|
CT Humerus w/ + w/o Contrast Bilateral
|
Facility
|
OP
|
$8,360.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
630000
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$7,691.20 |
| Rate for Payer: Aetna Commercial |
$7,524.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,189.60
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,434.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,180.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,012.80
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,430.80
|
| 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 |
$2,508.00
|
| Rate for Payer: Cash Price |
$2,508.00
|
| Rate for Payer: Cigna Commercial |
$7,691.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,678.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$7,440.40
|
| Rate for Payer: HFN Commercial |
$7,691.20
|
| 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 |
$6,688.00
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,691.20
|
| Rate for Payer: Quartz Beloit One Network |
$4,096.40
|
| Rate for Payer: Quartz Commercial |
$5,434.00
|
| 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 |
$4,598.00
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$6,192.25
|
|
|
CT Humerus w/ + w/o Contrast Bilateral
|
Professional
|
Both
|
$8,360.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
630000
|
| Min. Negotiated Rate |
$941.80 |
| Max. Negotiated Rate |
$7,942.00 |
| Rate for Payer: Aetna Commercial |
$7,942.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,189.60
|
| Rate for Payer: Cash Price |
$2,508.00
|
| Rate for Payer: Cash Price |
$2,508.00
|
| Rate for Payer: Cigna Commercial |
$7,942.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,180.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,016.00
|
| Rate for Payer: Health EOS Commercial |
$7,607.60
|
| Rate for Payer: HFN Commercial |
$7,942.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$941.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$941.80
|
| Rate for Payer: Multiplan Commercial |
$6,688.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,942.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,678.40
|
| Rate for Payer: Quartz Commercial |
$4,765.20
|
| Rate for Payer: The Alliance Commercial |
$4,180.00
|
| Rate for Payer: WEA Trust Commercial |
$4,598.00
|
| Rate for Payer: WPS Commercial |
$6,192.25
|
|
|
CT Humerus w/ + w/o Contrast Left
|
Professional
|
Both
|
$4,102.00
|
|
|
Service Code
|
CPT 73202 LT,TC
|
| Hospital Charge Code |
1241140
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,804.88 |
| Max. Negotiated Rate |
$3,896.90 |
| Rate for Payer: Aetna Commercial |
$3,896.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,896.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,051.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,461.20
|
| Rate for Payer: Health EOS Commercial |
$3,732.82
|
| Rate for Payer: HFN Commercial |
$3,896.90
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,896.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,804.88
|
| Rate for Payer: Quartz Commercial |
$2,338.14
|
| Rate for Payer: The Alliance Commercial |
$2,051.00
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Humerus w/ + w/o Contrast Left
|
Facility
|
OP
|
$4,102.00
|
|
|
Service Code
|
CPT 73202 LT,TC
|
| Hospital Charge Code |
1241140
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,148.56 |
| Max. Negotiated Rate |
$16,408.00 |
| Rate for Payer: Aetna Commercial |
$3,691.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,148.56
|
| 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 |
$2,174.06
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,773.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,295.48
|
| Rate for Payer: Health EOS Commercial |
$3,650.78
|
| Rate for Payer: HFN Commercial |
$3,773.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,076.50
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,773.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.98
|
| Rate for Payer: Quartz Commercial |
$2,666.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,461.20
|
| Rate for Payer: The Alliance Commercial |
$16,408.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Humerus w/ + w/o Contrast Left
|
Facility
|
IP
|
$4,102.00
|
|
|
Service Code
|
CPT 73202 LT,TC
|
| Hospital Charge Code |
1241140
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,009.98 |
| Max. Negotiated Rate |
$3,773.84 |
| Rate for Payer: Aetna Commercial |
$3,691.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,174.06
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,773.84
|
| Rate for Payer: Health EOS Commercial |
$3,650.78
|
| Rate for Payer: HFN Commercial |
$3,773.84
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,773.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.98
|
| Rate for Payer: Quartz Commercial |
$2,461.20
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Humerus w/ + w/o Contrast Left
|
Facility
|
IP
|
$4,181.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
630004
|
| Min. Negotiated Rate |
$2,048.69 |
| Max. Negotiated Rate |
$3,846.52 |
| Rate for Payer: Aetna Commercial |
