|
NMIC 306
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
6196550
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$8.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.36
|
| Rate for Payer: Anthem Medicaid |
$8.94
|
| Rate for Payer: Anthem Medicare Advantage |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.65
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Dean Health Medicaid |
$8.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.65
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.65
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.65
|
| Rate for Payer: Managed Health Services Medicaid |
$9.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.65
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$12.98
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.94
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$8.65
|
| Rate for Payer: The Alliance Commercial |
$34.60
|
| Rate for Payer: United Healthcare Medicaid |
$8.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.65
|
| Rate for Payer: United Healthcare PPO |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: Wellcare Medicare |
$8.65
|
| Rate for Payer: WMAP Medicaid |
$8.94
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
NMIC 306
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
6196550
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
NMIC/ID303
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313465
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.04 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$117.60
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
NMIC/ID303
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313465
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Aetna Managed Medicare |
$8.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.36
|
| Rate for Payer: Anthem Medicaid |
$8.94
|
| Rate for Payer: Anthem Medicare Advantage |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.65
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.68
|
| Rate for Payer: Dean Health Medicaid |
$8.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.65
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.65
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.65
|
| Rate for Payer: Managed Health Services Medicaid |
$9.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.65
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$12.98
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.94
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$127.40
|
| Rate for Payer: Quartz Medicare Advantage |
$8.65
|
| Rate for Payer: The Alliance Commercial |
$34.60
|
| Rate for Payer: United Healthcare Medicaid |
$8.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.65
|
| Rate for Payer: United Healthcare PPO |
$147.00
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: Wellcare Medicare |
$8.65
|
| Rate for Payer: WMAP Medicaid |
$8.94
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
NMIC/ID303
|
Professional
|
Both
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313465
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.53 |
| Max. Negotiated Rate |
$186.20 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$98.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$117.60
|
| Rate for Payer: Health EOS Commercial |
$178.36
|
| Rate for Payer: HFN Commercial |
$186.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.53
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: Preferred Network Access Commercial |
$186.20
|
| Rate for Payer: Quartz Beloit One Network |
$86.24
|
| Rate for Payer: Quartz Commercial |
$111.72
|
| Rate for Payer: The Alliance Commercial |
$98.00
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
NMIC/ID307
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5581862
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$172.04 |
| Rate for Payer: Aetna Commercial |
$168.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.82
|
| Rate for Payer: Aetna Managed Medicare |
$8.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.36
|
| Rate for Payer: Anthem Medicaid |
$8.94
|
| Rate for Payer: Anthem Medicare Advantage |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.65
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$172.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.65
|
| Rate for Payer: Dean Health Medicaid |
$8.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.65
|
| Rate for Payer: Health EOS Commercial |
$166.43
