|
CT Ankle w/ + w/o Contrast Right
|
Facility
|
OP
|
$3,773.00
|
|
|
Service Code
|
CPT 73702 TC,RT
|
| Hospital Charge Code |
2980083
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,098.70 |
| Max. Negotiated Rate |
$3,610.01 |
| Rate for Payer: Aetna Commercial |
$3,531.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,374.57
|
| Rate for Payer: Aetna Managed Medicare |
$1,098.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,079.68
|
| Rate for Payer: Cash Price |
$1,131.90
|
| Rate for Payer: Cash Price |
$1,131.90
|
| Rate for Payer: Cash Price |
$1,131.90
|
| Rate for Payer: Cigna Commercial |
$3,610.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,195.89
|
| Rate for Payer: Health EOS Commercial |
$3,492.29
|
| Rate for Payer: HFN Commercial |
$3,610.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,942.94
|
| Rate for Payer: Multiplan Commercial |
$3,139.14
|
| Rate for Payer: NAPHCARE Commercial |
$2,354.35
|
| Rate for Payer: Preferred Network Access Commercial |
$3,610.01
|
| Rate for Payer: Quartz Beloit One Network |
$1,922.72
|
| Rate for Payer: Quartz Commercial |
$2,550.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,354.35
|
| Rate for Payer: The Alliance Commercial |
$1,961.96
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$2,158.16
|
| Rate for Payer: WPS Commercial |
$2,906.34
|
|
|
CT Ankle w/ + w/o Contrast Right
|
Professional
|
Both
|
$3,845.00
|
|
|
Service Code
|
CPT 73702
|
| Hospital Charge Code |
625684
|
| Min. Negotiated Rate |
$193.71 |
| Max. Negotiated Rate |
$3,798.86 |
| Rate for Payer: Aetna Commercial |
$3,798.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,438.97
|
| Rate for Payer: Aetna Managed Medicare |
$193.71
|
| Rate for Payer: Anthem Medicare Advantage |
$193.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$193.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$193.71
|
| Rate for Payer: Cash Price |
$1,153.50
|
| Rate for Payer: Cash Price |
$1,153.50
|
| Rate for Payer: Cash Price |
$1,153.50
|
| Rate for Payer: Cigna Commercial |
$3,798.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,999.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.71
|
| Rate for Payer: Health EOS Commercial |
$3,638.91
|
| Rate for Payer: HFN Commercial |
$3,798.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$747.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$747.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$193.71
|
| Rate for Payer: Multiplan Commercial |
$3,199.04
|
| Rate for Payer: NAPHCARE Commercial |
$290.57
|
| Rate for Payer: Preferred Network Access Commercial |
$3,798.86
|
| Rate for Payer: Quartz Beloit One Network |
$1,759.47
|
| Rate for Payer: Quartz Commercial |
$2,279.32
|
| Rate for Payer: Quartz Medicare Advantage |
$193.71
|
| Rate for Payer: The Alliance Commercial |
$736.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.71
|
| Rate for Payer: WEA Trust Commercial |
$2,199.34
|
| Rate for Payer: WPS Commercial |
$968.55
|
|
|
CT Ankle w/ + w/o Contrast Right
|
Facility
|
OP
|
$3,845.00
|
|
|
Service Code
|
CPT 73702
|
| Hospital Charge Code |
625684
|
| Min. Negotiated Rate |
$184.59 |
| Max. Negotiated Rate |
$3,678.90 |
| Rate for Payer: Aetna Commercial |
$3,598.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,438.97
|
| Rate for Payer: Aetna Managed Medicare |
$184.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,599.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,999.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,919.42
|
| Rate for Payer: Anthem Medicare Advantage |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,119.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$184.59
|
| Rate for Payer: Cash Price |
$1,153.50
|
| Rate for Payer: Cash Price |
$1,153.50
|
| Rate for Payer: Cigna Commercial |
$3,678.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$184.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,237.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$184.59
|
| Rate for Payer: Health EOS Commercial |
$3,558.93
|
| Rate for Payer: HFN Commercial |
$3,678.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$184.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$184.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$184.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$184.59
|
| Rate for Payer: Multiplan Commercial |
$3,199.04
|