$3,762.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,595.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,215.93
|
| Rate for Payer: Cash Price |
$1,254.30
|
| Rate for Payer: Cigna Commercial |
$3,846.52
|
| Rate for Payer: Health EOS Commercial |
$3,721.09
|
| Rate for Payer: HFN Commercial |
$3,846.52
|
| Rate for Payer: Multiplan Commercial |
$3,344.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,508.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,846.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,048.69
|
| Rate for Payer: Quartz Commercial |
$2,508.60
|
| Rate for Payer: WEA Trust Commercial |
$2,299.55
|
| Rate for Payer: WPS Commercial |
$3,096.87
|
|
|
CT Humerus w/ + w/o Contrast Left
|
Professional
|
Both
|
$4,181.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
630004
|
| Min. Negotiated Rate |
$941.80 |
| Max. Negotiated Rate |
$3,971.95 |
| Rate for Payer: Aetna Commercial |
$3,971.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,595.66
|
| Rate for Payer: Cash Price |
$1,254.30
|
| Rate for Payer: Cash Price |
$1,254.30
|
| Rate for Payer: Cigna Commercial |
$3,971.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,090.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,508.60
|
| Rate for Payer: Health EOS Commercial |
$3,804.71
|
| Rate for Payer: HFN Commercial |
$3,971.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$941.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$941.80
|
| Rate for Payer: Multiplan Commercial |
$3,344.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,971.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,839.64
|
| Rate for Payer: Quartz Commercial |
$2,383.17
|
| Rate for Payer: The Alliance Commercial |
$2,090.50
|
| Rate for Payer: WEA Trust Commercial |
$2,299.55
|
| Rate for Payer: WPS Commercial |
$3,096.87
|
|
|
CT Humerus w/ + w/o Contrast Left
|
Facility
|
OP
|
$4,181.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
630004
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$3,846.52 |
| Rate for Payer: Aetna Commercial |
$3,762.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,595.66
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,717.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,090.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,006.88
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,215.93
|
| 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 |
$1,254.30
|
| Rate for Payer: Cash Price |
$1,254.30
|
| Rate for Payer: Cigna Commercial |
$3,846.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,339.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$3,721.09
|
| Rate for Payer: HFN Commercial |
$3,846.52
|
| 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 |
$3,344.80
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,846.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,048.69
|
| Rate for Payer: Quartz Commercial |
$2,717.65
|
| 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 |
$2,299.55
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$3,096.87
|
|
|
CT Humerus w/ + w/o Contrast Right
|
Facility
|
OP
|
$4,102.00
|
|
|
Service Code
|
CPT 73202 RT,TC
|
| Hospital Charge Code |
1241142
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,148.56 |
| Max. Negotiated Rate |
$16,408.00 |
| Rate for Payer: Aetna Commercial |
$3,691.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,148.56
|
| 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 |
$2,174.06
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,773.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,295.48
|
| Rate for Payer: Health EOS Commercial |
$3,650.78
|
| Rate for Payer: HFN Commercial |
$3,773.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,076.50
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,773.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.98
|
| Rate for Payer: Quartz Commercial |
$2,666.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,461.20
|
| Rate for Payer: The Alliance Commercial |
$16,408.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Humerus w/ + w/o Contrast Right
|
Professional
|
Both
|
$4,102.00
|
|
|
Service Code
|
CPT 73202 RT,TC
|
| Hospital Charge Code |
1241142
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,804.88 |
| Max. Negotiated Rate |
$3,896.90 |
| Rate for Payer: Aetna Commercial |
$3,896.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,896.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,051.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,461.20
|
| Rate for Payer: Health EOS Commercial |
$3,732.82
|
| Rate for Payer: HFN Commercial |
$3,896.90
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,896.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,804.88
|
| Rate for Payer: Quartz Commercial |
$2,338.14
|
| Rate for Payer: The Alliance Commercial |
$2,051.00
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Humerus w/ + w/o Contrast Right
|
Professional
|
Both
|
$4,102.00
|
|
|
Service Code
|
CPT 73202 TC,RT
|
| Hospital Charge Code |
2980022
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,804.88 |
| Max. Negotiated Rate |
$3,896.90 |
| Rate for Payer: Aetna Commercial |
