alliance Commercial |
$369.16
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$698.41
|
| Rate for Payer: WPS Commercial |
$940.54
|
|
|
XR Upper GI w/ Air
|
Professional
|
Both
|
$1,221.00
|
|
|
Service Code
|
CPT 74246 TC
|
| Hospital Charge Code |
5597616
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$92.29 |
| Max. Negotiated Rate |
$1,206.35 |
| Rate for Payer: Aetna Commercial |
$1,206.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,092.06
|
| Rate for Payer: Aetna Managed Medicare |
$92.29
|
| Rate for Payer: Anthem Medicare Advantage |
$92.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$92.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$92.29
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,206.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$634.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.29
|
| Rate for Payer: Health EOS Commercial |
$1,155.55
|
| Rate for Payer: HFN Commercial |
$1,206.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$355.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$355.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$92.29
|
| Rate for Payer: Multiplan Commercial |
$1,015.87
|
| Rate for Payer: NAPHCARE Commercial |
$138.43
|
| Rate for Payer: Preferred Network Access Commercial |
$1,206.35
|
| Rate for Payer: Quartz Beloit One Network |
$558.73
|
| Rate for Payer: Quartz Commercial |
$723.81
|
| Rate for Payer: Quartz Medicare Advantage |
$92.29
|
| Rate for Payer: The Alliance Commercial |
$350.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$92.29
|
| Rate for Payer: WEA Trust Commercial |
$698.41
|
| Rate for Payer: WPS Commercial |
$461.45
|
|
|
XR Upper GI w/ Air Contrast
|
Facility
|
IP
|
$1,174.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
613598
|
| Min. Negotiated Rate |
$598.27 |
| Max. Negotiated Rate |
$1,123.28 |
| Rate for Payer: Aetna Commercial |
$1,098.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$647.11
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cigna Commercial |
$1,123.28
|
| Rate for Payer: Health EOS Commercial |
$1,086.65
|
| Rate for Payer: HFN Commercial |
$1,123.28
|
| Rate for Payer: Multiplan Commercial |
$976.77
|
| Rate for Payer: Preferred Network Access Commercial |
$1,123.28
|
| Rate for Payer: Quartz Beloit One Network |
$598.27
|
| Rate for Payer: Quartz Commercial |
$732.58
|
| Rate for Payer: WEA Trust Commercial |
$671.53
|
| Rate for Payer: WPS Commercial |
$904.33
|
|
|
XR Upper GI w/ Air Contrast
|
Professional
|
Both
|
$1,269.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
1537443
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$134.04 |
| Max. Negotiated Rate |
$1,253.77 |
| Rate for Payer: Aetna Commercial |
$1,253.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,134.99
|
| Rate for Payer: Aetna Managed Medicare |
$134.04
|
| Rate for Payer: Anthem Medicare Advantage |
$134.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$134.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$134.04
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cigna Commercial |
$1,253.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$659.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.04
|
| Rate for Payer: Health EOS Commercial |
$1,200.98
|
| Rate for Payer: HFN Commercial |
$1,253.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$510.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$510.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$134.04
|
| Rate for Payer: Multiplan Commercial |
$1,055.81
|
| Rate for Payer: NAPHCARE Commercial |
$201.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,253.77
|
| Rate for Payer: Quartz Beloit One Network |
$580.69
|
| Rate for Payer: Quartz Commercial |
$752.26
|
| Rate for Payer: Quartz Medicare Advantage |
$134.04
|
| Rate for Payer: The Alliance Commercial |
$509.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$134.04
|
| Rate for Payer: WEA Trust Commercial |
$725.87
|
| Rate for Payer: WPS Commercial |
$670.18
|
|
|
XR Upper GI w/ Air Contrast
|
Facility
|
IP
|
$1,269.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
1537443
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$646.68 |
| Max. Negotiated Rate |
$1,214.18 |
| Rate for Payer: Aetna Commercial |