| Rate for Payer: NAPHCARE Commercial |
$276.88
|
| Rate for Payer: Preferred Network Access Commercial |
$3,678.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,959.41
|
| Rate for Payer: Quartz Commercial |
$2,599.22
|
| Rate for Payer: Quartz Medicare Advantage |
$184.59
|
| Rate for Payer: The Alliance Commercial |
$738.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$184.59
|
| Rate for Payer: WEA Trust Commercial |
$2,199.34
|
| Rate for Payer: Wellcare Medicare |
$184.59
|
| Rate for Payer: WPS Commercial |
$2,961.80
|
|
|
CT Arthrogram Knee w/ Contrast Left
|
Facility
|
IP
|
$2,916.00
|
|
|
Service Code
|
CPT 73701 TC,LT
|
| Hospital Charge Code |
5724136
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,485.99 |
| Max. Negotiated Rate |
$2,790.03 |
| Rate for Payer: Aetna Commercial |
$2,729.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,608.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,607.30
|
| Rate for Payer: Cash Price |
$874.80
|
| Rate for Payer: Cigna Commercial |
$2,790.03
|
| Rate for Payer: Health EOS Commercial |
$2,699.05
|
| Rate for Payer: HFN Commercial |
$2,790.03
|
| Rate for Payer: Multiplan Commercial |
$2,426.11
|
| Rate for Payer: Preferred Network Access Commercial |
$2,790.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,485.99
|
| Rate for Payer: Quartz Commercial |
$1,819.58
|
| Rate for Payer: WEA Trust Commercial |
$1,667.95
|
| Rate for Payer: WPS Commercial |
$2,246.19
|
|
|
CT Arthrogram Knee w/ Contrast Left
|
Facility
|
OP
|
$2,916.00
|
|
|
Service Code
|
CPT 73701 TC,LT
|
| Hospital Charge Code |
5724136
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$849.14 |
| Max. Negotiated Rate |
$3,333.20 |
| Rate for Payer: Aetna Commercial |
$2,729.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,608.07
|
| Rate for Payer: Aetna Managed Medicare |
$849.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,607.30
|
| 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 |
$2,790.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,697.11
|
| Rate for Payer: Health EOS Commercial |
$2,699.05
|
| Rate for Payer: HFN Commercial |
$2,790.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,274.48
|
| Rate for Payer: Multiplan Commercial |
$2,426.11
|
| Rate for Payer: NAPHCARE Commercial |
$1,819.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,790.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,485.99
|
| Rate for Payer: Quartz Commercial |
$1,971.22
|
| Rate for Payer: Quartz Medicare Advantage |
$1,819.58
|
| Rate for Payer: The Alliance Commercial |
$1,516.32
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$1,667.95
|
| Rate for Payer: WPS Commercial |
$2,246.19
|
|
|
CT Arthrogram Knee w/ Contrast Left
|
Professional
|
Both
|
$2,916.00
|
|
|
Service Code
|
CPT 73701 TC,LT
|
| Hospital Charge Code |
5724136
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$640.81 |
| Max. Negotiated Rate |
$2,881.01 |
| Rate for Payer: Aetna Commercial |
$2,881.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,608.07
|
| 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 |
$2,881.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,516.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,819.58
|
| Rate for Payer: Health EOS Commercial |
$2,759.70
|
| Rate for Payer: HFN Commercial |
$2,881.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$640.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$640.81
|
| Rate for Payer: Multiplan Commercial |
$2,426.11
|
| Rate for Payer: Preferred Network Access Commercial |
$2,881.01
|
| Rate for Payer: Quartz Beloit One Network |
$1,334.36
|
| Rate for Payer: Quartz Commercial |
$1,728.60
|
| Rate for Payer: The Alliance Commercial |
$1,516.32
|
| Rate for Payer: WEA Trust Commercial |
$1,667.95
|
| Rate for Payer: WPS Commercial |
$2,246.19
|
|
|
CT Arthrogram Knee w/ Contrast Right
|
Facility
|
IP
|
$2,916.00
|
|
|
Service Code
|
CPT 73701 TC,RT
|
| Hospital Charge Code |
5724139
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,485.99 |
| Max. Negotiated Rate |
$2,790.03 |
| Rate for Payer: Aetna Commercial |
$2,729.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,608.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,607.30
|
| Rate for Payer: Cash Price |
$874.80
|
| Rate for Payer: Cigna Commercial |
$2,790.03
|
| Rate for Payer: Health EOS Commercial |
$2,699.05
|
| Rate for Payer: HFN Commercial |
