|
CT Angiography Pelvis w/ + w/o Contrast
|
Facility
|
IP
|
$5,302.00
|
|
|
Service Code
|
CPT 72191 TC
|
| Hospital Charge Code |
1240849
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,597.98 |
| Max. Negotiated Rate |
$4,877.84 |
| Rate for Payer: Aetna Commercial |
$4,771.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,559.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,810.06
|
| Rate for Payer: Cash Price |
$1,590.60
|
| Rate for Payer: Cigna Commercial |
$4,877.84
|
| Rate for Payer: Health EOS Commercial |
$4,718.78
|
| Rate for Payer: HFN Commercial |
$4,877.84
|
| Rate for Payer: Multiplan Commercial |
$4,241.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,181.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,877.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,597.98
|
| Rate for Payer: Quartz Commercial |
$3,181.20
|
| Rate for Payer: WEA Trust Commercial |
$2,916.10
|
| Rate for Payer: WPS Commercial |
$3,927.19
|
|
|
CT Angiography Upper Extremity Bilat
|
Professional
|
Both
|
$3,269.00
|
|
|
Service Code
|
CPT 73206 LT,TC
|
| Hospital Charge Code |
1240851
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,438.36 |
| Max. Negotiated Rate |
$3,105.55 |
| Rate for Payer: Aetna Commercial |
$3,105.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,811.34
|
| Rate for Payer: Cash Price |
$980.70
|
| Rate for Payer: Cash Price |
$980.70
|
| Rate for Payer: Cigna Commercial |
$3,105.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,634.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,961.40
|
| Rate for Payer: Health EOS Commercial |
$2,974.79
|
| Rate for Payer: HFN Commercial |
$3,105.55
|
| Rate for Payer: Multiplan Commercial |
$2,615.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,105.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,438.36
|
| Rate for Payer: Quartz Commercial |
$1,863.33
|
| Rate for Payer: The Alliance Commercial |
$1,634.50
|
| Rate for Payer: WEA Trust Commercial |
$1,797.95
|
| Rate for Payer: WPS Commercial |
$2,421.35
|
|
|
CT Angiography Upper Extremity Bilat
|
Facility
|
IP
|
$3,269.00
|
|
|
Service Code
|
CPT 73206 LT,TC
|
| Hospital Charge Code |
1240851
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,601.81 |
| Max. Negotiated Rate |
$3,007.48 |
| Rate for Payer: Aetna Commercial |
$2,942.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,811.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,732.57
|
| Rate for Payer: Cash Price |
$980.70
|
| Rate for Payer: Cigna Commercial |
$3,007.48
|
| Rate for Payer: Health EOS Commercial |
$2,909.41
|
| Rate for Payer: HFN Commercial |
$3,007.48
|
| Rate for Payer: Multiplan Commercial |
$2,615.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,961.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,007.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,601.81
|
| Rate for Payer: Quartz Commercial |
$1,961.40
|
| Rate for Payer: WEA Trust Commercial |
$1,797.95
|
| Rate for Payer: WPS Commercial |
$2,421.35
|
|
|
CT Angiography Upper Extremity Bilat
|
Facility
|
OP
|
$3,269.00
|
|
|
Service Code
|
CPT 73206 LT,TC
|
| Hospital Charge Code |
1240851
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$915.32 |
| Max. Negotiated Rate |
$13,076.00 |
| Rate for Payer: Aetna Commercial |
$2,942.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,811.34
|
| Rate for Payer: Aetna Managed Medicare |
$915.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,732.57
|
| Rate for Payer: Cash Price |
$980.70
|
| Rate for Payer: Cash Price |
$980.70
|
| Rate for Payer: Cash Price |
$980.70
|
| Rate for Payer: Cigna Commercial |
$3,007.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,829.33
|
| Rate for Payer: Health EOS Commercial |
$2,909.41
|
| Rate for Payer: HFN Commercial |
$3,007.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,451.75
|
| Rate for Payer: Multiplan Commercial |
$2,615.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,961.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,007.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,601.81
|
| Rate for Payer: Quartz Commercial |
$2,124.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,961.40
|
| Rate for Payer: The Alliance Commercial |
$13,076.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,797.95
|
| Rate for Payer: WPS Commercial |
$2,421.35
|
|
|
CT Angiography Upper Extremity Left
|
Facility
|
IP
|
$3,396.00
|
|
|
Service Code
|
CPT 73206 LT,TC
|
| Hospital Charge Code |
1240853
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,664.04 |
| Max. Negotiated Rate |
$3,124.32 |
