|
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 |
$143.04 |
| 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$143.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$143.04
|
| 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 Shoulder Complete Left
|
Facility
|
IP
|
$646.00
|
|
|
Service Code
|
CPT 73030 TC,LT
|
| Hospital Charge Code |
3925371
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$316.54 |
| Max. Negotiated Rate |
$594.32 |
| Rate for Payer: Aetna Commercial |
$581.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.38
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$594.32
|
| Rate for Payer: Health EOS Commercial |
$574.94
|
| Rate for Payer: HFN Commercial |
$594.32
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: NAPHCARE Commercial |
$387.60
|
| Rate for Payer: Preferred Network Access Commercial |
$594.32
|
| Rate for Payer: Quartz Beloit One Network |
$316.54
|
| Rate for Payer: Quartz Commercial |
$387.60
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$478.49
|
|
|
BCE XR Shoulder Complete Left
|
Professional
|
Both
|
$646.00
|
|
|
Service Code
|
CPT 73030 TC,LT
|
| Hospital Charge Code |
3925371
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$115.71 |
| Max. Negotiated Rate |
$613.70 |
| Rate for Payer: Aetna Commercial |
$613.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.56
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$613.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$323.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$387.60
|
| Rate for Payer: Health EOS Commercial |
$587.86
|
| Rate for Payer: HFN Commercial |
$613.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$115.71
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: Preferred Network Access Commercial |
$613.70
|
| Rate for Payer: Quartz Beloit One Network |
$284.24
|
| Rate for Payer: Quartz Commercial |
$368.22
|
| Rate for Payer: The Alliance Commercial |
$323.00
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$478.49
|
|
|
BCE XR Shoulder Complete Left
|
Facility
|
OP
|
$646.00
|
|
|
Service Code
|
CPT 73030 TC,LT
|
| Hospital Charge Code |
3925371
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$594.32 |
| Rate for Payer: Aetna Commercial |
$581.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.56
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.99
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$594.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$361.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$574.94
|
| Rate for Payer: HFN Commercial |
$594.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$594.32
|
| Rate for Payer: Quartz Beloit One Network |
$316.54
|
| Rate for Payer: Quartz Commercial |
$419.90
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$478.49
|
|
|
BCE XR Shoulder Complete Right
|
Facility
|
OP
|
$671.00
|
|
|
Service Code
|
CPT 73030 TC,RT
|
| Hospital Charge Code |
3091466
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$617.32 |
| Rate for Payer: Aetna Commercial |
$603.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.06
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.99
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$355.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$617.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$375.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$597.19
|
| Rate for Payer: HFN Commercial |
$617.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$536.80
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$617.32
|
| Rate for Payer: Quartz Beloit One Network |
$328.79
|
| Rate for Payer: Quartz Commercial |
$436.15
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$369.05
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$497.01
|
|
|
BCE XR Shoulder Complete Right
|
Facility
|
IP
|
$671.00
|
|
|
Service Code
|
CPT 73030 TC,RT
|
| Hospital Charge Code |
3091466
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$328.79 |
| Max. Negotiated Rate |
$617.32 |
| Rate for Payer: Aetna Commercial |
$603.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$355.63
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$617.32
|
| Rate for Payer: Health EOS Commercial |
$597.19
|
| Rate for Payer: HFN Commercial |
$617.32
|
| Rate for Payer: Multiplan Commercial |
$536.80
|
| Rate for Payer: NAPHCARE Commercial |
$402.60
|
| Rate for Payer: Preferred Network Access Commercial |
$617.32
|
| Rate for Payer: Quartz Beloit One Network |
$328.79
|
| Rate for Payer: Quartz Commercial |
$402.60
|
| Rate for Payer: WEA Trust Commercial |
$369.05
|
| Rate for Payer: WPS Commercial |
$497.01
|
|
|
BCE XR Shoulder Complete Right
|
Professional
|
Both
|
$671.00
|
|
|
Service Code
|
CPT 73030 TC,RT
|
| Hospital Charge Code |
3091466
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$115.71 |
| Max. Negotiated Rate |
$637.45 |
| Rate for Payer: Aetna Commercial |
$637.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.06
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$637.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$335.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$402.60
|
| Rate for Payer: Health EOS Commercial |
$610.61
|
| Rate for Payer: HFN Commercial |
$637.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$115.71
|
| Rate for Payer: Multiplan Commercial |
$536.80
|
| Rate for Payer: Preferred Network Access Commercial |
$637.45
|
| Rate for Payer: Quartz Beloit One Network |
$295.24
|
| Rate for Payer: Quartz Commercial |
$382.47
|