$2,790.03
|
| Rate for Payer: Multiplan Commercial |
$2,426.11
|
| Rate for Payer: Preferred Network Access Commercial |
$2,790.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,485.99
|
| Rate for Payer: Quartz Commercial |
$1,819.58
|
| Rate for Payer: WEA Trust Commercial |
$1,667.95
|
| Rate for Payer: WPS Commercial |
$2,246.19
|
|
|
CT Arthrogram Knee w/ Contrast Right
|
Facility
|
OP
|
$2,916.00
|
|
|
Service Code
|
CPT 73701 TC,RT
|
| Hospital Charge Code |
5724139
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$849.14 |
| Max. Negotiated Rate |
$3,333.20 |
| Rate for Payer: Aetna Commercial |
$2,729.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,608.07
|
| Rate for Payer: Aetna Managed Medicare |
$849.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,607.30
|
| 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 |
$2,790.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,697.11
|
| Rate for Payer: Health EOS Commercial |
$2,699.05
|
| Rate for Payer: HFN Commercial |
$2,790.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,274.48
|
| Rate for Payer: Multiplan Commercial |
$2,426.11
|
| Rate for Payer: NAPHCARE Commercial |
$1,819.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,790.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,485.99
|
| Rate for Payer: Quartz Commercial |
$1,971.22
|
| Rate for Payer: Quartz Medicare Advantage |
$1,819.58
|
| Rate for Payer: The Alliance Commercial |
$1,516.32
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$1,667.95
|
| Rate for Payer: WPS Commercial |
$2,246.19
|
|
|
CT Arthrogram Knee w/ Contrast Right
|
Professional
|
Both
|
$2,916.00
|
|
|
Service Code
|
CPT 73701 TC,RT
|
| Hospital Charge Code |
5724139
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$640.81 |
| Max. Negotiated Rate |
$2,881.01 |
| Rate for Payer: Aetna Commercial |
$2,881.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,608.07
|
| 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 |
$2,881.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,516.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,819.58
|
| Rate for Payer: Health EOS Commercial |
$2,759.70
|
| Rate for Payer: HFN Commercial |
$2,881.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$640.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$640.81
|
| Rate for Payer: Multiplan Commercial |
$2,426.11
|
| Rate for Payer: Preferred Network Access Commercial |
$2,881.01
|
| Rate for Payer: Quartz Beloit One Network |
$1,334.36
|
| Rate for Payer: Quartz Commercial |
$1,728.60
|
| Rate for Payer: The Alliance Commercial |
$1,516.32
|
| Rate for Payer: WEA Trust Commercial |
$1,667.95
|
| Rate for Payer: WPS Commercial |
$2,246.19
|
|
|
CT Aspiration
|
Professional
|
Both
|
$2,945.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
627588
|
| Min. Negotiated Rate |
$122.34 |
| Max. Negotiated Rate |
$2,909.66 |
| Rate for Payer: Aetna Commercial |
$2,909.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,634.01
|
| Rate for Payer: Aetna Managed Medicare |
$122.34
|
| Rate for Payer: Anthem Medicare Advantage |
$122.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$122.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$122.34
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cigna Commercial |
$2,909.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,531.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.34
|
| Rate for Payer: Health EOS Commercial |
$2,787.15
|
| Rate for Payer: HFN Commercial |
$2,909.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$525.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$525.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$122.34
|
| Rate for Payer: Multiplan Commercial |
$2,450.24
|
| Rate for Payer: NAPHCARE Commercial |
$183.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,909.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,347.63
|
| Rate for Payer: Quartz Commercial |
$1,745.80
|
| Rate for Payer: Quartz Medicare Advantage |
$122.34
|
| Rate for Payer: The Alliance Commercial |
$464.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.34
|
| Rate for Payer: WEA Trust Commercial |
$1,684.54
|
| Rate for Payer: WPS Commercial |
$611.68
|
|
|
CT Aspiration
|
Professional
|
Both
|
$3,970.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
1240881
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$122.34 |
