|
BCE XR Humerus Right
|
Facility
|
OP
|
$557.00
|
|
|
Service Code
|
CPT 73060 TC,RT
|
| Hospital Charge Code |
3925422
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$155.96 |
| Max. Negotiated Rate |
$2,228.00 |
| Rate for Payer: Aetna Commercial |
$501.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.02
|
| Rate for Payer: Aetna Managed Medicare |
$155.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$278.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$267.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.21
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$512.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$311.70
|
| Rate for Payer: Health EOS Commercial |
$495.73
|
| Rate for Payer: HFN Commercial |
$512.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$417.75
|
| Rate for Payer: Multiplan Commercial |
$445.60
|
| Rate for Payer: NAPHCARE Commercial |
$334.20
|
| Rate for Payer: Preferred Network Access Commercial |
$512.44
|
| Rate for Payer: Quartz Beloit One Network |
$272.93
|
| Rate for Payer: Quartz Commercial |
$362.05
|
| Rate for Payer: Quartz Medicare Advantage |
$334.20
|
| Rate for Payer: The Alliance Commercial |
$2,228.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$306.35
|
| Rate for Payer: WPS Commercial |
$412.57
|
|
|
BCE XR Humerus Right
|
Professional
|
Both
|
$557.00
|
|
|
Service Code
|
CPT 73060 TC,RT
|
| Hospital Charge Code |
3925422
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$245.08 |
| Max. Negotiated Rate |
$529.15 |
| Rate for Payer: Aetna Commercial |
$529.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.02
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$529.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$278.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$334.20
|
| Rate for Payer: Health EOS Commercial |
$506.87
|
| Rate for Payer: HFN Commercial |
$529.15
|
| Rate for Payer: Multiplan Commercial |
$445.60
|
| Rate for Payer: Preferred Network Access Commercial |
$529.15
|
| Rate for Payer: Quartz Beloit One Network |
$245.08
|
| Rate for Payer: Quartz Commercial |
$317.49
|
| Rate for Payer: The Alliance Commercial |
$278.50
|
| Rate for Payer: WEA Trust Commercial |
$306.35
|
| Rate for Payer: WPS Commercial |
$412.57
|
|
|
BCE XR Humerus Right
|
Facility
|
IP
|
$557.00
|
|
|
Service Code
|
CPT 73060 TC,RT
|
| Hospital Charge Code |
3925422
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$272.93 |
| Max. Negotiated Rate |
$512.44 |
| Rate for Payer: Aetna Commercial |
$501.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.21
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$512.44
|
| Rate for Payer: Health EOS Commercial |
$495.73
|
| Rate for Payer: HFN Commercial |
$512.44
|
| Rate for Payer: Multiplan Commercial |
$445.60
|
| Rate for Payer: NAPHCARE Commercial |
$334.20
|
| Rate for Payer: Preferred Network Access Commercial |
$512.44
|
| Rate for Payer: Quartz Beloit One Network |
$272.93
|
| Rate for Payer: Quartz Commercial |
$334.20
|
| Rate for Payer: WEA Trust Commercial |
$306.35
|
| Rate for Payer: WPS Commercial |
$412.57
|
|
|
BCE XR Knee 3 Views Left
|
Professional
|
Both
|
$609.00
|
|
|
Service Code
|
CPT 73562 TC,LT
|
| Hospital Charge Code |
3925460
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$267.96 |
| Max. Negotiated Rate |
$578.55 |
| Rate for Payer: Aetna Commercial |
$578.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$523.74
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cigna Commercial |
$578.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$304.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$365.40
|
| Rate for Payer: Health EOS Commercial |
$554.19
|
| Rate for Payer: HFN Commercial |
$578.55
|
| Rate for Payer: Multiplan Commercial |
$487.20
|
| Rate for Payer: Preferred Network Access Commercial |
$578.55
|
| Rate for Payer: Quartz Beloit One Network |
$267.96
|
| Rate for Payer: Quartz Commercial |
$347.13
|
| Rate for Payer: The Alliance Commercial |
$304.50
|
| Rate for Payer: WEA Trust Commercial |
$334.95
|
| Rate for Payer: WPS Commercial |
$451.09
|
|
|
BCE XR Knee 3 Views Left
|
Facility
|
IP
|
$609.00
|
|
|
Service Code
|
CPT 73562 TC,LT
|
| Hospital Charge Code |
3925460
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$298.41 |
| Max. Negotiated Rate |
$560.28 |
| Rate for Payer: Aetna Commercial |
$548.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$523.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$322.77
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cigna Commercial |
