|
XR Ureteral Cath/Stent Place Right
|
Professional
|
Both
|
$588.00
|
|
|
Service Code
|
CPT 74021 TC,RT
|
| Hospital Charge Code |
5577652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$151.18 |
| Max. Negotiated Rate |
$580.94 |
| Rate for Payer: Aetna Commercial |
$580.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.91
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$580.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$305.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$366.91
|
| Rate for Payer: Health EOS Commercial |
$556.48
|
| Rate for Payer: HFN Commercial |
$580.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$151.18
|
| Rate for Payer: Multiplan Commercial |
$489.22
|
| Rate for Payer: Preferred Network Access Commercial |
$580.94
|
| Rate for Payer: Quartz Beloit One Network |
$269.07
|
| Rate for Payer: Quartz Commercial |
$348.57
|
| Rate for Payer: The Alliance Commercial |
$305.76
|
| Rate for Payer: WEA Trust Commercial |
$336.34
|
| Rate for Payer: WPS Commercial |
$452.94
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
|
IP
|
$565.00
|
|
|
Service Code
|
CPT 74020
|
| Hospital Charge Code |
2448819
|
| Min. Negotiated Rate |
$287.92 |
| Max. Negotiated Rate |
$540.59 |
| Rate for Payer: Aetna Commercial |
$528.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$505.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.43
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$540.59
|
| Rate for Payer: Health EOS Commercial |
$522.96
|
| Rate for Payer: HFN Commercial |
$540.59
|
| Rate for Payer: Multiplan Commercial |
$470.08
|
| Rate for Payer: Preferred Network Access Commercial |
$540.59
|
| Rate for Payer: Quartz Beloit One Network |
$287.92
|
| Rate for Payer: Quartz Commercial |
$352.56
|
| Rate for Payer: WEA Trust Commercial |
$323.18
|
| Rate for Payer: WPS Commercial |
$435.22
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
|
IP
|
$588.00
|
|
|
Service Code
|
CPT 74021 TC,RT
|
| Hospital Charge Code |
5577652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$299.64 |
| Max. Negotiated Rate |
$562.60 |
| Rate for Payer: Aetna Commercial |
$550.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$324.11
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$562.60
|
| Rate for Payer: Health EOS Commercial |
$544.25
|
| Rate for Payer: HFN Commercial |
$562.60
|
| Rate for Payer: Multiplan Commercial |
$489.22
|
| Rate for Payer: Preferred Network Access Commercial |
$562.60
|
| Rate for Payer: Quartz Beloit One Network |
$299.64
|
| Rate for Payer: Quartz Commercial |
$366.91
|
| Rate for Payer: WEA Trust Commercial |
$336.34
|
| Rate for Payer: WPS Commercial |
$452.94
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
2587325
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$583.65 |
| Rate for Payer: Aetna Commercial |
$570.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$545.58
|
| Rate for Payer: Aetna Managed Medicare |
$110.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.10
|
| Rate for Payer: Anthem Medicare Advantage |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$336.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$110.02
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$583.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$110.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$355.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$110.02
|
| Rate for Payer: Health EOS Commercial |
$564.62
|
| Rate for Payer: HFN Commercial |
$583.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$409.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$110.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$110.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$110.02
|
| Rate for Payer: Multiplan Commercial |
$507.52
|
| Rate for Payer: NAPHCARE Commercial |
$165.03
|
| Rate for Payer: Preferred Network Access Commercial |
$583.65
|
| Rate for Payer: Quartz Beloit One Network |
$310.86
|
| Rate for Payer: Quartz Commercial |
$412.36
|
| Rate for Payer: Quartz Medicare Advantage |
$110.02
|
| Rate for Payer: The Alliance Commercial |
$440.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.02
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$348.92
|
| Rate for Payer: Wellcare Medicare |
$110.02
|
| Rate for Payer: WPS Commercial |
$469.88
|
|
|
XR Ureteral Cath/Stent Place Right
|
Facility
|
OP
|
$565.00
|
|
|
Service Code
|
CPT 74020
|
| Hospital Charge Code |
2448819
|
| Min. Negotiated Rate |
$164.53 |
| Max. Negotiated Rate |
$540.59 |
| Rate for Payer: Aetna Commercial |
$528.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$505.34
|
| Rate for Payer: Aetna Managed Medicare |
$164.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$381.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$293.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.43
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$540.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$328.83
|
| Rate for Payer: Health EOS Commercial |
$522.96
|
| Rate for Payer: HFN Commercial |
$540.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$440.70
|
| Rate for Payer: Multiplan Commercial |
$470.08
|
| Rate for Payer: NAPHCARE Commercial |
$352.56
|
| Rate for Payer: Preferred Network Access Commercial |
$540.59
|
| Rate for Payer: Quartz Beloit One Network |
$287.92
|
| Rate for Payer: Quartz Commercial |
$381.94
|
| Rate for Payer: Quartz Medicare Advantage |