| Max. Negotiated Rate |
$3,922.36 |
| Rate for Payer: Aetna Commercial |
$3,922.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,550.77
|
| Rate for Payer: Aetna Managed Medicare |
$122.34
|
| Rate for Payer: Anthem Medicare Advantage |
$122.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$122.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$122.34
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cigna Commercial |
$3,922.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,064.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.34
|
| Rate for Payer: Health EOS Commercial |
$3,757.21
|
| Rate for Payer: HFN Commercial |
$3,922.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$525.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$525.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$122.34
|
| Rate for Payer: Multiplan Commercial |
$3,303.04
|
| Rate for Payer: NAPHCARE Commercial |
$183.50
|
| Rate for Payer: Preferred Network Access Commercial |
$3,922.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,816.67
|
| Rate for Payer: Quartz Commercial |
$2,353.42
|
| Rate for Payer: Quartz Medicare Advantage |
$122.34
|
| Rate for Payer: The Alliance Commercial |
$464.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.34
|
| Rate for Payer: WEA Trust Commercial |
$2,270.84
|
| Rate for Payer: WPS Commercial |
$611.68
|
|
|
CT Aspiration
|
Facility
|
IP
|
$3,970.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
1240881
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,023.11 |
| Max. Negotiated Rate |
$3,798.50 |
| Rate for Payer: Aetna Commercial |
$3,715.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,550.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,188.26
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cigna Commercial |
$3,798.50
|
| Rate for Payer: Health EOS Commercial |
$3,674.63
|
| Rate for Payer: HFN Commercial |
$3,798.50
|
| Rate for Payer: Multiplan Commercial |
$3,303.04
|
| Rate for Payer: Preferred Network Access Commercial |
$3,798.50
|
| Rate for Payer: Quartz Beloit One Network |
$2,023.11
|
| Rate for Payer: Quartz Commercial |
$2,477.28
|
| Rate for Payer: WEA Trust Commercial |
$2,270.84
|
| Rate for Payer: WPS Commercial |
$3,058.09
|
|
|
CT Aspiration
|
Facility
|
IP
|
$2,945.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
627588
|
| Min. Negotiated Rate |
$1,500.77 |
| Max. Negotiated Rate |
$2,817.78 |
| Rate for Payer: Aetna Commercial |
$2,756.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,634.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,623.28
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cigna Commercial |
$2,817.78
|
| Rate for Payer: Health EOS Commercial |
$2,725.89
|
| Rate for Payer: HFN Commercial |
$2,817.78
|
| Rate for Payer: Multiplan Commercial |
$2,450.24
|
| Rate for Payer: Preferred Network Access Commercial |
$2,817.78
|
| Rate for Payer: Quartz Beloit One Network |
$1,500.77
|
| Rate for Payer: Quartz Commercial |
$1,837.68
|
| Rate for Payer: WEA Trust Commercial |
$1,684.54
|
| Rate for Payer: WPS Commercial |
$2,268.53
|
|
|
CT Aspiration
|
Facility
|
OP
|
$2,945.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
627588
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$2,817.78 |
| Rate for Payer: Aetna Commercial |
$2,756.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,634.01
|
| Rate for Payer: Aetna Managed Medicare |
$857.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,990.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,531.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,470.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,623.28
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cigna Commercial |
$2,817.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,713.99
|
| Rate for Payer: Health EOS Commercial |
$2,725.89
|
| Rate for Payer: HFN Commercial |
$2,817.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,297.10
|
| Rate for Payer: Multiplan Commercial |
$2,450.24
|
| Rate for Payer: NAPHCARE Commercial |
$1,837.68
|
| Rate for Payer: Preferred Network Access Commercial |
$2,817.78
|
| Rate for Payer: Quartz Beloit One Network |
$1,500.77
|
| Rate for Payer: Quartz Commercial |
$1,990.82
|
| Rate for Payer: Quartz Medicare Advantage |
$1,837.68
|
| Rate for Payer: The Alliance Commercial |
$489.34
|
| Rate for Payer: WEA Trust Commercial |
$1,684.54