|
| Rate for Payer: HFN Commercial |
$172.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.65
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.65
|
| Rate for Payer: Managed Health Services Medicaid |
$9.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.65
|
| Rate for Payer: Multiplan Commercial |
$149.60
|
| Rate for Payer: NAPHCARE Commercial |
$12.98
|
| Rate for Payer: Preferred Network Access Commercial |
$172.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.94
|
| Rate for Payer: Quartz Beloit One Network |
$91.63
|
| Rate for Payer: Quartz Commercial |
$121.55
|
| Rate for Payer: Quartz Medicare Advantage |
$8.65
|
| Rate for Payer: The Alliance Commercial |
$34.60
|
| Rate for Payer: United Healthcare Medicaid |
$8.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.65
|
| Rate for Payer: United Healthcare PPO |
$140.25
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: Wellcare Medicare |
$8.65
|
| Rate for Payer: WMAP Medicaid |
$8.94
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
NMIC/ID307
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5581862
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$91.63 |
| Max. Negotiated Rate |
$172.04 |
| Rate for Payer: Aetna Commercial |
$168.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.11
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$172.04
|
| Rate for Payer: Health EOS Commercial |
$166.43
|
| Rate for Payer: HFN Commercial |
$172.04
|
| Rate for Payer: Multiplan Commercial |
$149.60
|
| Rate for Payer: NAPHCARE Commercial |
$112.20
|
| Rate for Payer: Preferred Network Access Commercial |
$172.04
|
| Rate for Payer: Quartz Beloit One Network |
$91.63
|
| Rate for Payer: Quartz Commercial |
$112.20
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
NMIC/ID307
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5581862
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.53 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna Commercial |
$177.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.82
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$93.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.20
|
| Rate for Payer: Health EOS Commercial |
$170.17
|
| Rate for Payer: HFN Commercial |
$177.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.53
|
| Rate for Payer: Multiplan Commercial |
$149.60
|
| Rate for Payer: Preferred Network Access Commercial |
$177.65
|
| Rate for Payer: Quartz Beloit One Network |
$82.28
|
| Rate for Payer: Quartz Commercial |
$106.59
|
| Rate for Payer: The Alliance Commercial |
$93.50
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
NM Intestine Imaging
|
Facility
|
OP
|
$2,104.00
|
|
|
Service Code
|
CPT 78290
|
| Hospital Charge Code |
2586881
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$407.66 |
| Max. Negotiated Rate |
$2,304.00 |
| Rate for Payer: Aetna Commercial |
$1,893.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,809.44
|
| Rate for Payer: Aetna Managed Medicare |
$407.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,528.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,222.98
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,161.83
|
| Rate for Payer: Anthem Medicare Advantage |
$407.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,115.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$407.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$407.66
|
| Rate for Payer: Cash Price |
$631.20
|
| Rate for Payer: Cash Price |
$631.20
|
| Rate for Payer: Cash Price |
$631.20
|
| Rate for Payer: Cigna Commercial |
$1,935.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$407.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,177.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$407.66
|
| Rate for Payer: Health EOS Commercial |
$1,872.56
|
| Rate for Payer: HFN Commercial |
$1,935.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,516.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$407.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$407.66
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$407.66
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$407.66
|
| Rate for Payer: Multiplan Commercial |
$1,683.20
|
| Rate for Payer: NAPHCARE Commercial |
$611.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,935.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,030.96
|
| Rate for Payer: Quartz Commercial |
$1,367.60
|
| Rate for Payer: Quartz Medicare Advantage |
$407.66
|
| Rate for Payer: The Alliance Commercial |