| Rate for Payer: The Alliance Commercial |
$335.50
|
| Rate for Payer: WEA Trust Commercial |
$369.05
|
| Rate for Payer: WPS Commercial |
$497.01
|
|
|
BCE XR Spine, C,T,L incl Skull 2 or 3 Views
|
Facility
|
IP
|
$625.00
|
|
|
Service Code
|
CPT 72082 TC
|
| Hospital Charge Code |
4598708
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$306.25 |
| Max. Negotiated Rate |
$575.00 |
| Rate for Payer: Aetna Commercial |
$562.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$537.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.25
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$575.00
|
| Rate for Payer: Health EOS Commercial |
$556.25
|
| Rate for Payer: HFN Commercial |
$575.00
|
| Rate for Payer: Multiplan Commercial |
$500.00
|
| Rate for Payer: NAPHCARE Commercial |
$375.00
|
| Rate for Payer: Preferred Network Access Commercial |
$575.00
|
| Rate for Payer: Quartz Beloit One Network |
$306.25
|
| Rate for Payer: Quartz Commercial |
$375.00
|
| Rate for Payer: WEA Trust Commercial |
$343.75
|
| Rate for Payer: WPS Commercial |
$462.94
|
|
|
BCE XR Spine, C,T,L incl Skull 2 or 3 Views
|
Professional
|
Both
|
$625.00
|
|
|
Service Code
|
CPT 72082 TC
|
| Hospital Charge Code |
4598708
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$184.87 |
| Max. Negotiated Rate |
$593.75 |
| Rate for Payer: Aetna Commercial |
$593.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$537.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$593.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$312.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$375.00
|
| Rate for Payer: Health EOS Commercial |
$568.75
|
| Rate for Payer: HFN Commercial |
$593.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$184.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$184.87
|
| Rate for Payer: Multiplan Commercial |
$500.00
|
| Rate for Payer: Preferred Network Access Commercial |
$593.75
|
| Rate for Payer: Quartz Beloit One Network |
$275.00
|
| Rate for Payer: Quartz Commercial |
$356.25
|
| Rate for Payer: The Alliance Commercial |
$312.50
|
| Rate for Payer: WEA Trust Commercial |
$343.75
|
| Rate for Payer: WPS Commercial |
$462.94
|
|
|
BCE XR Spine, C,T,L incl Skull 2 or 3 Views
|
Facility
|
OP
|
$625.00
|
|
|
Service Code
|
CPT 72082 TC
|
| Hospital Charge Code |
4598708
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$575.00 |
| Rate for Payer: Aetna Commercial |
$562.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$537.50
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$407.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$326.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$309.71
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$575.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$349.75
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$556.25
|
| Rate for Payer: HFN Commercial |
$575.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$500.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$575.00
|
| Rate for Payer: Quartz Beloit One Network |
$306.25
|
| Rate for Payer: Quartz Commercial |
$406.25
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$343.75
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$462.94
|
|
|
BCE XR Spine Lumbosacral 2 or 3 View
|
Facility
|
OP
|
$705.00
|
|
|
Service Code
|
CPT 72100 TC
|
| Hospital Charge Code |
3925416
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$648.60 |
| Rate for Payer: Aetna Commercial |
$634.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.30
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$407.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$326.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$309.71
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$648.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$394.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$627.45
|
| Rate for Payer: HFN Commercial |
$648.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$564.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$648.60
|
| Rate for Payer: Quartz Beloit One Network |
$345.45
|
| Rate for Payer: Quartz Commercial |
$458.25
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$387.75
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$522.19
|
|
|
BCE XR Spine Lumbosacral 2 or 3 View
|
Professional
|
Both
|
$705.00
|
|
|
Service Code
|
CPT 72100 TC
|
| Hospital Charge Code |
3925416
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$96.65 |
| Max. Negotiated Rate |
$669.75 |
| Rate for Payer: Aetna Commercial |
$669.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.30
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$669.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$352.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$423.00
|
| Rate for Payer: Health EOS Commercial |
$641.55
|
| Rate for Payer: HFN Commercial |
$669.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$96.65
|
| Rate for Payer: Multiplan Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$669.75
|
| Rate for Payer: Quartz Beloit One Network |
$310.20
|
| Rate for Payer: Quartz Commercial |
$401.85
|
| Rate for Payer: The Alliance Commercial |
$352.50
|
| Rate for Payer: WEA Trust Commercial |
$387.75
|
| Rate for Payer: WPS Commercial |
$522.19
|
|
|
BCE XR Spine Lumbosacral 2 or 3 View
|
Facility
|
IP
|
$705.00
|
|
|
Service Code
|
CPT 72100 TC
|
| Hospital Charge Code |
3925416
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$345.45 |
| Max. Negotiated Rate |
$648.60 |
| Rate for Payer: Aetna Commercial |