|
| Rate for Payer: WPS Commercial |
$2,268.53
|
|
|
CT Aspiration
|
Facility
|
OP
|
$3,970.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
1240881
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,798.50 |
| Rate for Payer: Aetna Commercial |
$3,715.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,550.77
|
| Rate for Payer: Aetna Managed Medicare |
$1,156.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,188.26
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cigna Commercial |
$3,798.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,310.54
|
| Rate for Payer: Health EOS Commercial |
$3,674.63
|
| Rate for Payer: HFN Commercial |
$3,798.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,096.60
|
| Rate for Payer: Multiplan Commercial |
$3,303.04
|
| Rate for Payer: NAPHCARE Commercial |
$2,477.28
|
| Rate for Payer: Preferred Network Access Commercial |
$3,798.50
|
| Rate for Payer: Quartz Beloit One Network |
$2,023.11
|
| Rate for Payer: Quartz Commercial |
$2,683.72
|
| Rate for Payer: Quartz Medicare Advantage |
$2,477.28
|
| Rate for Payer: The Alliance Commercial |
$489.34
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$2,270.84
|
| Rate for Payer: WPS Commercial |
$856.35
|
|
|
CT Aspiration Renal Left
|
Professional
|
Both
|
$2,945.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
629780
|
| Min. Negotiated Rate |
$122.34 |
| Max. Negotiated Rate |
$2,909.66 |
| Rate for Payer: Aetna Commercial |
$2,909.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,634.01
|
| Rate for Payer: Aetna Managed Medicare |
$122.34
|
| Rate for Payer: Anthem Medicare Advantage |
$122.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$122.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$122.34
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cigna Commercial |
$2,909.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,531.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.34
|
| Rate for Payer: Health EOS Commercial |
$2,787.15
|
| Rate for Payer: HFN Commercial |
$2,909.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$525.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$525.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$122.34
|
| Rate for Payer: Multiplan Commercial |
$2,450.24
|
| Rate for Payer: NAPHCARE Commercial |
$183.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,909.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,347.63
|
| Rate for Payer: Quartz Commercial |
$1,745.80
|
| Rate for Payer: Quartz Medicare Advantage |
$122.34
|
| Rate for Payer: The Alliance Commercial |
$464.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.34
|
| Rate for Payer: WEA Trust Commercial |
$1,684.54
|
| Rate for Payer: WPS Commercial |
$611.68
|
|
|
CT Aspiration Renal Left
|
Professional
|
Both
|
$3,970.00
|
|
|
Service Code
|
CPT 77012 LT
|
| Hospital Charge Code |
1240883
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$525.39 |
| Max. Negotiated Rate |
$3,922.36 |
| Rate for Payer: Aetna Commercial |
$3,922.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,550.77
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cigna Commercial |
$3,922.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,064.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,477.28
|
| Rate for Payer: Health EOS Commercial |
$3,757.21
|
| Rate for Payer: HFN Commercial |
$3,922.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$525.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$525.39
|
| Rate for Payer: Multiplan Commercial |
$3,303.04
|
| Rate for Payer: Preferred Network Access Commercial |
$3,922.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,816.67
|
| Rate for Payer: Quartz Commercial |
$2,353.42
|
| Rate for Payer: The Alliance Commercial |
$2,064.40
|
| Rate for Payer: WEA Trust Commercial |
$2,270.84
|
| Rate for Payer: WPS Commercial |
$3,058.09
|
|
|
CT Aspiration Renal Left
|
Facility
|
IP
|
$3,970.00
|
|
|
Service Code
|
CPT 77012 LT
|
| Hospital Charge Code |
1240883
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,023.11 |
| Max. Negotiated Rate |
$3,798.50 |
| Rate for Payer: Aetna Commercial |
$3,715.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,550.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,188.26
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cigna Commercial |
$3,798.50
|
| Rate for Payer: Health EOS Commercial |
