|
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 |
$77.63 |
| Max. Negotiated Rate |
$531.98 |
| Rate for Payer: Aetna Commercial |
$520.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.29
|
| Rate for Payer: Aetna Managed Medicare |
$161.91
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$306.47
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$531.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$323.59
|
| Rate for Payer: Health EOS Commercial |
$514.63
|
| Rate for Payer: HFN Commercial |
$531.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$433.68
|
| Rate for Payer: Multiplan Commercial |
$462.59
|
| Rate for Payer: NAPHCARE Commercial |
$346.94
|
| Rate for Payer: Preferred Network Access Commercial |
$531.98
|
| Rate for Payer: Quartz Beloit One Network |
$283.34
|
| Rate for Payer: Quartz Commercial |
$375.86
|
| Rate for Payer: Quartz Medicare Advantage |
$346.94
|
| Rate for Payer: The Alliance Commercial |
$77.63
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$318.03
|
| Rate for Payer: WPS Commercial |
$428.29
|
|
|
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 |
$19.41 |
| Max. Negotiated Rate |
$549.33 |
| Rate for Payer: Aetna Commercial |
$549.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.29
|
| Rate for Payer: Aetna Managed Medicare |
$19.41
|
| Rate for Payer: Anthem Medicare Advantage |
$19.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.41
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$549.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$289.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.41
|
| Rate for Payer: Health EOS Commercial |
$526.20
|
| Rate for Payer: HFN Commercial |
$549.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.41
|
| Rate for Payer: Multiplan Commercial |
$462.59
|
| Rate for Payer: NAPHCARE Commercial |
$29.11
|
| Rate for Payer: Preferred Network Access Commercial |
$549.33
|
| Rate for Payer: Quartz Beloit One Network |
$254.43
|
| Rate for Payer: Quartz Commercial |
$329.60
|
| Rate for Payer: Quartz Medicare Advantage |
$19.41
|
| Rate for Payer: The Alliance Commercial |
$73.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.41
|
| Rate for Payer: WEA Trust Commercial |
$318.03
|
| Rate for Payer: WPS Commercial |
$97.03
|
|
|
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 |
$401.06 |
| Max. Negotiated Rate |
$753.00 |
| Rate for Payer: Aetna Commercial |
$736.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$703.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$433.79
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cigna Commercial |
$753.00
|
| Rate for Payer: Health EOS Commercial |
$728.45
|
| Rate for Payer: HFN Commercial |
$753.00
|
| Rate for Payer: Multiplan Commercial |
$654.78
|
| Rate for Payer: Preferred Network Access Commercial |
$753.00
|
| Rate for Payer: Quartz Beloit One Network |
$401.06
|
| Rate for Payer: Quartz Commercial |
$491.09
|
| Rate for Payer: WEA Trust Commercial |
$450.16
|
| Rate for Payer: WPS Commercial |
$606.23
|
|
|
BCE XR Ribs w/PA Chest Left
|
Facility
|
OP
|
$787.00
|
|
|
Service Code
|
CPT 71101 TC,LT
|
| Hospital Charge Code |
5280646
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$229.17 |
| Max. Negotiated Rate |
$753.00 |
| Rate for Payer: Aetna Commercial |
$736.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$703.89
|
| Rate for Payer: Aetna Managed Medicare |
$229.17
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$433.79
|
| 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 |
$753.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$458.03
|
| Rate for Payer: Health EOS Commercial |
$728.45
|
| Rate for Payer: HFN Commercial |
$753.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$613.86
|
| Rate for Payer: Multiplan Commercial |
$654.78
|
| Rate for Payer: NAPHCARE Commercial |
$491.09
|
| Rate for Payer: Preferred Network Access Commercial |
$753.00
|
| Rate for Payer: Quartz Beloit One Network |
$401.06
|
| Rate for Payer: Quartz Commercial |
$532.01
|
| Rate for Payer: Quartz Medicare Advantage |
$491.09
|
| Rate for Payer: The Alliance Commercial |
$409.24
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$450.16
|
| Rate for Payer: WPS Commercial |
$606.23
|
|
|
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 |
$148.76 |
| Max. Negotiated Rate |
$777.56 |
| Rate for Payer: Aetna Commercial |
$777.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$703.89
|
| 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 |
$777.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$409.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$491.09
|
| Rate for Payer: Health EOS Commercial |
$744.82
|
| Rate for Payer: HFN Commercial |
$777.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$148.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$148.76
|
| Rate for Payer: Multiplan Commercial |