$560.28
|
| Rate for Payer: Health EOS Commercial |
$542.01
|
| Rate for Payer: HFN Commercial |
$560.28
|
| Rate for Payer: Multiplan Commercial |
$487.20
|
| Rate for Payer: NAPHCARE Commercial |
$365.40
|
| Rate for Payer: Preferred Network Access Commercial |
$560.28
|
| Rate for Payer: Quartz Beloit One Network |
$298.41
|
| Rate for Payer: Quartz Commercial |
$365.40
|
| Rate for Payer: WEA Trust Commercial |
$334.95
|
| Rate for Payer: WPS Commercial |
$451.09
|
|
|
BCE XR Knee 3 Views Left
|
Facility
|
OP
|
$609.00
|
|
|
Service Code
|
CPT 73562 TC,LT
|
| Hospital Charge Code |
3925460
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$170.52 |
| Max. Negotiated Rate |
$2,436.00 |
| Rate for Payer: Aetna Commercial |
$548.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$523.74
|
| Rate for Payer: Aetna Managed Medicare |
$170.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$395.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$304.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$292.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$322.77
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cigna Commercial |
$560.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$340.80
|
| Rate for Payer: Health EOS Commercial |
$542.01
|
| Rate for Payer: HFN Commercial |
$560.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$456.75
|
| Rate for Payer: Multiplan Commercial |
$487.20
|
| Rate for Payer: NAPHCARE Commercial |
$365.40
|
| Rate for Payer: Preferred Network Access Commercial |
$560.28
|
| Rate for Payer: Quartz Beloit One Network |
$298.41
|
| Rate for Payer: Quartz Commercial |
$395.85
|
| Rate for Payer: Quartz Medicare Advantage |
$365.40
|
| Rate for Payer: The Alliance Commercial |
$2,436.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$334.95
|
| Rate for Payer: WPS Commercial |
$451.09
|
|
|
BCE XR Knee 3 Views Right
|
Facility
|
OP
|
$609.00
|
|
|
Service Code
|
CPT 73562 TC,RT
|
| Hospital Charge Code |
3091484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$170.52 |
| Max. Negotiated Rate |
$2,436.00 |
| Rate for Payer: Aetna Commercial |
$548.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$523.74
|
| Rate for Payer: Aetna Managed Medicare |
$170.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$395.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$304.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$292.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$322.77
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cigna Commercial |
$560.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$340.80
|
| Rate for Payer: Health EOS Commercial |
$542.01
|
| Rate for Payer: HFN Commercial |
$560.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$456.75
|
| Rate for Payer: Multiplan Commercial |
$487.20
|
| Rate for Payer: NAPHCARE Commercial |
$365.40
|
| Rate for Payer: Preferred Network Access Commercial |
$560.28
|
| Rate for Payer: Quartz Beloit One Network |
$298.41
|
| Rate for Payer: Quartz Commercial |
$395.85
|
| Rate for Payer: Quartz Medicare Advantage |
$365.40
|
| Rate for Payer: The Alliance Commercial |
$2,436.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$334.95
|
| Rate for Payer: WPS Commercial |
$451.09
|
|
|
BCE XR Knee 3 Views Right
|
Facility
|
IP
|
$609.00
|
|
|
Service Code
|
CPT 73562 TC,RT
|
| Hospital Charge Code |
3091484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$298.41 |
| Max. Negotiated Rate |
$560.28 |
| Rate for Payer: Aetna Commercial |
$548.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$523.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$322.77
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cigna Commercial |
$560.28
|
| Rate for Payer: Health EOS Commercial |
$542.01
|
| Rate for Payer: HFN Commercial |
$560.28
|
| Rate for Payer: Multiplan Commercial |
$487.20
|
| Rate for Payer: NAPHCARE Commercial |
$365.40
|
| Rate for Payer: Preferred Network Access Commercial |
$560.28
|
| Rate for Payer: Quartz Beloit One Network |
$298.41
|
| Rate for Payer: Quartz Commercial |
$365.40
|
| Rate for Payer: WEA Trust Commercial |
$334.95
|
| Rate for Payer: WPS Commercial |
$451.09
|
|
|
BCE XR Knee 3 Views Right
|
Professional
|
Both
|
$609.00
|
|
|
Service Code
|
CPT 73562 TC,RT
|
| Hospital Charge Code |
3091484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$267.96 |
| Max. Negotiated Rate |
$578.55 |
| Rate for Payer: Aetna Commercial |
$578.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$523.74