| Rate for Payer: Aetna Commercial |
$3,056.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,920.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,799.88
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cigna Commercial |
$3,124.32
|
| Rate for Payer: Health EOS Commercial |
$3,022.44
|
| Rate for Payer: HFN Commercial |
$3,124.32
|
| Rate for Payer: Multiplan Commercial |
$2,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,037.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,124.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,664.04
|
| Rate for Payer: Quartz Commercial |
$2,037.60
|
| Rate for Payer: WEA Trust Commercial |
$1,867.80
|
| Rate for Payer: WPS Commercial |
$2,515.42
|
|
|
CT Angiography Upper Extremity Left
|
Facility
|
OP
|
$3,396.00
|
|
|
Service Code
|
CPT 73206 LT,TC
|
| Hospital Charge Code |
1240853
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$950.88 |
| Max. Negotiated Rate |
$13,584.00 |
| Rate for Payer: Aetna Commercial |
$3,056.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,920.56
|
| Rate for Payer: Aetna Managed Medicare |
$950.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,799.88
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cigna Commercial |
$3,124.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,900.40
|
| Rate for Payer: Health EOS Commercial |
$3,022.44
|
| Rate for Payer: HFN Commercial |
$3,124.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,547.00
|
| Rate for Payer: Multiplan Commercial |
$2,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,037.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,124.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,664.04
|
| Rate for Payer: Quartz Commercial |
$2,207.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,037.60
|
| Rate for Payer: The Alliance Commercial |
$13,584.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,867.80
|
| Rate for Payer: WPS Commercial |
$2,515.42
|
|
|
CT Angiography Upper Extremity Left
|
Professional
|
Both
|
$3,396.00
|
|
|
Service Code
|
CPT 73206 LT,TC
|
| Hospital Charge Code |
1240853
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,494.24 |
| Max. Negotiated Rate |
$3,226.20 |
| Rate for Payer: Aetna Commercial |
$3,226.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,920.56
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cigna Commercial |
$3,226.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,698.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,037.60
|
| Rate for Payer: Health EOS Commercial |
$3,090.36
|
| Rate for Payer: HFN Commercial |
$3,226.20
|
| Rate for Payer: Multiplan Commercial |
$2,716.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,226.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,494.24
|
| Rate for Payer: Quartz Commercial |
$1,935.72
|
| Rate for Payer: The Alliance Commercial |
$1,698.00
|
| Rate for Payer: WEA Trust Commercial |
$1,867.80
|
| Rate for Payer: WPS Commercial |
$2,515.42
|
|
|
CT Angiography Upper Extremity Right
|
Professional
|
Both
|
$2,974.00
|
|
|
Service Code
|
CPT 73206 TC,RT
|
| Hospital Charge Code |
1966799
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,308.56 |
| Max. Negotiated Rate |
$2,825.30 |
| Rate for Payer: Aetna Commercial |
$2,825.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,557.64
|
| Rate for Payer: Cash Price |
$892.20
|
| Rate for Payer: Cash Price |
$892.20
|
| Rate for Payer: Cigna Commercial |
$2,825.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,487.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,784.40
|
| Rate for Payer: Health EOS Commercial |
$2,706.34
|
| Rate for Payer: HFN Commercial |
$2,825.30
|
| Rate for Payer: Multiplan Commercial |
$2,379.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,825.30
|
| Rate for Payer: Quartz Beloit One Network |
$1,308.56
|
| Rate for Payer: Quartz Commercial |
$1,695.18
|
| Rate for Payer: The Alliance Commercial |
$1,487.00
|
| Rate for Payer: WEA Trust Commercial |
$1,635.70
|
| Rate for Payer: WPS Commercial |
$2,202.84
|
|
|
CT Angiography Upper Extremity Right
|
Facility
|
IP
|
$3,396.00
|
|
|
Service Code
|
CPT 73206 RT,TC
|
| Hospital Charge Code |
1240855
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,664.04 |
| Max. Negotiated Rate |
$3,124.32 |
| Rate for Payer: Aetna Commercial |
$3,056.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,920.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,799.88
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cigna Commercial |
$3,124.32
|
| Rate for Payer: Health EOS Commercial |
$3,022.44
|