$1,187.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,134.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$699.47
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cigna Commercial |
$1,214.18
|
| Rate for Payer: Health EOS Commercial |
$1,174.59
|
| Rate for Payer: HFN Commercial |
$1,214.18
|
| Rate for Payer: Multiplan Commercial |
$1,055.81
|
| Rate for Payer: Preferred Network Access Commercial |
$1,214.18
|
| Rate for Payer: Quartz Beloit One Network |
$646.68
|
| Rate for Payer: Quartz Commercial |
$791.86
|
| Rate for Payer: WEA Trust Commercial |
$725.87
|
| Rate for Payer: WPS Commercial |
$977.51
|
|
|
XR Upper GI w/ Air Contrast
|
Facility
|
OP
|
$1,269.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
1537443
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$184.59 |
| Max. Negotiated Rate |
$1,214.18 |
| Rate for Payer: Aetna Commercial |
$1,187.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,134.99
|
| Rate for Payer: Aetna Managed Medicare |
$184.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$708.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.26
|
| Rate for Payer: Anthem Medicare Advantage |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$699.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$184.59
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cigna Commercial |
$1,214.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$184.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$738.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$184.59
|
| Rate for Payer: Health EOS Commercial |
$1,174.59
|
| Rate for Payer: HFN Commercial |
$1,214.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$184.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$184.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$184.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$184.59
|
| Rate for Payer: Multiplan Commercial |
$1,055.81
|
| Rate for Payer: NAPHCARE Commercial |
$276.88
|
| Rate for Payer: Preferred Network Access Commercial |
$1,214.18
|
| Rate for Payer: Quartz Beloit One Network |
$646.68
|
| Rate for Payer: Quartz Commercial |
$857.84
|
| Rate for Payer: Quartz Medicare Advantage |
$184.59
|
| Rate for Payer: The Alliance Commercial |
$738.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$184.59
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$725.87
|
| Rate for Payer: Wellcare Medicare |
$184.59
|
| Rate for Payer: WPS Commercial |
$977.51
|
|
|
XR Upper GI w/ Air Contrast
|
Professional
|
Both
|
$1,174.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
613598
|
| Min. Negotiated Rate |
$134.04 |
| Max. Negotiated Rate |
$1,159.91 |
| Rate for Payer: Aetna Commercial |
$1,159.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.03
|
| Rate for Payer: Aetna Managed Medicare |
$134.04
|
| Rate for Payer: Anthem Medicare Advantage |
$134.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$134.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$134.04
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cigna Commercial |
$1,159.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$610.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.04
|
| Rate for Payer: Health EOS Commercial |
$1,111.07
|
| Rate for Payer: HFN Commercial |
$1,159.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$510.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$510.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$134.04
|
| Rate for Payer: Multiplan Commercial |
$976.77
|
| Rate for Payer: NAPHCARE Commercial |
$201.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.91
|
| Rate for Payer: Quartz Beloit One Network |
$537.22
|
| Rate for Payer: Quartz Commercial |
$695.95
|
| Rate for Payer: Quartz Medicare Advantage |
$134.04
|
| Rate for Payer: The Alliance Commercial |
$509.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$134.04
|
| Rate for Payer: WEA Trust Commercial |
$671.53
|
| Rate for Payer: WPS Commercial |
$670.18
|
|
|
XR Upper GI w/ Air Contrast
|
Facility
|
OP
|
$1,174.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
613598
|
| Min. Negotiated Rate |
$184.59 |
| Max. Negotiated Rate |
$1,123.28 |
| Rate for Payer: Aetna Commercial |
$1,098.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.03
|
| Rate for Payer: Aetna Managed Medicare |