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cigna Commercial |
$578.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$304.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$365.40
|
| Rate for Payer: Health EOS Commercial |
$554.19
|
| Rate for Payer: HFN Commercial |
$578.55
|
| Rate for Payer: Multiplan Commercial |
$487.20
|
| Rate for Payer: Preferred Network Access Commercial |
$578.55
|
| Rate for Payer: Quartz Beloit One Network |
$267.96
|
| Rate for Payer: Quartz Commercial |
$347.13
|
| Rate for Payer: The Alliance Commercial |
$304.50
|
| Rate for Payer: WEA Trust Commercial |
$334.95
|
| Rate for Payer: WPS Commercial |
$451.09
|
|
|
BCE XR Major Joint Inj, Asp
|
Professional
|
Both
|
$742.00
|
|
|
Service Code
|
CPT 20610 TC
|
| Hospital Charge Code |
4052762
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$326.48 |
| Max. Negotiated Rate |
$704.90 |
| Rate for Payer: Aetna Commercial |
$704.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$638.12
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cigna Commercial |
$704.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$371.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$445.20
|
| Rate for Payer: Health EOS Commercial |
$675.22
|
| Rate for Payer: HFN Commercial |
$704.90
|
| Rate for Payer: Multiplan Commercial |
$593.60
|
| Rate for Payer: Preferred Network Access Commercial |
$704.90
|
| Rate for Payer: Quartz Beloit One Network |
$326.48
|
| Rate for Payer: Quartz Commercial |
$422.94
|
| Rate for Payer: The Alliance Commercial |
$371.00
|
| Rate for Payer: WEA Trust Commercial |
$408.10
|
| Rate for Payer: WPS Commercial |
$549.60
|
|
|
BCE XR Major Joint Inj, Asp
|
Facility
|
IP
|
$742.00
|
|
|
Service Code
|
CPT 20610 TC
|
| Hospital Charge Code |
4052762
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$363.58 |
| Max. Negotiated Rate |
$682.64 |
| Rate for Payer: Aetna Commercial |
$667.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$638.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$393.26
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cigna Commercial |
$682.64
|
| Rate for Payer: Health EOS Commercial |
$660.38
|
| Rate for Payer: HFN Commercial |
$682.64
|
| Rate for Payer: Multiplan Commercial |
$593.60
|
| Rate for Payer: NAPHCARE Commercial |
$445.20
|
| Rate for Payer: Preferred Network Access Commercial |
$682.64
|
| Rate for Payer: Quartz Beloit One Network |
$363.58
|
| Rate for Payer: Quartz Commercial |
$445.20
|
| Rate for Payer: WEA Trust Commercial |
$408.10
|
| Rate for Payer: WPS Commercial |
$549.60
|
|
|
BCE XR Major Joint Inj, Asp
|
Facility
|
OP
|
$742.00
|
|
|
Service Code
|
CPT 20610 TC
|
| Hospital Charge Code |
4052762
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$207.76 |
| Max. Negotiated Rate |
$2,968.00 |
| Rate for Payer: Aetna Commercial |
$667.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$638.12
|
| Rate for Payer: Aetna Managed Medicare |
$207.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$482.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$371.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$356.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$393.26
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cigna Commercial |
$682.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$415.22
|
| Rate for Payer: Health EOS Commercial |
$660.38
|
| Rate for Payer: HFN Commercial |
$682.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$556.50
|
| Rate for Payer: Multiplan Commercial |
$593.60
|
| Rate for Payer: NAPHCARE Commercial |
$445.20
|
| Rate for Payer: Preferred Network Access Commercial |
$682.64
|
| Rate for Payer: Quartz Beloit One Network |
$363.58
|
| Rate for Payer: Quartz Commercial |
$482.30
|
| Rate for Payer: Quartz Medicare Advantage |
$445.20
|
| Rate for Payer: The Alliance Commercial |
$2,968.00
|
| Rate for Payer: United Healthcare PPO |
$556.50
|
| Rate for Payer: WEA Trust Commercial |
$408.10
|
| Rate for Payer: WPS Commercial |
$549.60
|
|
|
BCE XR Nephrostogram
|
Facility
|
IP
|
$766.00
|
|
|
Service Code
|
CPT 74425 TC
|
| Hospital Charge Code |
4464921
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$375.34 |
| Max. Negotiated Rate |
$704.72 |
| Rate for Payer: Aetna Commercial |
$689.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$658.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.98
|
| Rate for Payer: Cash Price |
$229.80
|
| Rate for Payer: Cigna Commercial |
$704.72
|
| Rate for Payer: Health EOS Commercial |