| Rate for Payer: HFN Commercial |
$3,124.32
|
| Rate for Payer: Multiplan Commercial |
$2,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,037.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,124.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,664.04
|
| Rate for Payer: Quartz Commercial |
$2,037.60
|
| Rate for Payer: WEA Trust Commercial |
$1,867.80
|
| Rate for Payer: WPS Commercial |
$2,515.42
|
|
|
CT Angiography Upper Extremity Right
|
Professional
|
Both
|
$3,396.00
|
|
|
Service Code
|
CPT 73206 RT,TC
|
| Hospital Charge Code |
1240855
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,494.24 |
| Max. Negotiated Rate |
$3,226.20 |
| Rate for Payer: Aetna Commercial |
$3,226.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,920.56
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cigna Commercial |
$3,226.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,698.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,037.60
|
| Rate for Payer: Health EOS Commercial |
$3,090.36
|
| Rate for Payer: HFN Commercial |
$3,226.20
|
| Rate for Payer: Multiplan Commercial |
$2,716.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,226.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,494.24
|
| Rate for Payer: Quartz Commercial |
$1,935.72
|
| Rate for Payer: The Alliance Commercial |
$1,698.00
|
| Rate for Payer: WEA Trust Commercial |
$1,867.80
|
| Rate for Payer: WPS Commercial |
$2,515.42
|
|
|
CT Angiography Upper Extremity Right
|
Facility
|
OP
|
$2,974.00
|
|
|
Service Code
|
CPT 73206 TC,RT
|
| Hospital Charge Code |
1966799
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$832.72 |
| Max. Negotiated Rate |
$11,896.00 |
| Rate for Payer: Aetna Commercial |
$2,676.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,557.64
|
| Rate for Payer: Aetna Managed Medicare |
$832.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,576.22
|
| Rate for Payer: Cash Price |
$892.20
|
| Rate for Payer: Cash Price |
$892.20
|
| Rate for Payer: Cash Price |
$892.20
|
| Rate for Payer: Cigna Commercial |
$2,736.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,664.25
|
| Rate for Payer: Health EOS Commercial |
$2,646.86
|
| Rate for Payer: HFN Commercial |
$2,736.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,230.50
|
| Rate for Payer: Multiplan Commercial |
$2,379.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,784.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,736.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,457.26
|
| Rate for Payer: Quartz Commercial |
$1,933.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,784.40
|
| Rate for Payer: The Alliance Commercial |
$11,896.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,635.70
|
| Rate for Payer: WPS Commercial |
$2,202.84
|
|
|
CT Angiography Upper Extremity Right
|
Facility
|
OP
|
$3,396.00
|
|
|
Service Code
|
CPT 73206 RT,TC
|
| Hospital Charge Code |
1240855
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$950.88 |
| Max. Negotiated Rate |
$13,584.00 |
| Rate for Payer: Aetna Commercial |
$3,056.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,920.56
|
| Rate for Payer: Aetna Managed Medicare |
$950.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,799.88
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cash Price |
$1,018.80
|
| Rate for Payer: Cigna Commercial |
$3,124.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,900.40
|
| Rate for Payer: Health EOS Commercial |
$3,022.44
|
| Rate for Payer: HFN Commercial |
$3,124.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,547.00
|
| Rate for Payer: Multiplan Commercial |
$2,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,037.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,124.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,664.04
|
| Rate for Payer: Quartz Commercial |
$2,207.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,037.60
|
| Rate for Payer: The Alliance Commercial |
$13,584.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,867.80
|
| Rate for Payer: WPS Commercial |
$2,515.42
|
|
|
CT Angiography Upper Extremity Right
|
Facility
|
IP
|
$2,974.00
|
|
|
Service Code
|
CPT 73206 TC,RT
|
| Hospital Charge Code |
1966799
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,457.26 |
| Max. Negotiated Rate |
$2,736.08 |
| Rate for Payer: Aetna Commercial |
$2,676.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,557.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,576.22
|
| Rate for Payer: Cash Price |
$892.20
|
| Rate for Payer: Cigna Commercial |
$2,736.08
|
| Rate for Payer: Health EOS Commercial |
$2,646.86