$184.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$793.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$610.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$586.06
|
| Rate for Payer: Anthem Medicare Advantage |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$647.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$184.59
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cigna Commercial |
$1,123.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$184.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$683.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$184.59
|
| Rate for Payer: Health EOS Commercial |
$1,086.65
|
| Rate for Payer: HFN Commercial |
$1,123.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$184.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$184.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$184.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$184.59
|
| Rate for Payer: Multiplan Commercial |
$976.77
|
| Rate for Payer: NAPHCARE Commercial |
$276.88
|
| Rate for Payer: Preferred Network Access Commercial |
$1,123.28
|
| Rate for Payer: Quartz Beloit One Network |
$598.27
|
| Rate for Payer: Quartz Commercial |
$793.62
|
| Rate for Payer: Quartz Medicare Advantage |
$184.59
|
| Rate for Payer: The Alliance Commercial |
$738.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$184.59
|
| Rate for Payer: WEA Trust Commercial |
$671.53
|
| Rate for Payer: Wellcare Medicare |
$184.59
|
| Rate for Payer: WPS Commercial |
$904.33
|
|
|
XR Upper GI w/ Air Contrast + KUB
|
Professional
|
Both
|
$1,229.00
|
|
| Hospital Charge Code |
613600
|
| Min. Negotiated Rate |
$562.39 |
| Max. Negotiated Rate |
$1,214.25 |
| Rate for Payer: Aetna Commercial |
$1,214.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,099.22
|
| Rate for Payer: Cash Price |
$368.70
|
| Rate for Payer: Cigna Commercial |
$1,214.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$639.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$766.90
|
| Rate for Payer: Health EOS Commercial |
$1,163.13
|
| Rate for Payer: HFN Commercial |
$1,214.25
|
| Rate for Payer: Multiplan Commercial |
$1,022.53
|
| Rate for Payer: Preferred Network Access Commercial |
$1,214.25
|
| Rate for Payer: Quartz Beloit One Network |
$562.39
|
| Rate for Payer: Quartz Commercial |
$728.55
|
| Rate for Payer: The Alliance Commercial |
$639.08
|
| Rate for Payer: WEA Trust Commercial |
$702.99
|
| Rate for Payer: WPS Commercial |
$946.70
|
|
|
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 |
$651.27 |
| Max. Negotiated Rate |
$1,222.79 |
| Rate for Payer: Aetna Commercial |
$1,196.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,143.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$704.43
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$1,222.79
|
| Rate for Payer: Health EOS Commercial |
$1,182.92
|
| Rate for Payer: HFN Commercial |
$1,222.79
|
| Rate for Payer: Multiplan Commercial |
$1,063.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,222.79
|
| Rate for Payer: Quartz Beloit One Network |
$651.27
|
| Rate for Payer: Quartz Commercial |
$797.47
|
| Rate for Payer: WEA Trust Commercial |
$731.02
|
| Rate for Payer: WPS Commercial |
$984.44
|
|
|
XR Upper GI w/ Air Contrast + KUB
|
Facility
|
OP
|
$1,278.00
|
|
|
Service Code
|
CPT 74246 TC
|
| Hospital Charge Code |
1537445
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$1,222.79 |
| Rate for Payer: Aetna Commercial |
$1,196.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,143.04
|
| Rate for Payer: Aetna Managed Medicare |
$372.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$708.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$704.43
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$1,222.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$743.80
|
| Rate for Payer: Health EOS Commercial |
$1,182.92
|
| Rate for Payer: HFN Commercial |
$1,222.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$996.84
|
| Rate for Payer: Multiplan Commercial |
$1,063.30
|
| Rate for Payer: NAPHCARE Commercial |
$797.47
|
| Rate for Payer: Preferred Network Access Commercial |
$1,222.79
|
| Rate for Payer: Quartz Beloit One Network |
$651.27
|
| Rate for Payer: Quartz Commercial |
$863.93
|
| Rate for Payer: Quartz Medicare Advantage |
$797.47
|