$1,630.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$407.66
|
| Rate for Payer: United Healthcare PPO |
$2,304.00
|
| Rate for Payer: WEA Trust Commercial |
$1,157.20
|
| Rate for Payer: Wellcare Medicare |
$407.66
|
| Rate for Payer: WPS Commercial |
$1,558.43
|
|
|
NM Intestine Imaging
|
Facility
|
IP
|
$2,104.00
|
|
|
Service Code
|
CPT 78290
|
| Hospital Charge Code |
2586881
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,030.96 |
| Max. Negotiated Rate |
$1,935.68 |
| Rate for Payer: Aetna Commercial |
$1,893.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,809.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,115.12
|
| Rate for Payer: Cash Price |
$631.20
|
| Rate for Payer: Cigna Commercial |
$1,935.68
|
| Rate for Payer: Health EOS Commercial |
$1,872.56
|
| Rate for Payer: HFN Commercial |
$1,935.68
|
| Rate for Payer: Multiplan Commercial |
$1,683.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,262.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,935.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,030.96
|
| Rate for Payer: Quartz Commercial |
$1,262.40
|
| Rate for Payer: WEA Trust Commercial |
$1,157.20
|
| Rate for Payer: WPS Commercial |
$1,558.43
|
|
|
NM Intestine Imaging
|
Professional
|
Both
|
$2,104.00
|
|
|
Service Code
|
CPT 78290
|
| Hospital Charge Code |
2586881
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$925.76 |
| Max. Negotiated Rate |
$1,998.80 |
| Rate for Payer: Aetna Commercial |
$1,998.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,809.44
|
| Rate for Payer: Cash Price |
$631.20
|
| Rate for Payer: Cash Price |
$631.20
|
| Rate for Payer: Cash Price |
$631.20
|
| Rate for Payer: Cigna Commercial |
$1,998.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,052.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,262.40
|
| Rate for Payer: Health EOS Commercial |
$1,914.64
|
| Rate for Payer: HFN Commercial |
$1,998.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,125.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,125.51
|
| Rate for Payer: Multiplan Commercial |
$1,683.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,998.80
|
| Rate for Payer: Quartz Beloit One Network |
$925.76
|
| Rate for Payer: Quartz Commercial |
$1,199.28
|
| Rate for Payer: The Alliance Commercial |
$1,052.00
|
| Rate for Payer: WEA Trust Commercial |
$1,157.20
|
| Rate for Payer: WPS Commercial |
$1,558.43
|
|
|
NM Intestine Imaging/Meckel's
|
Professional
|
Both
|
$2,023.00
|
|
|
Service Code
|
CPT 78290
|
| Hospital Charge Code |
631225
|
| Min. Negotiated Rate |
$890.12 |
| Max. Negotiated Rate |
$1,921.85 |
| Rate for Payer: Aetna Commercial |
$1,921.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,739.78
|
| Rate for Payer: Cash Price |
$606.90
|
| Rate for Payer: Cash Price |
$606.90
|
| Rate for Payer: Cash Price |
$606.90
|
| Rate for Payer: Cigna Commercial |
$1,921.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,011.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,213.80
|
| Rate for Payer: Health EOS Commercial |
$1,840.93
|
| Rate for Payer: HFN Commercial |
$1,921.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,125.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,125.51
|
| Rate for Payer: Multiplan Commercial |
$1,618.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,921.85
|
| Rate for Payer: Quartz Beloit One Network |
$890.12
|
| Rate for Payer: Quartz Commercial |
$1,153.11
|
| Rate for Payer: The Alliance Commercial |
$1,011.50
|
| Rate for Payer: WEA Trust Commercial |
$1,112.65
|
| Rate for Payer: WPS Commercial |
$1,498.44
|
|
|
NM Intestine Imaging/Meckel's
|
Facility
|
OP
|
$2,023.00
|
|
|
Service Code
|
CPT 78290
|
| Hospital Charge Code |
631225
|
| Min. Negotiated Rate |
$407.66 |
| Max. Negotiated Rate |
$1,861.16 |
| Rate for Payer: Aetna Commercial |
$1,820.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,739.78
|
| Rate for Payer: Aetna Managed Medicare |
$407.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,314.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,011.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.04
|
| Rate for Payer: Anthem Medicare Advantage |
$407.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$407.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$407.66
|
| Rate for Payer: Cash Price |
$606.90
|
| Rate for Payer: Cash Price |
$606.90
|
| Rate for Payer: Cigna Commercial |