$3,674.63
|
| Rate for Payer: HFN Commercial |
$3,798.50
|
| Rate for Payer: Multiplan Commercial |
$3,303.04
|
| Rate for Payer: Preferred Network Access Commercial |
$3,798.50
|
| Rate for Payer: Quartz Beloit One Network |
$2,023.11
|
| Rate for Payer: Quartz Commercial |
$2,477.28
|
| Rate for Payer: WEA Trust Commercial |
$2,270.84
|
| Rate for Payer: WPS Commercial |
$3,058.09
|
|
|
CT Aspiration Renal Left
|
Facility
|
IP
|
$2,945.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
629780
|
| Min. Negotiated Rate |
$1,500.77 |
| Max. Negotiated Rate |
$2,817.78 |
| Rate for Payer: Aetna Commercial |
$2,756.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,634.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,623.28
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cigna Commercial |
$2,817.78
|
| Rate for Payer: Health EOS Commercial |
$2,725.89
|
| Rate for Payer: HFN Commercial |
$2,817.78
|
| Rate for Payer: Multiplan Commercial |
$2,450.24
|
| Rate for Payer: Preferred Network Access Commercial |
$2,817.78
|
| Rate for Payer: Quartz Beloit One Network |
$1,500.77
|
| Rate for Payer: Quartz Commercial |
$1,837.68
|
| Rate for Payer: WEA Trust Commercial |
$1,684.54
|
| Rate for Payer: WPS Commercial |
$2,268.53
|
|
|
CT Aspiration Renal Left
|
Facility
|
OP
|
$2,945.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
629780
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$2,817.78 |
| Rate for Payer: Aetna Commercial |
$2,756.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,634.01
|
| Rate for Payer: Aetna Managed Medicare |
$857.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,990.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,531.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,470.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,623.28
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cigna Commercial |
$2,817.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,713.99
|
| Rate for Payer: Health EOS Commercial |
$2,725.89
|
| Rate for Payer: HFN Commercial |
$2,817.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,297.10
|
| Rate for Payer: Multiplan Commercial |
$2,450.24
|
| Rate for Payer: NAPHCARE Commercial |
$1,837.68
|
| Rate for Payer: Preferred Network Access Commercial |
$2,817.78
|
| Rate for Payer: Quartz Beloit One Network |
$1,500.77
|
| Rate for Payer: Quartz Commercial |
$1,990.82
|
| Rate for Payer: Quartz Medicare Advantage |
$1,837.68
|
| Rate for Payer: The Alliance Commercial |
$489.34
|
| Rate for Payer: WEA Trust Commercial |
$1,684.54
|
| Rate for Payer: WPS Commercial |
$2,268.53
|
|
|
CT Aspiration Renal Left
|
Facility
|
OP
|
$3,970.00
|
|
|
Service Code
|
CPT 77012 LT
|
| Hospital Charge Code |
1240883
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,156.06 |
| Max. Negotiated Rate |
$3,798.50 |
| Rate for Payer: Aetna Commercial |
$3,715.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,550.77
|
| Rate for Payer: Aetna Managed Medicare |
$1,156.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,188.26
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cigna Commercial |
$3,798.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,310.54
|
| Rate for Payer: Health EOS Commercial |
$3,674.63
|
| Rate for Payer: HFN Commercial |
$3,798.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,096.60
|
| Rate for Payer: Multiplan Commercial |
$3,303.04
|
| Rate for Payer: NAPHCARE Commercial |
$2,477.28
|
| Rate for Payer: Preferred Network Access Commercial |
$3,798.50
|
| Rate for Payer: Quartz Beloit One Network |
$2,023.11
|
| Rate for Payer: Quartz Commercial |
$2,683.72
|
| Rate for Payer: Quartz Medicare Advantage |
$2,477.28
|
| Rate for Payer: The Alliance Commercial |
$2,064.40
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$2,270.84
|
| Rate for Payer: WPS Commercial |
$3,058.09
|
|
|
CT Aspiration Renal Right
|
Facility
|
OP
|
$2,945.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
627590
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$2,817.78 |
| Rate for Payer: Aetna Commercial |
$2,756.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,634.01
|
| Rate for Payer: Aetna Managed Medicare |
$857.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,990.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,531.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,470.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,623.28