| Rate for Payer: The Alliance Commercial |
$369.16
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$731.02
|
| Rate for Payer: WPS Commercial |
$984.44
|
|
|
XR Upper GI w/ Air Contrast + KUB
|
Facility
|
OP
|
$1,229.00
|
|
| Hospital Charge Code |
613600
|
| Min. Negotiated Rate |
$357.88 |
| Max. Negotiated Rate |
$1,175.91 |
| Rate for Payer: Aetna Commercial |
$1,150.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,099.22
|
| Rate for Payer: Aetna Managed Medicare |
$357.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$830.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$639.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$613.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$677.42
|
| Rate for Payer: Cash Price |
$368.70
|
| Rate for Payer: Cigna Commercial |
$1,175.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$715.28
|
| Rate for Payer: Health EOS Commercial |
$1,137.56
|
| Rate for Payer: HFN Commercial |
$1,175.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$958.62
|
| Rate for Payer: Multiplan Commercial |
$1,022.53
|
| Rate for Payer: NAPHCARE Commercial |
$766.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,175.91
|
| Rate for Payer: Quartz Beloit One Network |
$626.30
|
| Rate for Payer: Quartz Commercial |
$830.80
|
| Rate for Payer: Quartz Medicare Advantage |
$766.90
|
| Rate for Payer: The Alliance Commercial |
$639.08
|
| Rate for Payer: WEA Trust Commercial |
$702.99
|
| Rate for Payer: WPS Commercial |
$946.70
|
|
|
XR Upper GI w/ Air Contrast + KUB
|
Facility
|
IP
|
$1,229.00
|
|
| Hospital Charge Code |
613600
|
| Min. Negotiated Rate |
$626.30 |
| Max. Negotiated Rate |
$1,175.91 |
| Rate for Payer: Aetna Commercial |
$1,150.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,099.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$677.42
|
| Rate for Payer: Cash Price |
$368.70
|
| Rate for Payer: Cigna Commercial |
$1,175.91
|
| Rate for Payer: Health EOS Commercial |
$1,137.56
|
| Rate for Payer: HFN Commercial |
$1,175.91
|
| Rate for Payer: Multiplan Commercial |
$1,022.53
|
| Rate for Payer: Preferred Network Access Commercial |
$1,175.91
|
| Rate for Payer: Quartz Beloit One Network |
$626.30
|
| Rate for Payer: Quartz Commercial |
$766.90
|
| Rate for Payer: WEA Trust Commercial |
$702.99
|
| Rate for Payer: WPS Commercial |
$946.70
|
|
|
XR Upper GI w/ Air Contrast + KUB
|
Professional
|
Both
|
$1,278.00
|
|
|
Service Code
|
CPT 74246 TC
|
| Hospital Charge Code |
1537445
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$92.29 |
| Max. Negotiated Rate |
$1,262.66 |
| Rate for Payer: Aetna Commercial |
$1,262.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,143.04
|
| Rate for Payer: Aetna Managed Medicare |
$92.29
|
| Rate for Payer: Anthem Medicare Advantage |
$92.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$92.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$92.29
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$1,262.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$664.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.29
|
| Rate for Payer: Health EOS Commercial |
$1,209.50
|
| Rate for Payer: HFN Commercial |
$1,262.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$355.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$355.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$92.29
|
| Rate for Payer: Multiplan Commercial |
$1,063.30
|
| Rate for Payer: NAPHCARE Commercial |
$138.43
|
| Rate for Payer: Preferred Network Access Commercial |
$1,262.66
|
| Rate for Payer: Quartz Beloit One Network |
$584.81
|
| Rate for Payer: Quartz Commercial |
$757.60
|
| Rate for Payer: Quartz Medicare Advantage |
$92.29
|
| Rate for Payer: The Alliance Commercial |
$350.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$92.29
|
| Rate for Payer: WEA Trust Commercial |
$731.02
|
| Rate for Payer: WPS Commercial |
$461.45
|
|
|
XR Upper GI w/ Air w/ Small Bowel
|
Professional
|
Both
|
$1,824.00
|
|
| Hospital Charge Code |
613602
|
| Min. Negotiated Rate |
$834.66 |
| Max. Negotiated Rate |
$1,802.11 |
| Rate for Payer: Aetna Commercial |
$1,802.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,631.39
|
| Rate for Payer: Cash Price |
$547.20
|
| Rate for Payer: Cigna Commercial |