$654.78
|
| Rate for Payer: Preferred Network Access Commercial |
$777.56
|
| Rate for Payer: Quartz Beloit One Network |
$360.13
|
| Rate for Payer: Quartz Commercial |
$466.53
|
| Rate for Payer: The Alliance Commercial |
$409.24
|
| Rate for Payer: WEA Trust Commercial |
$450.16
|
| Rate for Payer: WPS Commercial |
$606.23
|
|
|
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 |
$120.34 |
| Max. Negotiated Rate |
$638.25 |
| Rate for Payer: Aetna Commercial |
$638.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| 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 |
$638.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$335.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$403.10
|
| Rate for Payer: Health EOS Commercial |
$611.37
|
| Rate for Payer: HFN Commercial |
$638.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$120.34
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: Preferred Network Access Commercial |
$638.25
|
| Rate for Payer: Quartz Beloit One Network |
$295.61
|
| Rate for Payer: Quartz Commercial |
$382.95
|
| Rate for Payer: The Alliance Commercial |
$335.92
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: WPS Commercial |
$497.61
|
|
|
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 |
$329.20 |
| Max. Negotiated Rate |
$618.09 |
| Rate for Payer: Aetna Commercial |
$604.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$356.08
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$618.09
|
| Rate for Payer: Health EOS Commercial |
$597.94
|
| Rate for Payer: HFN Commercial |
$618.09
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: Preferred Network Access Commercial |
$618.09
|
| Rate for Payer: Quartz Beloit One Network |
$329.20
|
| Rate for Payer: Quartz Commercial |
$403.10
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: WPS Commercial |
$497.61
|
|
|
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 |
$188.12 |
| Max. Negotiated Rate |
$618.09 |
| Rate for Payer: Aetna Commercial |
$604.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| Rate for Payer: Aetna Managed Medicare |
$188.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$356.08
|
| 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 |
$618.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$375.97
|
| Rate for Payer: Health EOS Commercial |
$597.94
|
| Rate for Payer: HFN Commercial |
$618.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$503.88
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: NAPHCARE Commercial |
$403.10
|
| Rate for Payer: Preferred Network Access Commercial |
$618.09
|
| Rate for Payer: Quartz Beloit One Network |
$329.20
|
| Rate for Payer: Quartz Commercial |
$436.70
|
| Rate for Payer: Quartz Medicare Advantage |
$403.10
|
| Rate for Payer: The Alliance Commercial |
$335.92
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: WPS Commercial |
$497.61
|
|
|
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 |
$341.94 |
| Max. Negotiated Rate |
$642.01 |
| Rate for Payer: Aetna Commercial |
$628.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$600.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$369.86
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$642.01
|
| Rate for Payer: Health EOS Commercial |
$621.08
|
| Rate for Payer: HFN Commercial |
$642.01
|
| Rate for Payer: Multiplan Commercial |
$558.27
|
| Rate for Payer: Preferred Network Access Commercial |
$642.01
|
| Rate for Payer: Quartz Beloit One Network |
$341.94
|
| Rate for Payer: Quartz Commercial |
$418.70
|
| Rate for Payer: WEA Trust Commercial |
$383.81
|
| Rate for Payer: WPS Commercial |
$516.87
|
|
|
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 |
$195.40 |
| Max. Negotiated Rate |
$642.01 |
| Rate for Payer: Aetna Commercial |
$628.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$600.14
|
| Rate for Payer: Aetna Managed Medicare |
$195.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$369.86
|
| 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 |
$642.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$390.52
|
| Rate for Payer: Health EOS Commercial |
$621.08
|
| Rate for Payer: HFN Commercial |
$642.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$523.38
|
| Rate for Payer: Multiplan Commercial |
$558.27
|
| Rate for Payer: NAPHCARE Commercial |
$418.70
|
| Rate for Payer: Preferred Network Access Commercial |
$642.01
|
| Rate for Payer: Quartz Beloit One Network |
$341.94
|
| Rate for Payer: Quartz Commercial |
$453.60
|
| Rate for Payer: Quartz Medicare Advantage |
$418.70
|
| Rate for Payer: The Alliance Commercial |
$348.92
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$383.81
|
| Rate for Payer: WPS Commercial |
$516.87
|
|
|
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 |
$120.34 |
| Max. Negotiated Rate |
$662.95 |
| Rate for Payer: Aetna Commercial |