$352.56
|
| Rate for Payer: The Alliance Commercial |
$293.80
|
| Rate for Payer: WEA Trust Commercial |
$323.18
|
| Rate for Payer: WPS Commercial |
$435.22
|
|
|
XR Urethrocystography Retrograde
|
Professional
|
Both
|
$720.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1537455
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$273.40 |
| Max. Negotiated Rate |
$711.36 |
| Rate for Payer: Aetna Commercial |
$711.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$711.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$374.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$449.28
|
| Rate for Payer: Health EOS Commercial |
$681.41
|
| Rate for Payer: HFN Commercial |
$711.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$273.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$273.40
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: Preferred Network Access Commercial |
$711.36
|
| Rate for Payer: Quartz Beloit One Network |
$329.47
|
| Rate for Payer: Quartz Commercial |
$426.82
|
| Rate for Payer: The Alliance Commercial |
$374.40
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
XR Urethrocystography Retrograde
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1537455
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$1,004.39 |
| Rate for Payer: Aetna Commercial |
$673.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Aetna Managed Medicare |
$251.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$944.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$755.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$717.88
|
| Rate for Payer: Anthem Medicare Advantage |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$251.10
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$688.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$251.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$419.04
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$251.10
|
| Rate for Payer: Health EOS Commercial |
$666.43
|
| Rate for Payer: HFN Commercial |
$688.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$934.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$251.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$251.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$251.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$251.10
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: NAPHCARE Commercial |
$376.65
|
| Rate for Payer: Preferred Network Access Commercial |
$688.90
|
| Rate for Payer: Quartz Beloit One Network |
$366.91
|
| Rate for Payer: Quartz Commercial |
$486.72
|
| Rate for Payer: Quartz Medicare Advantage |
$251.10
|
| Rate for Payer: The Alliance Commercial |
$1,004.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$251.10
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: Wellcare Medicare |
$251.10
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
XR Urethrocystography Retrograde
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1537455
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$366.91 |
| Max. Negotiated Rate |
$688.90 |
| Rate for Payer: Aetna Commercial |
$673.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.86
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$688.90
|
| Rate for Payer: Health EOS Commercial |
$666.43
|
| Rate for Payer: HFN Commercial |
$688.90
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: Preferred Network Access Commercial |
$688.90
|
| Rate for Payer: Quartz Beloit One Network |
$366.91
|
| Rate for Payer: Quartz Commercial |
$449.28
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
XR Urethrocystography Retrograde
|
Professional
|
Both
|
$683.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
613606
|
| Min. Negotiated Rate |
$273.40 |
| Max. Negotiated Rate |
$674.80 |
| Rate for Payer: Aetna Commercial |
$674.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$610.88
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cigna Commercial |
$674.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$355.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$426.19
|
| Rate for Payer: Health EOS Commercial |
$646.39
|
| Rate for Payer: HFN Commercial |
$674.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$273.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$273.40
|
| Rate for Payer: Multiplan Commercial |
$568.26
|
| Rate for Payer: Preferred Network Access Commercial |
$674.80
|
| Rate for Payer: Quartz Beloit One Network |
$312.54
|
| Rate for Payer: Quartz Commercial |
$404.88
|
| Rate for Payer: The Alliance Commercial |
$355.16
|
| Rate for Payer: WEA Trust Commercial |
$390.68
|
| Rate for Payer: WPS Commercial |
$526.11
|
|
|
XR Urethrocystography Retrograde
|
Facility
|
OP
|
$683.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
613606
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$1,004.39 |
| Rate for Payer: Aetna Commercial |
$639.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$610.88
|
| Rate for Payer: Aetna Managed Medicare |
$251.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$461.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$355.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$340.95
|
| Rate for Payer: Anthem Medicare Advantage |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$376.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$251.10
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cigna Commercial |