|
| Rate for Payer: HFN Commercial |
$2,736.08
|
| Rate for Payer: Multiplan Commercial |
$2,379.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,784.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,736.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,457.26
|
| Rate for Payer: Quartz Commercial |
$1,784.40
|
| Rate for Payer: WEA Trust Commercial |
$1,635.70
|
| Rate for Payer: WPS Commercial |
$2,202.84
|
|
|
CT Ankle w/ Contrast Bilateral
|
Professional
|
Both
|
$5,737.00
|
|
|
Service Code
|
CPT 73701
|
| Hospital Charge Code |
625686
|
| Min. Negotiated Rate |
$616.16 |
| Max. Negotiated Rate |
$5,450.15 |
| Rate for Payer: Aetna Commercial |
$5,450.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,933.82
|
| Rate for Payer: Cash Price |
$1,721.10
|
| Rate for Payer: Cash Price |
$1,721.10
|
| Rate for Payer: Cigna Commercial |
$5,450.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,868.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,442.20
|
| Rate for Payer: Health EOS Commercial |
$5,220.67
|
| Rate for Payer: HFN Commercial |
$5,450.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$616.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$616.16
|
| Rate for Payer: Multiplan Commercial |
$4,589.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,450.15
|
| Rate for Payer: Quartz Beloit One Network |
$2,524.28
|
| Rate for Payer: Quartz Commercial |
$3,270.09
|
| Rate for Payer: The Alliance Commercial |
$2,868.50
|
| Rate for Payer: WEA Trust Commercial |
$3,155.35
|
| Rate for Payer: WPS Commercial |
$4,249.40
|
|
|
CT Ankle w/ Contrast Bilateral
|
Facility
|
OP
|
$5,737.00
|
|
|
Service Code
|
CPT 73701
|
| Hospital Charge Code |
625686
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$5,278.04 |
| Rate for Payer: Aetna Commercial |
$5,163.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,933.82
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,729.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,868.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,753.76
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,040.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| Rate for Payer: Cash Price |
$1,721.10
|
| Rate for Payer: Cash Price |
$1,721.10
|
| Rate for Payer: Cigna Commercial |
$5,278.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,210.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$5,105.93
|
| Rate for Payer: HFN Commercial |
$5,278.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$4,589.60
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,278.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,811.13
|
| Rate for Payer: Quartz Commercial |
$3,729.05
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$726.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: WEA Trust Commercial |
$3,155.35
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$4,249.40
|
|
|
CT Ankle w/ Contrast Bilateral
|
Facility
|
OP
|
$2,808.00
|
|
|
Service Code
|
CPT 73701 LT,TC
|
| Hospital Charge Code |
1240863
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$786.24 |
| Max. Negotiated Rate |
$11,232.00 |
| Rate for Payer: Aetna Commercial |
$2,527.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,414.88
|
| Rate for Payer: Aetna Managed Medicare |
$786.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,488.24
|
| Rate for Payer: Cash Price |
$842.40
|
| Rate for Payer: Cash Price |
$842.40
|
| Rate for Payer: Cash Price |
$842.40
|
| Rate for Payer: Cigna Commercial |
$2,583.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$2,499.12
|
| Rate for Payer: HFN Commercial |
$2,583.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,106.00
|
| Rate for Payer: Multiplan Commercial |
$2,246.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,684.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,583.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,375.92
|
| Rate for Payer: Quartz Commercial |
$1,825.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,684.80
|
| Rate for Payer: The Alliance Commercial |
$11,232.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,544.40
|
| Rate for Payer: WPS Commercial |
$2,079.89
|
|
|
CT Ankle w/ Contrast Bilateral
|
Facility
|
IP
|
$5,737.00
|
|
|
Service Code
|
CPT 73701
|
| Hospital Charge Code |
625686
|
| Min. Negotiated Rate |
$2,811.13 |
| Max. Negotiated Rate |
$5,278.04 |
| Rate for Payer: Aetna Commercial |
$5,163.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,933.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,040.61
|
| Rate for Payer: Cash Price |
$1,721.10
|