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cigna Commercial |
$2,817.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,713.99
|
| Rate for Payer: Health EOS Commercial |
$2,725.89
|
| Rate for Payer: HFN Commercial |
$2,817.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,297.10
|
| Rate for Payer: Multiplan Commercial |
$2,450.24
|
| Rate for Payer: NAPHCARE Commercial |
$1,837.68
|
| Rate for Payer: Preferred Network Access Commercial |
$2,817.78
|
| Rate for Payer: Quartz Beloit One Network |
$1,500.77
|
| Rate for Payer: Quartz Commercial |
$1,990.82
|
| Rate for Payer: Quartz Medicare Advantage |
$1,837.68
|
| Rate for Payer: The Alliance Commercial |
$489.34
|
| Rate for Payer: WEA Trust Commercial |
$1,684.54
|
| Rate for Payer: WPS Commercial |
$2,268.53
|
|
|
CT Aspiration Renal Right
|
Professional
|
Both
|
$2,945.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
627590
|
| Min. Negotiated Rate |
$122.34 |
| Max. Negotiated Rate |
$2,909.66 |
| Rate for Payer: Aetna Commercial |
$2,909.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,634.01
|
| Rate for Payer: Aetna Managed Medicare |
$122.34
|
| Rate for Payer: Anthem Medicare Advantage |
$122.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$122.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$122.34
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cigna Commercial |
$2,909.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,531.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.34
|
| Rate for Payer: Health EOS Commercial |
$2,787.15
|
| Rate for Payer: HFN Commercial |
$2,909.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$525.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$525.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$122.34
|
| Rate for Payer: Multiplan Commercial |
$2,450.24
|
| Rate for Payer: NAPHCARE Commercial |
$183.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,909.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,347.63
|
| Rate for Payer: Quartz Commercial |
$1,745.80
|
| Rate for Payer: Quartz Medicare Advantage |
$122.34
|
| Rate for Payer: The Alliance Commercial |
$464.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.34
|
| Rate for Payer: WEA Trust Commercial |
$1,684.54
|
| Rate for Payer: WPS Commercial |
$611.68
|
|
|
CT Aspiration Renal Right
|
Professional
|
Both
|
$3,970.00
|
|
|
Service Code
|
CPT 77012 RT
|
| Hospital Charge Code |
1240885
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$525.39 |
| Max. Negotiated Rate |
$3,922.36 |
| Rate for Payer: Aetna Commercial |
$3,922.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,550.77
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cash Price |
$1,191.00
|
| Rate for Payer: Cigna Commercial |
$3,922.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,064.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,477.28
|
| Rate for Payer: Health EOS Commercial |
$3,757.21
|
| Rate for Payer: HFN Commercial |
$3,922.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$525.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$525.39
|
| Rate for Payer: Multiplan Commercial |
$3,303.04
|
| Rate for Payer: Preferred Network Access Commercial |
$3,922.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,816.67
|
| Rate for Payer: Quartz Commercial |
$2,353.42
|
| Rate for Payer: The Alliance Commercial |
$2,064.40
|
| Rate for Payer: WEA Trust Commercial |
$2,270.84
|
| Rate for Payer: WPS Commercial |
$3,058.09
|
|
|
CT Aspiration Renal Right
|
Facility
|
IP
|
$2,945.00
|
|
|
Service Code
|
CPT 77012
|
| Hospital Charge Code |
627590
|
| Min. Negotiated Rate |
$1,500.77 |
| Max. Negotiated Rate |
$2,817.78 |
| Rate for Payer: Aetna Commercial |
$2,756.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,634.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,623.28
|
| Rate for Payer: Cash Price |
$883.50
|
| Rate for Payer: Cigna Commercial |
$2,817.78
|
| Rate for Payer: Health EOS Commercial |
$2,725.89
|
| Rate for Payer: HFN Commercial |
$2,817.78
|
| Rate for Payer: Multiplan Commercial |
$2,450.24
|
| Rate for Payer: Preferred Network Access Commercial |
$2,817.78
|
| Rate for Payer: Quartz Beloit One Network |
$1,500.77
|
| Rate for Payer: Quartz Commercial |
$1,837.68
|
| Rate for Payer: WEA Trust Commercial |
$1,684.54
|
| Rate for Payer: WPS Commercial |
$2,268.53
|
|