$1,802.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$948.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,138.18
|
| Rate for Payer: Health EOS Commercial |
$1,726.23
|
| Rate for Payer: HFN Commercial |
$1,802.11
|
| Rate for Payer: Multiplan Commercial |
$1,517.57
|
| Rate for Payer: Preferred Network Access Commercial |
$1,802.11
|
| Rate for Payer: Quartz Beloit One Network |
$834.66
|
| Rate for Payer: Quartz Commercial |
$1,081.27
|
| Rate for Payer: The Alliance Commercial |
$948.48
|
| Rate for Payer: WEA Trust Commercial |
$1,043.33
|
| Rate for Payer: WPS Commercial |
$1,405.03
|
|
|
XR Upper GI w/ Air w/ Small Bowel
|
Professional
|
Both
|
$985.00
|
|
|
Service Code
|
CPT 74248 TC
|
| Hospital Charge Code |
1537447
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$47.03 |
| Max. Negotiated Rate |
$973.18 |
| Rate for Payer: Aetna Commercial |
$973.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$880.98
|
| Rate for Payer: Aetna Managed Medicare |
$47.03
|
| Rate for Payer: Anthem Medicare Advantage |
$47.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.03
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cigna Commercial |
$973.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$512.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.03
|
| Rate for Payer: Health EOS Commercial |
$932.20
|
| Rate for Payer: HFN Commercial |
$973.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$180.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.03
|
| Rate for Payer: Multiplan Commercial |
$819.52
|
| Rate for Payer: NAPHCARE Commercial |
$70.54
|
| Rate for Payer: Preferred Network Access Commercial |
$973.18
|
| Rate for Payer: Quartz Beloit One Network |
$450.74
|
| Rate for Payer: Quartz Commercial |
$583.91
|
| Rate for Payer: Quartz Medicare Advantage |
$47.03
|
| Rate for Payer: The Alliance Commercial |
$178.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.03
|
| Rate for Payer: WEA Trust Commercial |
$563.42
|
| Rate for Payer: WPS Commercial |
$235.14
|
|
|
XR Upper GI w/ Air w/ Small Bowel
|
Facility
|
IP
|
$985.00
|
|
|
Service Code
|
CPT 74248 TC
|
| Hospital Charge Code |
1537447
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$501.96 |
| Max. Negotiated Rate |
$942.45 |
| Rate for Payer: Aetna Commercial |
$921.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$880.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$542.93
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cigna Commercial |
$942.45
|
| Rate for Payer: Health EOS Commercial |
$911.72
|
| Rate for Payer: HFN Commercial |
$942.45
|
| Rate for Payer: Multiplan Commercial |
$819.52
|
| Rate for Payer: Preferred Network Access Commercial |
$942.45
|
| Rate for Payer: Quartz Beloit One Network |
$501.96
|
| Rate for Payer: Quartz Commercial |
$614.64
|
| Rate for Payer: WEA Trust Commercial |
$563.42
|
| Rate for Payer: WPS Commercial |
$758.75
|
|
|
XR Upper GI w/ Air w/ Small Bowel
|
Facility
|
OP
|
$985.00
|
|
|
Service Code
|
CPT 74248 TC
|
| Hospital Charge Code |
1537447
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$188.12 |
| Max. Negotiated Rate |
$942.45 |
| Rate for Payer: Aetna Commercial |
$921.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$880.98
|
| Rate for Payer: Aetna Managed Medicare |
$286.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$665.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$512.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$491.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$542.93
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cash Price |
$295.50
|
| Rate for Payer: Cigna Commercial |
$942.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$573.27
|
| Rate for Payer: Health EOS Commercial |
$911.72
|
| Rate for Payer: HFN Commercial |
$942.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$768.30
|
| Rate for Payer: Multiplan Commercial |
$819.52
|
| Rate for Payer: NAPHCARE Commercial |
$614.64
|
| Rate for Payer: Preferred Network Access Commercial |
$942.45
|
| Rate for Payer: Quartz Beloit One Network |
$501.96
|
| Rate for Payer: Quartz Commercial |
$665.86
|
| Rate for Payer: Quartz Medicare Advantage |
$614.64
|
| Rate for Payer: The Alliance Commercial |
$188.12
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$563.42
|
| Rate for Payer: WPS Commercial |
$758.75
|
|