$662.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$600.14
|
| 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 |
$662.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$348.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$418.70
|
| Rate for Payer: Health EOS Commercial |
$635.03
|
| Rate for Payer: HFN Commercial |
$662.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$120.34
|
| Rate for Payer: Multiplan Commercial |
$558.27
|
| Rate for Payer: Preferred Network Access Commercial |
$662.95
|
| Rate for Payer: Quartz Beloit One Network |
$307.05
|
| Rate for Payer: Quartz Commercial |
$397.77
|
| Rate for Payer: The Alliance Commercial |
$348.92
|
| Rate for Payer: WEA Trust Commercial |
$383.81
|
| Rate for Payer: WPS Commercial |
$516.87
|
|
|
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 |
$182.00 |
| Max. Negotiated Rate |
$598.00 |
| Rate for Payer: Aetna Commercial |
$585.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.00
|
| Rate for Payer: Aetna Managed Medicare |
$182.00
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$344.50
|
| 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 |
$598.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$363.75
|
| Rate for Payer: Health EOS Commercial |
$578.50
|
| Rate for Payer: HFN Commercial |
$598.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.50
|
| Rate for Payer: Multiplan Commercial |
$520.00
|
| Rate for Payer: NAPHCARE Commercial |
$390.00
|
| Rate for Payer: Preferred Network Access Commercial |
$598.00
|
| Rate for Payer: Quartz Beloit One Network |
$318.50
|
| Rate for Payer: Quartz Commercial |
$422.50
|
| Rate for Payer: Quartz Medicare Advantage |
$390.00
|
| Rate for Payer: The Alliance Commercial |
$225.39
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$357.50
|
| Rate for Payer: WPS Commercial |
$481.44
|
|
|
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 |
$318.50 |
| Max. Negotiated Rate |
$598.00 |
| Rate for Payer: Aetna Commercial |
$585.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$344.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$598.00
|
| Rate for Payer: Health EOS Commercial |
$578.50
|
| Rate for Payer: HFN Commercial |
$598.00
|
| Rate for Payer: Multiplan Commercial |
$520.00
|
| Rate for Payer: Preferred Network Access Commercial |
$598.00
|
| Rate for Payer: Quartz Beloit One Network |
$318.50
|
| Rate for Payer: Quartz Commercial |
$390.00
|
| Rate for Payer: WEA Trust Commercial |
$357.50
|
| Rate for Payer: WPS Commercial |
$481.44
|
|
|
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 |
$56.35 |
| Max. Negotiated Rate |
$617.50 |
| Rate for Payer: Aetna Commercial |
$617.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.00
|
| Rate for Payer: Aetna Managed Medicare |
$56.35
|
| Rate for Payer: Anthem Medicare Advantage |
$56.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$56.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$56.35
|
| 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 |
$617.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$325.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.35
|
| Rate for Payer: Health EOS Commercial |
$591.50
|
| Rate for Payer: HFN Commercial |
$617.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$192.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$192.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$56.35
|
| Rate for Payer: Multiplan Commercial |
$520.00
|
| Rate for Payer: NAPHCARE Commercial |
$84.52
|
| Rate for Payer: Preferred Network Access Commercial |
$617.50
|
| Rate for Payer: Quartz Beloit One Network |
$286.00
|
| Rate for Payer: Quartz Commercial |
$370.50
|
| Rate for Payer: Quartz Medicare Advantage |
$56.35
|
| Rate for Payer: The Alliance Commercial |
$214.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.35
|
| Rate for Payer: WEA Trust Commercial |
$357.50
|
| Rate for Payer: WPS Commercial |
$281.74
|
|
|
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 |
$117.56 |
| Max. Negotiated Rate |
$674.54 |
| Rate for Payer: Aetna Commercial |
$659.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$630.55
|
| Rate for Payer: Aetna Managed Medicare |
$205.30
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$388.60
|
| 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 |
$674.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$410.31
|
| Rate for Payer: Health EOS Commercial |
$652.55
|
| Rate for Payer: HFN Commercial |
$674.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$549.90
|
| Rate for Payer: Multiplan Commercial |
$586.56
|
| Rate for Payer: NAPHCARE Commercial |
$439.92
|
| Rate for Payer: Preferred Network Access Commercial |
$674.54
|
| Rate for Payer: Quartz Beloit One Network |
$359.27
|
| Rate for Payer: Quartz Commercial |
$476.58
|
| Rate for Payer: Quartz Medicare Advantage |
$439.92
|
| Rate for Payer: The Alliance Commercial |
$117.56