$3,896.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,896.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,051.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,461.20
|
| Rate for Payer: Health EOS Commercial |
$3,732.82
|
| Rate for Payer: HFN Commercial |
$3,896.90
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,896.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,804.88
|
| Rate for Payer: Quartz Commercial |
$2,338.14
|
| Rate for Payer: The Alliance Commercial |
$2,051.00
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Humerus w/ + w/o Contrast Right
|
Professional
|
Both
|
$4,181.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
630008
|
| Min. Negotiated Rate |
$941.80 |
| Max. Negotiated Rate |
$3,971.95 |
| Rate for Payer: Aetna Commercial |
$3,971.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,595.66
|
| Rate for Payer: Cash Price |
$1,254.30
|
| Rate for Payer: Cash Price |
$1,254.30
|
| Rate for Payer: Cigna Commercial |
$3,971.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,090.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,508.60
|
| Rate for Payer: Health EOS Commercial |
$3,804.71
|
| Rate for Payer: HFN Commercial |
$3,971.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$941.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$941.80
|
| Rate for Payer: Multiplan Commercial |
$3,344.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,971.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,839.64
|
| Rate for Payer: Quartz Commercial |
$2,383.17
|
| Rate for Payer: The Alliance Commercial |
$2,090.50
|
| Rate for Payer: WEA Trust Commercial |
$2,299.55
|
| Rate for Payer: WPS Commercial |
$3,096.87
|
|
|
CT Humerus w/ + w/o Contrast Right
|
Facility
|
IP
|
$4,102.00
|
|
|
Service Code
|
CPT 73202 TC,RT
|
| Hospital Charge Code |
2980022
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,009.98 |
| Max. Negotiated Rate |
$3,773.84 |
| Rate for Payer: Aetna Commercial |
$3,691.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,174.06
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,773.84
|
| Rate for Payer: Health EOS Commercial |
$3,650.78
|
| Rate for Payer: HFN Commercial |
$3,773.84
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,773.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.98
|
| Rate for Payer: Quartz Commercial |
$2,461.20
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Humerus w/ + w/o Contrast Right
|
Facility
|
IP
|
$4,102.00
|
|
|
Service Code
|
CPT 73202 RT,TC
|
| Hospital Charge Code |
1241142
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,009.98 |
| Max. Negotiated Rate |
$3,773.84 |
| Rate for Payer: Aetna Commercial |
$3,691.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,174.06
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,773.84
|
| Rate for Payer: Health EOS Commercial |
$3,650.78
|
| Rate for Payer: HFN Commercial |
$3,773.84
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,773.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.98
|
| Rate for Payer: Quartz Commercial |
$2,461.20
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Humerus w/ + w/o Contrast Right
|
Facility
|
OP
|
$4,181.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
630008
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$3,846.52 |
| Rate for Payer: Aetna Commercial |
$3,762.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,595.66
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,717.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,090.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,006.88
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,215.93
|
| 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 |
$1,254.30
|
| Rate for Payer: Cash Price |
$1,254.30
|
| Rate for Payer: Cigna Commercial |
$3,846.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,339.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$3,721.09
|
| Rate for Payer: HFN Commercial |
$3,846.52
|
| 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 |
$3,344.80
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,846.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,048.69
|
| Rate for Payer: Quartz Commercial |
$2,717.65
|
| 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 |
$2,299.55
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$3,096.87
|
|
|
CT Humerus w/ + w/o Contrast Right
|
Facility
|
IP
|
$4,181.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
630008
|
| Min. Negotiated Rate |
$2,048.69 |
| Max. Negotiated Rate |
$3,846.52 |
| Rate for Payer: Aetna Commercial |
$3,762.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,595.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,215.93
|
| Rate for Payer: Cash Price |
$1,254.30
|
| Rate for Payer: Cigna Commercial |
$3,846.52
|
| Rate for Payer: Health EOS Commercial |
$3,721.09
|
| Rate for Payer: HFN Commercial |
$3,846.52
|
| Rate for Payer: Multiplan Commercial |
$3,344.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,508.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,846.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,048.69
|
| Rate for Payer: Quartz Commercial |
$2,508.60
|
| Rate for Payer: WEA Trust Commercial |
$2,299.55
|