$1,861.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$407.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$407.66
|
| Rate for Payer: Health EOS Commercial |
$1,800.47
|
| Rate for Payer: HFN Commercial |
$1,861.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,516.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$407.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$407.66
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$407.66
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$407.66
|
| Rate for Payer: Multiplan Commercial |
$1,618.40
|
| Rate for Payer: NAPHCARE Commercial |
$611.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,861.16
|
| Rate for Payer: Quartz Beloit One Network |
$991.27
|
| Rate for Payer: Quartz Commercial |
$1,314.95
|
| Rate for Payer: Quartz Medicare Advantage |
$407.66
|
| Rate for Payer: The Alliance Commercial |
$1,630.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$407.66
|
| Rate for Payer: WEA Trust Commercial |
$1,112.65
|
| Rate for Payer: Wellcare Medicare |
$407.66
|
| Rate for Payer: WPS Commercial |
$1,498.44
|
|
|
NM Intestine Imaging/Meckel's
|
Facility
|
IP
|
$2,023.00
|
|
|
Service Code
|
CPT 78290
|
| Hospital Charge Code |
631225
|
| Min. Negotiated Rate |
$991.27 |
| Max. Negotiated Rate |
$1,861.16 |
| Rate for Payer: Aetna Commercial |
$1,820.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,739.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.19
|
| Rate for Payer: Cash Price |
$606.90
|
| Rate for Payer: Cigna Commercial |
$1,861.16
|
| Rate for Payer: Health EOS Commercial |
$1,800.47
|
| Rate for Payer: HFN Commercial |
$1,861.16
|
| Rate for Payer: Multiplan Commercial |
$1,618.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,213.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,861.16
|
| Rate for Payer: Quartz Beloit One Network |
$991.27
|
| Rate for Payer: Quartz Commercial |
$1,213.80
|
| Rate for Payer: WEA Trust Commercial |
$1,112.65
|
| Rate for Payer: WPS Commercial |
$1,498.44
|
|
|
NM Kidney Imaging Static
|
Facility
|
IP
|
$1,918.00
|
|
|
Service Code
|
CPT 78700
|
| Hospital Charge Code |
2586883
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$939.82 |
| Max. Negotiated Rate |
$1,764.56 |
| Rate for Payer: Aetna Commercial |
$1,726.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,649.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,016.54
|
| Rate for Payer: Cash Price |
$575.40
|
| Rate for Payer: Cigna Commercial |
$1,764.56
|
| Rate for Payer: Health EOS Commercial |
$1,707.02
|
| Rate for Payer: HFN Commercial |
$1,764.56
|
| Rate for Payer: Multiplan Commercial |
$1,534.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,150.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,764.56
|
| Rate for Payer: Quartz Beloit One Network |
$939.82
|
| Rate for Payer: Quartz Commercial |
$1,150.80
|
| Rate for Payer: WEA Trust Commercial |
$1,054.90
|
| Rate for Payer: WPS Commercial |
$1,420.66
|
|
|
NM Kidney Imaging Static
|
Facility
|
IP
|
$1,844.00
|
|
|
Service Code
|
CPT 78700
|
| Hospital Charge Code |
631437
|
| Min. Negotiated Rate |
$903.56 |
| Max. Negotiated Rate |
$1,696.48 |
| Rate for Payer: Aetna Commercial |
$1,659.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,585.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$977.32
|
| Rate for Payer: Cash Price |
$553.20
|
| Rate for Payer: Cigna Commercial |
$1,696.48
|
| Rate for Payer: Health EOS Commercial |
$1,641.16
|
| Rate for Payer: HFN Commercial |
$1,696.48
|
| Rate for Payer: Multiplan Commercial |
$1,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,106.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,696.48
|
| Rate for Payer: Quartz Beloit One Network |
$903.56
|
| Rate for Payer: Quartz Commercial |
$1,106.40
|
| Rate for Payer: WEA Trust Commercial |
$1,014.20
|
| Rate for Payer: WPS Commercial |
$1,365.85
|
|
|
NM Kidney Imaging Static
|
Facility
|
OP
|
$1,844.00
|
|
|
Service Code
|
CPT 78700
|
| Hospital Charge Code |
631437
|
| Min. Negotiated Rate |
$407.66 |
| Max. Negotiated Rate |
$1,696.48 |
| Rate for Payer: Aetna Commercial |
$1,659.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,585.84
|
| Rate for Payer: Aetna Managed Medicare |
$407.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,198.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$922.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$885.12
|
| Rate for Payer: Anthem Medicare Advantage |