| Rate for Payer: Cigna Commercial |
$5,278.04
|
| Rate for Payer: Health EOS Commercial |
$5,105.93
|
| Rate for Payer: HFN Commercial |
$5,278.04
|
| Rate for Payer: Multiplan Commercial |
$4,589.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,442.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,278.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,811.13
|
| Rate for Payer: Quartz Commercial |
$3,442.20
|
| Rate for Payer: WEA Trust Commercial |
$3,155.35
|
| Rate for Payer: WPS Commercial |
$4,249.40
|
|
|
CT Ankle w/ Contrast Bilateral
|
Facility
|
IP
|
$2,808.00
|
|
|
Service Code
|
CPT 73701 LT,TC
|
| Hospital Charge Code |
1240863
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,375.92 |
| Max. Negotiated Rate |
$2,583.36 |
| Rate for Payer: Aetna Commercial |
$2,527.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,414.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,488.24
|
| Rate for Payer: Cash Price |
$842.40
|
| Rate for Payer: Cigna Commercial |
$2,583.36
|
| Rate for Payer: Health EOS Commercial |
$2,499.12
|
| Rate for Payer: HFN Commercial |
$2,583.36
|
| Rate for Payer: Multiplan Commercial |
$2,246.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,684.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,583.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,375.92
|
| Rate for Payer: Quartz Commercial |
$1,684.80
|
| Rate for Payer: WEA Trust Commercial |
$1,544.40
|
| Rate for Payer: WPS Commercial |
$2,079.89
|
|
|
CT Ankle w/ Contrast Bilateral
|
Professional
|
Both
|
$2,808.00
|
|
|
Service Code
|
CPT 73701 LT,TC
|
| Hospital Charge Code |
1240863
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,235.52 |
| Max. Negotiated Rate |
$2,667.60 |
| Rate for Payer: Aetna Commercial |
$2,667.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,414.88
|
| Rate for Payer: Cash Price |
$842.40
|
| Rate for Payer: Cash Price |
$842.40
|
| Rate for Payer: Cigna Commercial |
$2,667.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,404.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,684.80
|
| Rate for Payer: Health EOS Commercial |
$2,555.28
|
| Rate for Payer: HFN Commercial |
$2,667.60
|
| Rate for Payer: Multiplan Commercial |
$2,246.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,667.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,235.52
|
| Rate for Payer: Quartz Commercial |
$1,600.56
|
| Rate for Payer: The Alliance Commercial |
$1,404.00
|
| Rate for Payer: WEA Trust Commercial |
$1,544.40
|
| Rate for Payer: WPS Commercial |
$2,079.89
|
|
|
CT Ankle w/ Contrast Left
|
Professional
|
Both
|
$2,916.00
|
|
|
Service Code
|
CPT 73701 TC,LT
|
| Hospital Charge Code |
1240865
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,283.04 |
| Max. Negotiated Rate |
$2,770.20 |
| Rate for Payer: Aetna Commercial |
$2,770.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,507.76
|
| Rate for Payer: Cash Price |
$874.80
|
| Rate for Payer: Cash Price |
$874.80
|
| Rate for Payer: Cigna Commercial |
$2,770.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,458.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,749.60
|
| Rate for Payer: Health EOS Commercial |
$2,653.56
|
| Rate for Payer: HFN Commercial |
$2,770.20
|
| Rate for Payer: Multiplan Commercial |
$2,332.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,770.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,283.04
|
| Rate for Payer: Quartz Commercial |
$1,662.12
|
| Rate for Payer: The Alliance Commercial |
$1,458.00
|
| Rate for Payer: WEA Trust Commercial |
$1,603.80
|
| Rate for Payer: WPS Commercial |
$2,159.88
|
|
|
CT Ankle w/ Contrast Left
|
Facility
|
OP
|
$2,916.00
|
|
|
Service Code
|
CPT 73701 TC,LT
|
| Hospital Charge Code |
1240865
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$816.48 |
| Max. Negotiated Rate |
$11,664.00 |
| Rate for Payer: Aetna Commercial |
$2,624.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,507.76
|
| Rate for Payer: Aetna Managed Medicare |
$816.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,545.48
|
| Rate for Payer: Cash Price |
$874.80
|
| Rate for Payer: Cash Price |
$874.80
|
| Rate for Payer: Cash Price |
$874.80
|
| Rate for Payer: Cigna Commercial |
$2,682.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,631.79
|
| Rate for Payer: Health EOS Commercial |
$2,595.24
|
| Rate for Payer: HFN Commercial |
$2,682.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,187.00
|
| Rate for Payer: Multiplan Commercial |
$2,332.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,749.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,682.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,428.84