| Rate for Payer: WPS Commercial |
$3,096.87
|
|
|
CT Humerus w/ + w/o Contrast Right
|
Facility
|
OP
|
$4,102.00
|
|
|
Service Code
|
CPT 73202 TC,RT
|
| Hospital Charge Code |
2980022
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,148.56 |
| Max. Negotiated Rate |
$16,408.00 |
| Rate for Payer: Aetna Commercial |
$3,691.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,148.56
|
| 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 |
$2,174.06
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,773.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,295.48
|
| Rate for Payer: Health EOS Commercial |
$3,650.78
|
| Rate for Payer: HFN Commercial |
$3,773.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,076.50
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,773.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.98
|
| Rate for Payer: Quartz Commercial |
$2,666.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,461.20
|
| Rate for Payer: The Alliance Commercial |
$16,408.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT IAC/Sella/Orbit/Temporal w/ Con
|
Facility
|
OP
|
$3,327.00
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
661607
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$3,060.84 |
| Rate for Payer: Aetna Commercial |
$2,994.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,861.22
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,162.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,663.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,596.96
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,763.31
|
| 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 |
$998.10
|
| Rate for Payer: Cash Price |
$998.10
|
| Rate for Payer: Cigna Commercial |
$3,060.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,861.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$2,961.03
|
| Rate for Payer: HFN Commercial |
$3,060.84
|
| 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 |
$2,661.60
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,060.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,630.23
|
| Rate for Payer: Quartz Commercial |
$2,162.55
|
| 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 |
$1,829.85
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$2,464.31
|
|
|
CT IAC/Sella/Orbit/Temporal w/ Con
|
Professional
|
Both
|
$3,327.00
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
661607
|
| Min. Negotiated Rate |
$670.45 |
| Max. Negotiated Rate |
$3,160.65 |
| Rate for Payer: Aetna Commercial |
$3,160.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,861.22
|
| Rate for Payer: Cash Price |
$998.10
|
| Rate for Payer: Cash Price |
$998.10
|
| Rate for Payer: Cigna Commercial |
$3,160.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,663.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,996.20
|
| Rate for Payer: Health EOS Commercial |
$3,027.57
|
| Rate for Payer: HFN Commercial |
$3,160.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$670.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$670.45
|
| Rate for Payer: Multiplan Commercial |
$2,661.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,160.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,463.88
|
| Rate for Payer: Quartz Commercial |
$1,896.39
|
| Rate for Payer: The Alliance Commercial |
$1,663.50
|
| Rate for Payer: WEA Trust Commercial |
$1,829.85
|
| Rate for Payer: WPS Commercial |
$2,464.31
|
|
|
CT IAC/Sella/Orbit/Temporal w/ Con
|
Facility
|
IP
|
$3,327.00
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
661607
|
| Min. Negotiated Rate |
$1,630.23 |
| Max. Negotiated Rate |
$3,060.84 |
| Rate for Payer: Aetna Commercial |
$2,994.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,861.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,763.31
|
| Rate for Payer: Cash Price |
$998.10
|
| Rate for Payer: Cigna Commercial |
$3,060.84
|
| Rate for Payer: Health EOS Commercial |
$2,961.03
|
| Rate for Payer: HFN Commercial |
$3,060.84
|
| Rate for Payer: Multiplan Commercial |
$2,661.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,996.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,060.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,630.23
|
| Rate for Payer: Quartz Commercial |
$1,996.20
|
| Rate for Payer: WEA Trust Commercial |
$1,829.85
|
| Rate for Payer: WPS Commercial |
$2,464.31
|
|
|
CT IAC/Sella/Orbit/Temporal w/ Con
|
Facility
|
IP
|
$3,389.00
|
|
|
Service Code
|
CPT 70481 TC
|
| Hospital Charge Code |
1241160
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,660.61 |
| Max. Negotiated Rate |
$3,117.88 |
| Rate for Payer: Aetna Commercial |
$3,050.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,914.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,796.17
|
| Rate for Payer: Cash Price |
$1,016.70
|
| Rate for Payer: Cigna Commercial |
$3,117.88
|
| Rate for Payer: Health EOS Commercial |
$3,016.21
|
| Rate for Payer: HFN Commercial |
$3,117.88
|
| Rate for Payer: Multiplan Commercial |
$2,711.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,033.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,117.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,660.61
|
| Rate for Payer: Quartz Commercial |