$634.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.65
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$648.60
|
| Rate for Payer: Health EOS Commercial |
$627.45
|
| Rate for Payer: HFN Commercial |
$648.60
|
| Rate for Payer: Multiplan Commercial |
$564.00
|
| Rate for Payer: NAPHCARE Commercial |
$423.00
|
| Rate for Payer: Preferred Network Access Commercial |
$648.60
|
| Rate for Payer: Quartz Beloit One Network |
$345.45
|
| Rate for Payer: Quartz Commercial |
$423.00
|
| Rate for Payer: WEA Trust Commercial |
$387.75
|
| Rate for Payer: WPS Commercial |
$522.19
|
|
|
BCE XR Tibia/Fibula Left
|
Facility
|
OP
|
$584.00
|
|
|
Service Code
|
CPT 73590 TC,LT
|
| Hospital Charge Code |
3091471
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$537.28 |
| Rate for Payer: Aetna Commercial |
$525.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.24
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.99
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cigna Commercial |
$537.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$326.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$519.76
|
| Rate for Payer: HFN Commercial |
$537.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$467.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$537.28
|
| Rate for Payer: Quartz Beloit One Network |
$286.16
|
| Rate for Payer: Quartz Commercial |
$379.60
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$321.20
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$432.57
|
|
|
BCE XR Tibia/Fibula Left
|
Professional
|
Both
|
$584.00
|
|
|
Service Code
|
CPT 73590 TC,LT
|
| Hospital Charge Code |
3091471
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$106.29 |
| Max. Negotiated Rate |
$554.80 |
| Rate for Payer: Aetna Commercial |
$554.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.24
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cigna Commercial |
$554.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$292.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$350.40
|
| Rate for Payer: Health EOS Commercial |
$531.44
|
| Rate for Payer: HFN Commercial |
$554.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$106.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$106.29
|
| Rate for Payer: Multiplan Commercial |
$467.20
|
| Rate for Payer: Preferred Network Access Commercial |
$554.80
|
| Rate for Payer: Quartz Beloit One Network |
$256.96
|
| Rate for Payer: Quartz Commercial |
$332.88
|
| Rate for Payer: The Alliance Commercial |
$292.00
|
| Rate for Payer: WEA Trust Commercial |
$321.20
|
| Rate for Payer: WPS Commercial |
$432.57
|
|
|
BCE XR Tibia/Fibula Left
|
Facility
|
IP
|
$584.00
|
|
|
Service Code
|
CPT 73590 TC,LT
|
| Hospital Charge Code |
3091471
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$286.16 |
| Max. Negotiated Rate |
$537.28 |
| Rate for Payer: Aetna Commercial |
$525.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.52
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cigna Commercial |
$537.28
|
| Rate for Payer: Health EOS Commercial |
$519.76
|
| Rate for Payer: HFN Commercial |
$537.28
|
| Rate for Payer: Multiplan Commercial |
$467.20
|
| Rate for Payer: NAPHCARE Commercial |
$350.40
|
| Rate for Payer: Preferred Network Access Commercial |
$537.28
|
| Rate for Payer: Quartz Beloit One Network |
$286.16
|
| Rate for Payer: Quartz Commercial |
$350.40
|
| Rate for Payer: WEA Trust Commercial |
$321.20
|
| Rate for Payer: WPS Commercial |
$432.57
|
|
|
BCE XR US Guided Midline
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552132
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$124.60 |
| Max. Negotiated Rate |
$1,780.00 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Aetna Managed Medicare |
$124.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$249.02
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.75
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$289.25
|
| Rate for Payer: Quartz Medicare Advantage |
$267.00
|
| Rate for Payer: The Alliance Commercial |
$1,780.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
BCE XR US Guided Midline
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552132
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$218.05 |
| Max. Negotiated Rate |
$409.40 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
BCE XR US Guided Midline
|
Professional
|
Both
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552132
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$83.56 |
| Max. Negotiated Rate |
$422.75 |
| Rate for Payer: Aetna Commercial |
$422.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$422.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$222.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$267.00
|
| Rate for Payer: Health EOS Commercial |
$404.95
|
| Rate for Payer: HFN Commercial |
$422.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.56
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: Preferred Network Access Commercial |
$422.75
|
| Rate for Payer: Quartz Beloit One Network |
$195.80
|
| Rate for Payer: Quartz Commercial |
$253.65
|
| Rate for Payer: The Alliance Commercial |
$222.50
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
BCG 1 Unit Charge
|
Professional
|
Both
|
$770.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
2958944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$731.50 |
| Rate for Payer: Aetna Commercial |
$731.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$662.20