$407.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$977.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$407.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$407.66
|
| Rate for Payer: Cash Price |
$553.20
|
| Rate for Payer: Cash Price |
$553.20
|
| Rate for Payer: Cigna Commercial |
$1,696.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$407.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,031.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$407.66
|
| Rate for Payer: Health EOS Commercial |
$1,641.16
|
| Rate for Payer: HFN Commercial |
$1,696.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,516.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$407.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$407.66
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$407.66
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$407.66
|
| Rate for Payer: Multiplan Commercial |
$1,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$611.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,696.48
|
| Rate for Payer: Quartz Beloit One Network |
$903.56
|
| Rate for Payer: Quartz Commercial |
$1,198.60
|
| Rate for Payer: Quartz Medicare Advantage |
$407.66
|
| Rate for Payer: The Alliance Commercial |
$1,630.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$407.66
|
| Rate for Payer: WEA Trust Commercial |
$1,014.20
|
| Rate for Payer: Wellcare Medicare |
$407.66
|
| Rate for Payer: WPS Commercial |
$1,365.85
|
|
|
NM Kidney Imaging Static
|
Professional
|
Both
|
$1,844.00
|
|
|
Service Code
|
CPT 78700
|
| Hospital Charge Code |
631437
|
| Min. Negotiated Rate |
$584.39 |
| Max. Negotiated Rate |
$1,751.80 |
| Rate for Payer: Aetna Commercial |
$1,751.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,585.84
|
| Rate for Payer: Cash Price |
$553.20
|
| Rate for Payer: Cash Price |
$553.20
|
| Rate for Payer: Cash Price |
$553.20
|
| Rate for Payer: Cigna Commercial |
$1,751.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$922.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,106.40
|
| Rate for Payer: Health EOS Commercial |
$1,678.04
|
| Rate for Payer: HFN Commercial |
$1,751.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$584.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$584.39
|
| Rate for Payer: Multiplan Commercial |
$1,475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.80
|
| Rate for Payer: Quartz Beloit One Network |
$811.36
|
| Rate for Payer: Quartz Commercial |
$1,051.08
|
| Rate for Payer: The Alliance Commercial |
$922.00
|
| Rate for Payer: WEA Trust Commercial |
$1,014.20
|
| Rate for Payer: WPS Commercial |
$1,365.85
|
|
|
NM Kidney Imaging Static
|
Facility
|
OP
|
$1,918.00
|
|
|
Service Code
|
CPT 78700
|
| Hospital Charge Code |
2586883
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$407.66 |
| Max. Negotiated Rate |
$2,304.00 |
| Rate for Payer: Aetna Commercial |
$1,726.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,649.48
|
| Rate for Payer: Aetna Managed Medicare |
$407.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,528.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,222.98
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,161.83
|
| Rate for Payer: Anthem Medicare Advantage |
$407.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,016.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$407.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$407.66
|
| Rate for Payer: Cash Price |
$575.40
|
| Rate for Payer: Cash Price |
$575.40
|
| Rate for Payer: Cash Price |
$575.40
|
| Rate for Payer: Cigna Commercial |
$1,764.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$407.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,073.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$407.66
|
| Rate for Payer: Health EOS Commercial |
$1,707.02
|
| Rate for Payer: HFN Commercial |
$1,764.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,516.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$407.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$407.66
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$407.66
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$407.66
|
| Rate for Payer: Multiplan Commercial |
$1,534.40
|
| Rate for Payer: NAPHCARE Commercial |
$611.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,764.56
|
| Rate for Payer: Quartz Beloit One Network |
$939.82
|
| Rate for Payer: Quartz Commercial |
$1,246.70
|
| Rate for Payer: Quartz Medicare Advantage |
$407.66
|
| Rate for Payer: The Alliance Commercial |
$1,630.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$407.66