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$403.26
|
| Rate for Payer: WPS Commercial |
$543.06
|
|
|
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 |
$29.39 |
| Max. Negotiated Rate |
$696.54 |
| Rate for Payer: Aetna Commercial |
$696.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$630.55
|
| Rate for Payer: Aetna Managed Medicare |
$29.39
|
| Rate for Payer: Anthem Medicare Advantage |
$29.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.39
|
| 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 |
$696.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$366.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.39
|
| Rate for Payer: Health EOS Commercial |
$667.21
|
| Rate for Payer: HFN Commercial |
$696.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$100.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.39
|
| Rate for Payer: Multiplan Commercial |
$586.56
|
| Rate for Payer: NAPHCARE Commercial |
$44.09
|
| Rate for Payer: Preferred Network Access Commercial |
$696.54
|
| Rate for Payer: Quartz Beloit One Network |
$322.61
|
| Rate for Payer: Quartz Commercial |
$417.92
|
| Rate for Payer: Quartz Medicare Advantage |
$29.39
|
| Rate for Payer: The Alliance Commercial |
$111.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.39
|
| Rate for Payer: WEA Trust Commercial |
$403.26
|
| Rate for Payer: WPS Commercial |
$146.95
|
|
|
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 |
$359.27 |
| Max. Negotiated Rate |
$674.54 |
| Rate for Payer: Aetna Commercial |
$659.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$630.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$388.60
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$674.54
|
| Rate for Payer: Health EOS Commercial |
$652.55
|
| Rate for Payer: HFN Commercial |
$674.54
|
| Rate for Payer: Multiplan Commercial |
$586.56
|
| Rate for Payer: Preferred Network Access Commercial |
$674.54
|
| Rate for Payer: Quartz Beloit One Network |
$359.27
|
| Rate for Payer: Quartz Commercial |
$439.92
|
| Rate for Payer: WEA Trust Commercial |
$403.26
|
| Rate for Payer: WPS Commercial |
$543.06
|
|
|
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 |
$297.61 |
| Max. Negotiated Rate |
$558.77 |
| Rate for Payer: Aetna Commercial |
$546.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$522.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$321.90
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cigna Commercial |
$558.77
|
| Rate for Payer: Health EOS Commercial |
$540.55
|
| Rate for Payer: HFN Commercial |
$558.77
|
| Rate for Payer: Multiplan Commercial |
$485.89
|
| Rate for Payer: Preferred Network Access Commercial |
$558.77
|
| Rate for Payer: Quartz Beloit One Network |
$297.61
|
| Rate for Payer: Quartz Commercial |
$364.42
|
| Rate for Payer: WEA Trust Commercial |
$334.05
|
| Rate for Payer: WPS Commercial |
$449.86
|
|
|
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 |
$170.06 |
| Max. Negotiated Rate |
$558.77 |
| Rate for Payer: Aetna Commercial |
$546.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$522.33
|
| Rate for Payer: Aetna Managed Medicare |
$170.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$321.90
|
| 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 |
$558.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$339.89
|
| Rate for Payer: Health EOS Commercial |
$540.55
|
| Rate for Payer: HFN Commercial |
$558.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$455.52
|
| Rate for Payer: Multiplan Commercial |
$485.89
|
| Rate for Payer: NAPHCARE Commercial |
$364.42
|
| Rate for Payer: Preferred Network Access Commercial |
$558.77
|
| Rate for Payer: Quartz Beloit One Network |
$297.61
|
| Rate for Payer: Quartz Commercial |
$394.78
|
| Rate for Payer: Quartz Medicare Advantage |
$364.42
|
| Rate for Payer: The Alliance Commercial |
$303.68
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$334.05
|
| Rate for Payer: WPS Commercial |
$449.86
|
|
|
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 |
$110.54 |
| Max. Negotiated Rate |
$576.99 |
| Rate for Payer: Aetna Commercial |
$576.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$522.33
|
| 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 |
$576.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$303.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$364.42
|
| Rate for Payer: Health EOS Commercial |
$552.70
|
| Rate for Payer: HFN Commercial |
$576.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$110.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.54
|
| Rate for Payer: Multiplan Commercial |
$485.89
|
| Rate for Payer: Preferred Network Access Commercial |
$576.99
|
| Rate for Payer: Quartz Beloit One Network |
$267.24
|
| Rate for Payer: Quartz Commercial |
$346.20
|
| Rate for Payer: The Alliance Commercial |
$303.68
|
| Rate for Payer: WEA Trust Commercial |
$334.05