$681.74
|
| Rate for Payer: HFN Commercial |
$704.72
|
| Rate for Payer: Multiplan Commercial |
$612.80
|
| Rate for Payer: NAPHCARE Commercial |
$459.60
|
| Rate for Payer: Preferred Network Access Commercial |
$704.72
|
| Rate for Payer: Quartz Beloit One Network |
$375.34
|
| Rate for Payer: Quartz Commercial |
$459.60
|
| Rate for Payer: WEA Trust Commercial |
$421.30
|
| Rate for Payer: WPS Commercial |
$567.38
|
|
|
BCE XR Nephrostogram
|
Facility
|
OP
|
$766.00
|
|
|
Service Code
|
CPT 74425 TC
|
| Hospital Charge Code |
4464921
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$214.48 |
| Max. Negotiated Rate |
$3,064.00 |
| Rate for Payer: Aetna Commercial |
$689.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$658.76
|
| Rate for Payer: Aetna Managed Medicare |
$214.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$497.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$383.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$367.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.98
|
| Rate for Payer: Cash Price |
$229.80
|
| Rate for Payer: Cash Price |
$229.80
|
| Rate for Payer: Cigna Commercial |
$704.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$428.65
|
| Rate for Payer: Health EOS Commercial |
$681.74
|
| Rate for Payer: HFN Commercial |
$704.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.50
|
| Rate for Payer: Multiplan Commercial |
$612.80
|
| Rate for Payer: NAPHCARE Commercial |
$459.60
|
| Rate for Payer: Preferred Network Access Commercial |
$704.72
|
| Rate for Payer: Quartz Beloit One Network |
$375.34
|
| Rate for Payer: Quartz Commercial |
$497.90
|
| Rate for Payer: Quartz Medicare Advantage |
$459.60
|
| Rate for Payer: The Alliance Commercial |
$3,064.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$421.30
|
| Rate for Payer: WPS Commercial |
$567.38
|
|
|
BCE XR Nephrostomy Dilation Bilateral
|
Facility
|
IP
|
$5,405.00
|
|
|
Service Code
|
CPT 50432 TC
|
| Hospital Charge Code |
5430695
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$2,648.45 |
| Max. Negotiated Rate |
$4,972.60 |
| Rate for Payer: Aetna Commercial |
$4,864.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,648.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,864.65
|
| Rate for Payer: Cash Price |
$1,621.50
|
| Rate for Payer: Cigna Commercial |
$4,972.60
|
| Rate for Payer: Health EOS Commercial |
$4,810.45
|
| Rate for Payer: HFN Commercial |
$4,972.60
|
| Rate for Payer: Multiplan Commercial |
$4,324.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,972.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,648.45
|
| Rate for Payer: Quartz Commercial |
$3,243.00
|
| Rate for Payer: WEA Trust Commercial |
$2,972.75
|
| Rate for Payer: WPS Commercial |
$4,003.48
|
|
|
BCE XR Nephrostomy Dilation Bilateral
|
Facility
|
OP
|
$5,405.00
|
|
|
Service Code
|
CPT 50432 TC
|
| Hospital Charge Code |
5430695
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$21,620.00 |
| Rate for Payer: Aetna Commercial |
$4,864.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,648.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,513.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,513.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,702.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,594.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,864.65
|
| Rate for Payer: Cash Price |
$1,621.50
|
| Rate for Payer: Cash Price |
$1,621.50
|
| Rate for Payer: Cigna Commercial |
$4,972.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,024.64
|
| Rate for Payer: Health EOS Commercial |
$4,810.45
|
| Rate for Payer: HFN Commercial |
$4,972.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,053.75
|
| Rate for Payer: Multiplan Commercial |
$4,324.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,972.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,648.45
|
| Rate for Payer: Quartz Commercial |
$3,513.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,243.00
|
| Rate for Payer: The Alliance Commercial |
$21,620.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$2,972.75
|
| Rate for Payer: WPS Commercial |
$4,003.48
|
|
|
BCE XR Nephrostomy Dilation Bilateral
|
Professional
|
Both
|
$5,405.00
|
|
|
Service Code
|
CPT 50432 TC
|
| Hospital Charge Code |
5430695
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$2,378.20 |
| Max. Negotiated Rate |
$5,134.75 |
| Rate for Payer: Aetna Commercial |
$5,134.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,648.30
|
| Rate for Payer: Cash Price |