|
| Rate for Payer: United Healthcare PPO |
$2,304.00
|
| Rate for Payer: WEA Trust Commercial |
$1,054.90
|
| Rate for Payer: Wellcare Medicare |
$407.66
|
| Rate for Payer: WPS Commercial |
$1,420.66
|
|
|
NM Kidney Imaging Static
|
Professional
|
Both
|
$1,918.00
|
|
|
Service Code
|
CPT 78700
|
| Hospital Charge Code |
2586883
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$584.39 |
| Max. Negotiated Rate |
$1,822.10 |
| Rate for Payer: Aetna Commercial |
$1,822.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,649.48
|
| Rate for Payer: Cash Price |
$575.40
|
| Rate for Payer: Cash Price |
$575.40
|
| Rate for Payer: Cash Price |
$575.40
|
| Rate for Payer: Cigna Commercial |
$1,822.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$959.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,150.80
|
| Rate for Payer: Health EOS Commercial |
$1,745.38
|
| Rate for Payer: HFN Commercial |
$1,822.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$584.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$584.39
|
| Rate for Payer: Multiplan Commercial |
$1,534.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,822.10
|
| Rate for Payer: Quartz Beloit One Network |
$843.92
|
| Rate for Payer: Quartz Commercial |
$1,093.26
|
| Rate for Payer: The Alliance Commercial |
$959.00
|
| Rate for Payer: WEA Trust Commercial |
$1,054.90
|
| Rate for Payer: WPS Commercial |
$1,420.66
|
|
|
NM Kidney Imaging w/ Flow w/o Pharm
|
Professional
|
Both
|
$2,281.00
|
|
|
Service Code
|
CPT 78707
|
| Hospital Charge Code |
631451
|
| Min. Negotiated Rate |
$789.48 |
| Max. Negotiated Rate |
$2,166.95 |
| Rate for Payer: Aetna Commercial |
$2,166.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,961.66
|
| Rate for Payer: Cash Price |
$684.30
|
| Rate for Payer: Cash Price |
$684.30
|
| Rate for Payer: Cash Price |
$684.30
|
| Rate for Payer: Cigna Commercial |
$2,166.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,140.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,368.60
|
| Rate for Payer: Health EOS Commercial |
$2,075.71
|
| Rate for Payer: HFN Commercial |
$2,166.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$789.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$789.48
|
| Rate for Payer: Multiplan Commercial |
$1,824.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,166.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,003.64
|
| Rate for Payer: Quartz Commercial |
$1,300.17
|
| Rate for Payer: The Alliance Commercial |
$1,140.50
|
| Rate for Payer: WEA Trust Commercial |
$1,254.55
|
| Rate for Payer: WPS Commercial |
$1,689.54
|
|
|
NM Kidney Imaging w/ Flow w/o Pharm
|
Facility
|
IP
|
$2,464.00
|
|
|
Service Code
|
CPT 78707
|
| Hospital Charge Code |
2586889
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,207.36 |
| Max. Negotiated Rate |
$2,266.88 |
| Rate for Payer: Aetna Commercial |
$2,217.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,119.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,305.92
|
| Rate for Payer: Cash Price |
$739.20
|
| Rate for Payer: Cigna Commercial |
$2,266.88
|
| Rate for Payer: Health EOS Commercial |
$2,192.96
|
| Rate for Payer: HFN Commercial |
$2,266.88
|
| Rate for Payer: Multiplan Commercial |
$1,971.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,478.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,266.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,207.36
|
| Rate for Payer: Quartz Commercial |
$1,478.40
|
| Rate for Payer: WEA Trust Commercial |
$1,355.20
|
| Rate for Payer: WPS Commercial |
$1,825.08
|
|
|
NM Kidney Imaging w/ Flow w/o Pharm
|
Facility
|
OP
|
$2,281.00
|
|
|
Service Code
|
CPT 78707
|
| Hospital Charge Code |
631451
|
| Min. Negotiated Rate |
$534.24 |
| Max. Negotiated Rate |
$2,136.96 |
| Rate for Payer: Aetna Commercial |
$2,052.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,961.66
|
| Rate for Payer: Aetna Managed Medicare |
$534.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,140.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,094.88
|
| Rate for Payer: Anthem Medicare Advantage |
$534.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,208.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$534.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$534.24
|
| Rate for Payer: Cash Price |
$684.30
|
| Rate for Payer: Cash Price |
$684.30
|
| Rate for Payer: Cigna Commercial |