|
| Rate for Payer: Quartz Commercial |
$1,895.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,749.60
|
| Rate for Payer: The Alliance Commercial |
$11,664.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,603.80
|
| Rate for Payer: WPS Commercial |
$2,159.88
|
|
|
CT Ankle w/ Contrast Left
|
Facility
|
IP
|
$2,868.00
|
|
|
Service Code
|
CPT 73701
|
| Hospital Charge Code |
625688
|
| Min. Negotiated Rate |
$1,405.32 |
| Max. Negotiated Rate |
$2,638.56 |
| Rate for Payer: Aetna Commercial |
$2,581.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,466.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,520.04
|
| Rate for Payer: Cash Price |
$860.40
|
| Rate for Payer: Cigna Commercial |
$2,638.56
|
| Rate for Payer: Health EOS Commercial |
$2,552.52
|
| Rate for Payer: HFN Commercial |
$2,638.56
|
| Rate for Payer: Multiplan Commercial |
$2,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,638.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,405.32
|
| Rate for Payer: Quartz Commercial |
$1,720.80
|
| Rate for Payer: WEA Trust Commercial |
$1,577.40
|
| Rate for Payer: WPS Commercial |
$2,124.33
|
|
|
CT Ankle w/ Contrast Left
|
Facility
|
IP
|
$2,916.00
|
|
|
Service Code
|
CPT 73701 TC,LT
|
| Hospital Charge Code |
1240865
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,428.84 |
| Max. Negotiated Rate |
$2,682.72 |
| Rate for Payer: Aetna Commercial |
$2,624.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,507.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,545.48
|
| Rate for Payer: Cash Price |
$874.80
|
| Rate for Payer: Cigna Commercial |
$2,682.72
|
| Rate for Payer: Health EOS Commercial |
$2,595.24
|
| Rate for Payer: HFN Commercial |
$2,682.72
|
| Rate for Payer: Multiplan Commercial |
$2,332.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,749.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,682.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,428.84
|
| Rate for Payer: Quartz Commercial |
$1,749.60
|
| Rate for Payer: WEA Trust Commercial |
$1,603.80
|
| Rate for Payer: WPS Commercial |
$2,159.88
|
|
|
CT Ankle w/ Contrast Left
|
Facility
|
OP
|
$2,868.00
|
|
|
Service Code
|
CPT 73701
|
| Hospital Charge Code |
625688
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$2,638.56 |
| Rate for Payer: Aetna Commercial |
$2,581.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,466.48
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,864.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,434.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,376.64
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,520.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| Rate for Payer: Cash Price |
$860.40
|
| Rate for Payer: Cash Price |
$860.40
|
| Rate for Payer: Cigna Commercial |
$2,638.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,604.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$2,552.52
|
| Rate for Payer: HFN Commercial |
$2,638.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$2,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,638.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,405.32
|
| Rate for Payer: Quartz Commercial |
$1,864.20
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$726.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: WEA Trust Commercial |
$1,577.40
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$2,124.33
|
|
|
CT Ankle w/ Contrast Left
|
Professional
|
Both
|
$2,868.00
|
|
|
Service Code
|
CPT 73701
|
| Hospital Charge Code |
625688
|
| Min. Negotiated Rate |
$616.16 |
| Max. Negotiated Rate |
$2,724.60 |
| Rate for Payer: Aetna Commercial |
$2,724.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,466.48
|
| Rate for Payer: Cash Price |
$860.40
|
| Rate for Payer: Cash Price |
$860.40
|
| Rate for Payer: Cigna Commercial |
$2,724.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,434.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,720.80
|
| Rate for Payer: Health EOS Commercial |
$2,609.88
|
| Rate for Payer: HFN Commercial |
$2,724.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$616.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$616.16
|
| Rate for Payer: Multiplan Commercial |
$2,294.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,724.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,261.92
|
| Rate for Payer: Quartz Commercial |
$1,634.76
|
| Rate for Payer: The Alliance Commercial |
$1,434.00
|
| Rate for Payer: WEA Trust Commercial |
$1,577.40
|
| Rate for Payer: WPS Commercial |
$2,124.33
|
|