$653.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$251.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$397.51
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$251.10
|
| Rate for Payer: Health EOS Commercial |
$632.18
|
| Rate for Payer: HFN Commercial |
$653.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$934.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$251.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$251.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$251.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$251.10
|
| Rate for Payer: Multiplan Commercial |
$568.26
|
| Rate for Payer: NAPHCARE Commercial |
$376.65
|
| Rate for Payer: Preferred Network Access Commercial |
$653.49
|
| Rate for Payer: Quartz Beloit One Network |
$348.06
|
| Rate for Payer: Quartz Commercial |
$461.71
|
| Rate for Payer: Quartz Medicare Advantage |
$251.10
|
| Rate for Payer: The Alliance Commercial |
$1,004.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$251.10
|
| Rate for Payer: WEA Trust Commercial |
$390.68
|
| Rate for Payer: Wellcare Medicare |
$251.10
|
| Rate for Payer: WPS Commercial |
$526.11
|
|
|
XR Urethrocystography Retrograde
|
Facility
|
IP
|
$683.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
613606
|
| Min. Negotiated Rate |
$348.06 |
| Max. Negotiated Rate |
$653.49 |
| Rate for Payer: Aetna Commercial |
$639.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$610.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$376.47
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cigna Commercial |
$653.49
|
| Rate for Payer: Health EOS Commercial |
$632.18
|
| Rate for Payer: HFN Commercial |
$653.49
|
| Rate for Payer: Multiplan Commercial |
$568.26
|
| Rate for Payer: Preferred Network Access Commercial |
$653.49
|
| Rate for Payer: Quartz Beloit One Network |
$348.06
|
| Rate for Payer: Quartz Commercial |
$426.19
|
| Rate for Payer: WEA Trust Commercial |
$390.68
|
| Rate for Payer: WPS Commercial |
$526.11
|
|
|
XR Urethrocystography Voiding
|
Facility
|
IP
|
$1,161.00
|
|
|
Service Code
|
CPT 74455 TC
|
| Hospital Charge Code |
3072720
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$591.65 |
| Max. Negotiated Rate |
$1,110.84 |
| Rate for Payer: Aetna Commercial |
$1,086.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,038.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$639.94
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cigna Commercial |
$1,110.84
|
| Rate for Payer: Health EOS Commercial |
$1,074.62
|
| Rate for Payer: HFN Commercial |
$1,110.84
|
| Rate for Payer: Multiplan Commercial |
$965.95
|
| Rate for Payer: Preferred Network Access Commercial |
$1,110.84
|
| Rate for Payer: Quartz Beloit One Network |
$591.65
|
| Rate for Payer: Quartz Commercial |
$724.46
|
| Rate for Payer: WEA Trust Commercial |
$664.09
|
| Rate for Payer: WPS Commercial |
$894.32
|
|
|
XR Urethrocystography Voiding
|
Professional
|
Both
|
$1,161.00
|
|
|
Service Code
|
CPT 74455 TC
|
| Hospital Charge Code |
3072720
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.29 |
| Max. Negotiated Rate |
$1,147.07 |
| Rate for Payer: Aetna Commercial |
$1,147.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,038.40
|
| Rate for Payer: Aetna Managed Medicare |
$89.29
|
| Rate for Payer: Anthem Medicare Advantage |
$89.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.29
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cigna Commercial |
$1,147.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$603.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.29
|
| Rate for Payer: Health EOS Commercial |
$1,098.77
|
| Rate for Payer: HFN Commercial |
$1,147.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$317.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$317.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.29
|
| Rate for Payer: Multiplan Commercial |
$965.95
|
| Rate for Payer: NAPHCARE Commercial |
$133.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,147.07
|
| Rate for Payer: Quartz Beloit One Network |
$531.27
|
| Rate for Payer: Quartz Commercial |
$688.24
|
| Rate for Payer: Quartz Medicare Advantage |
$89.29
|
| Rate for Payer: The Alliance Commercial |
$339.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.29
|
| Rate for Payer: WEA Trust Commercial |
$664.09
|
| Rate for Payer: WPS Commercial |
$446.47
|
|
|
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 |
$271.67 |
| 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$271.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$271.67
|
| 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 |
$271.67 |
| 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$271.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$271.67
|
| 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
|
Professional
|
Both
|
$1,252.00
|
|
|
Service Code
|
CPT 74420 TC,RT
|
| Hospital Charge Code |
3072646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$271.67 |
| 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$271.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$271.67
|
| 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 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 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: Humana Commercial/EPO/HMO/POS/PPO |
$182.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$182.57
|
| 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
|
|