|
| Rate for Payer: WPS Commercial |
$449.86
|
|
|
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 |
$26.40 |
| Max. Negotiated Rate |
$439.66 |
| Rate for Payer: Aetna Commercial |
$439.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Aetna Managed Medicare |
$26.40
|
| Rate for Payer: Anthem Medicare Advantage |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26.40
|
| 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 |
$439.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$231.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.40
|
| Rate for Payer: Health EOS Commercial |
$421.15
|
| Rate for Payer: HFN Commercial |
$439.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$86.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: NAPHCARE Commercial |
$39.59
|
| Rate for Payer: Preferred Network Access Commercial |
$439.66
|
| Rate for Payer: Quartz Beloit One Network |
$203.63
|
| Rate for Payer: Quartz Commercial |
$263.80
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$100.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$131.98
|
|
|
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 |
$226.77 |
| Max. Negotiated Rate |
$425.78 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.28
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$425.78
|
| Rate for Payer: Health EOS Commercial |
$411.89
|
| Rate for Payer: HFN Commercial |
$425.78
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: Preferred Network Access Commercial |
$425.78
|
| Rate for Payer: Quartz Beloit One Network |
$226.77
|
| Rate for Payer: Quartz Commercial |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$342.78
|
|
|
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 |
$105.58 |
| Max. Negotiated Rate |
$848.64 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Aetna Managed Medicare |
$129.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$848.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$681.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.28
|
| 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 |
$425.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.99
|
| Rate for Payer: Health EOS Commercial |
$411.89
|
| Rate for Payer: HFN Commercial |
$425.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.10
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: NAPHCARE Commercial |
$277.68
|
| Rate for Payer: Preferred Network Access Commercial |
$425.78
|
| Rate for Payer: Quartz Beloit One Network |
$226.77
|
| Rate for Payer: Quartz Commercial |
$300.82
|
| Rate for Payer: Quartz Medicare Advantage |
$277.68
|
| Rate for Payer: The Alliance Commercial |
$105.58
|
| Rate for Payer: United Healthcare PPO |
$596.96
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$342.78
|
|
|
BCG 1 Unit Charge
|
Facility
|
IP
|
$770.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
2958944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$392.39 |
| Max. Negotiated Rate |
$736.74 |
| Rate for Payer: Aetna Commercial |
$720.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$688.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$424.42
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$736.74
|
| Rate for Payer: Health EOS Commercial |
$712.71
|
| Rate for Payer: HFN Commercial |
$736.74
|
| Rate for Payer: Multiplan Commercial |
$640.64
|
| Rate for Payer: Preferred Network Access Commercial |
$736.74
|
| Rate for Payer: Quartz Beloit One Network |
$392.39
|
| Rate for Payer: Quartz Commercial |
$480.48
|
| Rate for Payer: WEA Trust Commercial |
$440.44
|
| Rate for Payer: WPS Commercial |
$593.13
|
|
|
BCG 1 Unit Charge
|
Professional
|
Both
|
$770.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
2958944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$760.76 |
| Rate for Payer: Aetna Commercial |
$760.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$688.69
|
| Rate for Payer: Aetna Managed Medicare |
$3.41
|
| Rate for Payer: Anthem Medicare Advantage |
$3.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.41
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$760.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.01
|
| Rate for Payer: Health EOS Commercial |
$728.73
|
| Rate for Payer: HFN Commercial |
$760.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.41
|
| Rate for Payer: Multiplan Commercial |
$640.64
|
| Rate for Payer: NAPHCARE Commercial |
$5.12
|
| Rate for Payer: Preferred Network Access Commercial |
$760.76
|
| Rate for Payer: Quartz Beloit One Network |
$352.35
|
| Rate for Payer: Quartz Commercial |
$456.46
|
| Rate for Payer: Quartz Medicare Advantage |
$3.41
|
| Rate for Payer: The Alliance Commercial |
$9.38
|
| Rate for Payer: United Healthcare Medicaid |
$3.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.41
|
| Rate for Payer: WEA Trust Commercial |
$440.44
|
| Rate for Payer: WPS Commercial |
$7.51
|
|