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$731.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.89
|
| Rate for Payer: Health EOS Commercial |
$700.70
|
| Rate for Payer: HFN Commercial |
$731.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.10
|
| Rate for Payer: Multiplan Commercial |
$616.00
|
| Rate for Payer: Preferred Network Access Commercial |
$731.50
|
| Rate for Payer: Quartz Beloit One Network |
$338.80
|
| Rate for Payer: Quartz Commercial |
$438.90
|
| Rate for Payer: The Alliance Commercial |
$385.00
|
| Rate for Payer: United Healthcare Medicaid |
$2.89
|
| Rate for Payer: WEA Trust Commercial |
$423.50
|
| Rate for Payer: WPS Commercial |
$7.22
|
|
|
BCG 1 Unit Charge
|
Facility
|
IP
|
$770.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
2958944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$377.30 |
| Max. Negotiated Rate |
$708.40 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$662.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$408.10
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$708.40
|
| Rate for Payer: Health EOS Commercial |
$685.30
|
| Rate for Payer: HFN Commercial |
$708.40
|
| Rate for Payer: Multiplan Commercial |
$616.00
|
| Rate for Payer: NAPHCARE Commercial |
$462.00
|
| Rate for Payer: Preferred Network Access Commercial |
$708.40
|
| Rate for Payer: Quartz Beloit One Network |
$377.30
|
| Rate for Payer: Quartz Commercial |
$462.00
|
| Rate for Payer: WEA Trust Commercial |
$423.50
|
| Rate for Payer: WPS Commercial |
$570.34
|
|
|
BCG 1 Unit Charge
|
Facility
|
OP
|
$770.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
2958944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$3,080.00 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$662.20
|
| Rate for Payer: Aetna Managed Medicare |
$215.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$500.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$385.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$369.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$408.10
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$708.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.82
|
| Rate for Payer: Health EOS Commercial |
$685.30
|
| Rate for Payer: HFN Commercial |
$708.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$577.50
|
| Rate for Payer: Multiplan Commercial |
$616.00
|
| Rate for Payer: NAPHCARE Commercial |
$462.00
|
| Rate for Payer: Preferred Network Access Commercial |
$708.40
|
| Rate for Payer: Quartz Beloit One Network |
$377.30
|
| Rate for Payer: Quartz Commercial |
$500.50
|
| Rate for Payer: Quartz Medicare Advantage |
$462.00
|
| Rate for Payer: The Alliance Commercial |
$3,080.00
|
| Rate for Payer: WEA Trust Commercial |
$423.50
|
| Rate for Payer: WPS Commercial |
$7.22
|
|
|
Bcg live intravesical vac J9030
|
Facility
|
OP
|
$368.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
5528774
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$1,472.00 |
| Rate for Payer: Aetna Commercial |
$331.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.48
|
| Rate for Payer: Aetna Managed Medicare |
$103.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.04
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$338.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.82
|
| Rate for Payer: Health EOS Commercial |
$327.52
|
| Rate for Payer: HFN Commercial |
$338.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.00
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: NAPHCARE Commercial |
$220.80
|
| Rate for Payer: Preferred Network Access Commercial |
$338.56
|
| Rate for Payer: Quartz Beloit One Network |
$180.32
|
| Rate for Payer: Quartz Commercial |
$239.20
|
| Rate for Payer: Quartz Medicare Advantage |
$220.80
|
| Rate for Payer: The Alliance Commercial |
$1,472.00
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$7.22
|
|
|
Bcg live intravesical vac J9030
|
Professional
|
Both
|
$368.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
5528774
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$349.60 |
| Rate for Payer: Aetna Commercial |
$349.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.48
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$349.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.89
|
| Rate for Payer: Health EOS Commercial |
$334.88
|
| Rate for Payer: HFN Commercial |
$349.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.10
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: Preferred Network Access Commercial |
$349.60
|
| Rate for Payer: Quartz Beloit One Network |
$161.92
|
| Rate for Payer: Quartz Commercial |
$209.76
|
| Rate for Payer: The Alliance Commercial |
$184.00
|
| Rate for Payer: United Healthcare Medicaid |
$2.89
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$7.22
|
|
|
Bcg live intravesical vac J9030
|
Facility
|
IP
|
$368.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
5528774
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.32 |
| Max. Negotiated Rate |
$338.56 |
| Rate for Payer: Aetna Commercial |
$331.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.04
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$338.56
|
| Rate for Payer: Health EOS Commercial |
$327.52
|
| Rate for Payer: HFN Commercial |
$338.56
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: NAPHCARE Commercial |
$220.80
|
| Rate for Payer: Preferred Network Access Commercial |
$338.56
|
| Rate for Payer: Quartz Beloit One Network |
$180.32
|
| Rate for Payer: Quartz Commercial |
$220.80
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$272.58
|
|