$1,621.50
|
| Rate for Payer: Cash Price |
$1,621.50
|
| Rate for Payer: Cigna Commercial |
$5,134.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,702.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,243.00
|
| Rate for Payer: Health EOS Commercial |
$4,918.55
|
| Rate for Payer: HFN Commercial |
$5,134.75
|
| Rate for Payer: Multiplan Commercial |
$4,324.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,134.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,378.20
|
| Rate for Payer: Quartz Commercial |
$3,080.85
|
| Rate for Payer: The Alliance Commercial |
$2,702.50
|
| Rate for Payer: WEA Trust Commercial |
$2,972.75
|
| Rate for Payer: WPS Commercial |
$4,003.48
|
|
|
BCE XR Neph Tube Exchange Percutaneous
|
Professional
|
Both
|
$3,505.00
|
|
|
Service Code
|
CPT 50435 TC
|
| Hospital Charge Code |
4616667
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,542.20 |
| Max. Negotiated Rate |
$3,329.75 |
| Rate for Payer: Aetna Commercial |
$3,329.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,014.30
|
| Rate for Payer: Cash Price |
$1,051.50
|
| Rate for Payer: Cash Price |
$1,051.50
|
| Rate for Payer: Cigna Commercial |
$3,329.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,752.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,103.00
|
| Rate for Payer: Health EOS Commercial |
$3,189.55
|
| Rate for Payer: HFN Commercial |
$3,329.75
|
| Rate for Payer: Multiplan Commercial |
$2,804.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,329.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,542.20
|
| Rate for Payer: Quartz Commercial |
$1,997.85
|
| Rate for Payer: The Alliance Commercial |
$1,752.50
|
| Rate for Payer: WEA Trust Commercial |
$1,927.75
|
| Rate for Payer: WPS Commercial |
$2,596.15
|
|
|
BCE XR Neph Tube Exchange Percutaneous
|
Facility
|
OP
|
$3,505.00
|
|
|
Service Code
|
CPT 50435 TC
|
| Hospital Charge Code |
4616667
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$14,020.00 |
| Rate for Payer: Aetna Commercial |
$3,154.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,014.30
|
| Rate for Payer: Aetna Managed Medicare |
$981.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,278.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,752.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,682.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,857.65
|
| Rate for Payer: Cash Price |
$1,051.50
|
| Rate for Payer: Cash Price |
$1,051.50
|
| Rate for Payer: Cigna Commercial |
$3,224.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,961.40
|
| Rate for Payer: Health EOS Commercial |
$3,119.45
|
| Rate for Payer: HFN Commercial |
$3,224.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,628.75
|
| Rate for Payer: Multiplan Commercial |
$2,804.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,103.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,224.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,717.45
|
| Rate for Payer: Quartz Commercial |
$2,278.25
|
| Rate for Payer: Quartz Medicare Advantage |
$2,103.00
|
| Rate for Payer: The Alliance Commercial |
$14,020.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$1,927.75
|
| Rate for Payer: WPS Commercial |
$2,596.15
|
|
|
BCE XR Neph Tube Exchange Percutaneous
|
Facility
|
IP
|
$3,505.00
|
|
|
Service Code
|
CPT 50435 TC
|
| Hospital Charge Code |
4616667
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,717.45 |
| Max. Negotiated Rate |
$3,224.60 |
| Rate for Payer: Aetna Commercial |
$3,154.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,014.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,857.65
|
| Rate for Payer: Cash Price |
$1,051.50
|
| Rate for Payer: Cigna Commercial |
$3,224.60
|
| Rate for Payer: Health EOS Commercial |
$3,119.45
|
| Rate for Payer: HFN Commercial |
$3,224.60
|
| Rate for Payer: Multiplan Commercial |
$2,804.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,103.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,224.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,717.45
|
| Rate for Payer: Quartz Commercial |
$2,103.00
|
| Rate for Payer: WEA Trust Commercial |
$1,927.75
|
| Rate for Payer: WPS Commercial |
$2,596.15
|
|
|
BCE XR Pelvis 1 or 2 Views
|
Professional
|
Both
|
$556.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
3925398
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$64.18 |
| Max. Negotiated Rate |
$528.20 |
| Rate for Payer: Aetna Commercial |
$528.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.16