$2,098.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$534.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,276.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$534.24
|
| Rate for Payer: Health EOS Commercial |
$2,030.09
|
| Rate for Payer: HFN Commercial |
$2,098.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,987.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$534.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$534.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$534.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$534.24
|
| Rate for Payer: Multiplan Commercial |
$1,824.80
|
| Rate for Payer: NAPHCARE Commercial |
$801.36
|
| Rate for Payer: Preferred Network Access Commercial |
$2,098.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,117.69
|
| Rate for Payer: Quartz Commercial |
$1,482.65
|
| Rate for Payer: Quartz Medicare Advantage |
$534.24
|
| Rate for Payer: The Alliance Commercial |
$2,136.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$534.24
|
| Rate for Payer: WEA Trust Commercial |
$1,254.55
|
| Rate for Payer: Wellcare Medicare |
$534.24
|
| Rate for Payer: WPS Commercial |
$1,689.54
|
|
|
NM Kidney Imaging w/ Flow w/o Pharm
|
Facility
|
OP
|
$2,464.00
|
|
|
Service Code
|
CPT 78707
|
| Hospital Charge Code |
2586889
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$534.24 |
| Max. Negotiated Rate |
$2,304.00 |
| Rate for Payer: Aetna Commercial |
$2,217.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,119.04
|
| Rate for Payer: Aetna Managed Medicare |
$534.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,003.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,602.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,522.58
|
| Rate for Payer: Anthem Medicare Advantage |
$534.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,305.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$534.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$534.24
|
| Rate for Payer: Cash Price |
$739.20
|
| Rate for Payer: Cash Price |
$739.20
|
| Rate for Payer: Cash Price |
$739.20
|
| Rate for Payer: Cigna Commercial |
$2,266.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$534.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,378.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$534.24
|
| Rate for Payer: Health EOS Commercial |
$2,192.96
|
| Rate for Payer: HFN Commercial |
$2,266.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,987.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$534.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$534.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$534.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$534.24
|
| Rate for Payer: Multiplan Commercial |
$1,971.20
|
| Rate for Payer: NAPHCARE Commercial |
$801.36
|
| Rate for Payer: Preferred Network Access Commercial |
$2,266.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,207.36
|
| Rate for Payer: Quartz Commercial |
$1,601.60
|
| Rate for Payer: Quartz Medicare Advantage |
$534.24
|
| Rate for Payer: The Alliance Commercial |
$2,136.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$534.24
|
| Rate for Payer: United Healthcare PPO |
$2,304.00
|
| Rate for Payer: WEA Trust Commercial |
$1,355.20
|
| Rate for Payer: Wellcare Medicare |
$534.24
|
| Rate for Payer: WPS Commercial |
$1,825.08
|
|
|
NM Kidney Imaging w/ Flow w/o Pharm
|
Professional
|
Both
|
$2,464.00
|
|
|
Service Code
|
CPT 78707
|
| Hospital Charge Code |
2586889
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$789.48 |
| Max. Negotiated Rate |
$2,340.80 |
| Rate for Payer: Aetna Commercial |
$2,340.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,119.04
|
| Rate for Payer: Cash Price |
$739.20
|
| Rate for Payer: Cash Price |
$739.20
|
| Rate for Payer: Cash Price |
$739.20
|
| Rate for Payer: Cigna Commercial |
$2,340.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,232.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,478.40
|
| Rate for Payer: Health EOS Commercial |
$2,242.24
|
| Rate for Payer: HFN Commercial |
$2,340.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$789.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$789.48
|
| Rate for Payer: Multiplan Commercial |
$1,971.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,340.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,084.16
|
| Rate for Payer: Quartz Commercial |
$1,404.48
|
| Rate for Payer: The Alliance Commercial |
$1,232.00
|
| Rate for Payer: WEA Trust Commercial |
$1,355.20
|
| Rate for Payer: WPS Commercial |
$1,825.08
|
|