$2,033.40
|
| Rate for Payer: WEA Trust Commercial |
$1,863.95
|
| Rate for Payer: WPS Commercial |
$2,510.23
|
|
|
CT IAC/Sella/Orbit/Temporal w/ Con
|
Professional
|
Both
|
$3,389.00
|
|
|
Service Code
|
CPT 70481 TC
|
| Hospital Charge Code |
1241160
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$481.88 |
| Max. Negotiated Rate |
$3,219.55 |
| Rate for Payer: Aetna Commercial |
$3,219.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,914.54
|
| Rate for Payer: Cash Price |
$1,016.70
|
| Rate for Payer: Cash Price |
$1,016.70
|
| Rate for Payer: Cigna Commercial |
$3,219.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,694.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,033.40
|
| Rate for Payer: Health EOS Commercial |
$3,083.99
|
| Rate for Payer: HFN Commercial |
$3,219.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$481.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$481.88
|
| Rate for Payer: Multiplan Commercial |
$2,711.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,219.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,491.16
|
| Rate for Payer: Quartz Commercial |
$1,931.73
|
| Rate for Payer: The Alliance Commercial |
$1,694.50
|
| Rate for Payer: WEA Trust Commercial |
$1,863.95
|
| Rate for Payer: WPS Commercial |
$2,510.23
|
|
|
CT IAC/Sella/Orbit/Temporal w/ Con
|
Facility
|
OP
|
$3,389.00
|
|
|
Service Code
|
CPT 70481 TC
|
| Hospital Charge Code |
1241160
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$948.92 |
| Max. Negotiated Rate |
$13,556.00 |
| Rate for Payer: Aetna Commercial |
$3,050.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,914.54
|
| Rate for Payer: Aetna Managed Medicare |
$948.92
|
| 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 |
$1,796.17
|
| Rate for Payer: Cash Price |
$1,016.70
|
| Rate for Payer: Cash Price |
$1,016.70
|
| Rate for Payer: Cash Price |
$1,016.70
|
| Rate for Payer: Cigna Commercial |
$3,117.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,896.48
|
| Rate for Payer: Health EOS Commercial |
$3,016.21
|
| Rate for Payer: HFN Commercial |
$3,117.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,541.75
|
| Rate for Payer: Multiplan Commercial |
$2,711.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,033.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,117.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,660.61
|
| Rate for Payer: Quartz Commercial |
$2,202.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,033.40
|
| Rate for Payer: The Alliance Commercial |
$13,556.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,863.95
|
| Rate for Payer: WPS Commercial |
$2,510.23
|
|
|
CT IAC/ Sella/ Orbit/ Temporal w/ Contrast
|
Facility
|
OP
|
$3,265.00
|
|
|
Service Code
|
CPT 70481 TC
|
| Hospital Charge Code |
3072756
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$914.20 |
| Max. Negotiated Rate |
$13,060.00 |
| Rate for Payer: Aetna Commercial |
$2,938.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,807.90
|
| Rate for Payer: Aetna Managed Medicare |
$914.20
|
| 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 |
$1,730.45
|
| Rate for Payer: Cash Price |
$979.50
|
| Rate for Payer: Cash Price |
$979.50
|
| Rate for Payer: Cash Price |
$979.50
|
| Rate for Payer: Cigna Commercial |
$3,003.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,827.09
|
| Rate for Payer: Health EOS Commercial |
$2,905.85
|
| Rate for Payer: HFN Commercial |
$3,003.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,448.75
|
| Rate for Payer: Multiplan Commercial |
$2,612.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,959.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,003.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,599.85
|
| Rate for Payer: Quartz Commercial |
$2,122.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,959.00
|
| Rate for Payer: The Alliance Commercial |
$13,060.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,795.75
|
| Rate for Payer: WPS Commercial |
$2,418.39
|
|
|
CT IAC/ Sella/ Orbit/ Temporal w/ Contrast
|
Professional
|
Both
|
$3,265.00
|
|
|
Service Code
|
CPT 70481 TC
|
| Hospital Charge Code |
3072756
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$481.88 |
| Max. Negotiated Rate |
$3,101.75 |
| Rate for Payer: Aetna Commercial |
$3,101.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,807.90
|
| Rate for Payer: Cash Price |
$979.50
|
| Rate for Payer: Cash Price |
$979.50
|
| Rate for Payer: Cigna Commercial |
$3,101.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,632.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,959.00
|
| Rate for Payer: Health EOS Commercial |
$2,971.15
|
| Rate for Payer: HFN Commercial |
$3,101.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$481.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$481.88
|
| Rate for Payer: Multiplan Commercial |
$2,612.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,101.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,436.60
|
| Rate for Payer: Quartz Commercial |
$1,861.05
|
| Rate for Payer: The Alliance Commercial |
$1,632.50
|
| Rate for Payer: WEA Trust Commercial |
$1,795.75
|
| Rate for Payer: WPS Commercial |
$2,418.39
|
|