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$528.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$278.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$333.60
|
| Rate for Payer: Health EOS Commercial |
$505.96
|
| Rate for Payer: HFN Commercial |
$528.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.18
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$528.20
|
| Rate for Payer: Quartz Beloit One Network |
$244.64
|
| Rate for Payer: Quartz Commercial |
$316.92
|
| Rate for Payer: The Alliance Commercial |
$278.00
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$411.83
|
|
|
BCE XR Pelvis 1 or 2 Views
|
Facility
|
IP
|
$556.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
3925398
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$272.44 |
| Max. Negotiated Rate |
$511.52 |
| Rate for Payer: Aetna Commercial |
$500.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.68
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$511.52
|
| Rate for Payer: Health EOS Commercial |
$494.84
|
| Rate for Payer: HFN Commercial |
$511.52
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: NAPHCARE Commercial |
$333.60
|
| Rate for Payer: Preferred Network Access Commercial |
$511.52
|
| Rate for Payer: Quartz Beloit One Network |
$272.44
|
| Rate for Payer: Quartz Commercial |
$333.60
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$411.83
|
|
|
BCE XR Pelvis 1 or 2 Views
|
Facility
|
OP
|
$556.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
3925398
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$155.68 |
| Max. Negotiated Rate |
$2,224.00 |
| Rate for Payer: Aetna Commercial |
$500.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.16
|
| Rate for Payer: Aetna Managed Medicare |
$155.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$361.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$278.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.68
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$511.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$311.14
|
| Rate for Payer: Health EOS Commercial |
$494.84
|
| Rate for Payer: HFN Commercial |
$511.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$417.00
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: NAPHCARE Commercial |
$333.60
|
| Rate for Payer: Preferred Network Access Commercial |
$511.52
|
| Rate for Payer: Quartz Beloit One Network |
$272.44
|
| Rate for Payer: Quartz Commercial |
$361.40
|
| Rate for Payer: Quartz Medicare Advantage |
$333.60
|
| Rate for Payer: The Alliance Commercial |
$2,224.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$411.83
|
|
|
BCE XR Ribs w/PA Chest Left
|
Professional
|
Both
|
$787.00
|
|
|
Service Code
|
CPT 71101 TC,LT
|
| Hospital Charge Code |
5280646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$346.28 |
| Max. Negotiated Rate |
$747.65 |
| Rate for Payer: Aetna Commercial |
$747.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$676.82
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cigna Commercial |
$747.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$393.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$472.20
|
| Rate for Payer: Health EOS Commercial |
$716.17
|
| Rate for Payer: HFN Commercial |
$747.65
|
| Rate for Payer: Multiplan Commercial |
$629.60
|
| Rate for Payer: Preferred Network Access Commercial |
$747.65
|
| Rate for Payer: Quartz Beloit One Network |
$346.28
|
| Rate for Payer: Quartz Commercial |
$448.59
|
| Rate for Payer: The Alliance Commercial |
$393.50
|
| Rate for Payer: WEA Trust Commercial |
$432.85
|
| Rate for Payer: WPS Commercial |
$582.93
|
|
|
BCE XR Ribs w/PA Chest Left
|
Facility
|
IP
|
$787.00
|
|
|
Service Code
|
CPT 71101 TC,LT
|
| Hospital Charge Code |
5280646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$385.63 |
| Max. Negotiated Rate |
$724.04 |
| Rate for Payer: Aetna Commercial |
$708.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$676.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$417.11
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cigna Commercial |
$724.04
|
| Rate for Payer: Health EOS Commercial |
$700.43
|
| Rate for Payer: HFN Commercial |
$724.04
|
| Rate for Payer: Multiplan Commercial |
$629.60
|
| Rate for Payer: NAPHCARE Commercial |
$472.20
|
| Rate for Payer: Preferred Network Access Commercial |
$724.04
|
| Rate for Payer: Quartz Beloit One Network |
$385.63
|
| Rate for Payer: Quartz Commercial |
$472.20
|
| Rate for Payer: WEA Trust Commercial |
$432.85
|
| Rate for Payer: WPS Commercial |
$582.93
|
|
