|
Radiation Tx Simple
|
Facility
|
OP
|
$1,016.00
|
|
|
Service Code
|
CPT 77402
|
| Hospital Charge Code |
3040394
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$118.52 |
| Max. Negotiated Rate |
$934.72 |
| Rate for Payer: Aetna Commercial |
$914.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$873.76
|
| Rate for Payer: Aetna Managed Medicare |
$118.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$444.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$355.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$337.78
|
| Rate for Payer: Anthem Medicare Advantage |
$118.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$538.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$118.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$118.52
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$934.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$118.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$568.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$118.52
|
| Rate for Payer: Health EOS Commercial |
$904.24
|
| Rate for Payer: HFN Commercial |
$934.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$440.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$118.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$118.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$118.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$118.52
|
| Rate for Payer: Multiplan Commercial |
$812.80
|
| Rate for Payer: NAPHCARE Commercial |
$177.78
|
| Rate for Payer: Preferred Network Access Commercial |
$934.72
|
| Rate for Payer: Quartz Beloit One Network |
$497.84
|
| Rate for Payer: Quartz Commercial |
$660.40
|
| Rate for Payer: Quartz Medicare Advantage |
$118.52
|
| Rate for Payer: The Alliance Commercial |
$474.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$118.52
|
| Rate for Payer: United Healthcare PPO |
$762.00
|
| Rate for Payer: WEA Trust Commercial |
$558.80
|
| Rate for Payer: Wellcare Medicare |
$118.52
|
| Rate for Payer: WPS Commercial |
$752.55
|
|
|
Radiation Tx Simple
|
Facility
|
IP
|
$1,016.00
|
|
|
Service Code
|
CPT 77402
|
| Hospital Charge Code |
3040394
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$497.84 |
| Max. Negotiated Rate |
$934.72 |
| Rate for Payer: Aetna Commercial |
$914.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$873.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$538.48
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$934.72
|
| Rate for Payer: Health EOS Commercial |
$904.24
|
| Rate for Payer: HFN Commercial |
$934.72
|
| Rate for Payer: Multiplan Commercial |
$812.80
|
| Rate for Payer: NAPHCARE Commercial |
$609.60
|
| Rate for Payer: Preferred Network Access Commercial |
$934.72
|
| Rate for Payer: Quartz Beloit One Network |
$497.84
|
| Rate for Payer: Quartz Commercial |
$609.60
|
| Rate for Payer: WEA Trust Commercial |
$558.80
|
| Rate for Payer: WPS Commercial |
$752.55
|
|
|
RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS (EG, TENOSYNOVITIS, FUNGUS, TBC, OR OTHER GRANULOMAS, RHEUMATOID ARTHRITIS); EXTENSORS, WITH OR WITHOUT TRANSPOSITION OF DORSAL RETINACULUM
|
Facility
|
OP
|
$12,797.24
|
|
|
Service Code
|
CPT 25116
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,199.31 |
| Max. Negotiated Rate |
$12,797.24 |
| Rate for Payer: Aetna Managed Medicare |
$3,199.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,199.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,199.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,199.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,199.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,795.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,199.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,901.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,199.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,199.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,199.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,199.31
|
| Rate for Payer: NAPHCARE Commercial |
$4,798.96
|
| Rate for Payer: Quartz Medicare Advantage |
$3,199.31
|
| Rate for Payer: The Alliance Commercial |
$12,797.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,199.31
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,199.31
|
|
|
RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER
|
Facility
|
OP
|
$11,234.20
|
|
|
Service Code
|
CPT 22905
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,808.55 |
| Max. Negotiated Rate |
$11,234.20 |
| Rate for Payer: Aetna Managed Medicare |
$2,808.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$2,808.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,808.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,808.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,808.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,795.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,808.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,447.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,808.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,808.55
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,808.55
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,808.55
|
| Rate for Payer: NAPHCARE Commercial |
$4,212.82
|
| Rate for Payer: Quartz Medicare Advantage |
$2,808.55
|
| Rate for Payer: The Alliance Commercial |
$11,234.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,808.55
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$2,808.55
|
|
|
RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF BACK OR FLANK; 5 CM OR GREATER
|
Facility
|
OP
|
$11,234.20
|
|
|
Service Code
|
CPT 21936
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,808.55 |
| Max. Negotiated Rate |
$11,234.20 |
| Rate for Payer: Aetna Managed Medicare |
$2,808.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$2,808.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,808.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,808.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,808.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,808.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,447.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,808.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,808.55
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,808.55
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,808.55
|
| Rate for Payer: NAPHCARE Commercial |
$4,212.82
|
| Rate for Payer: Quartz Medicare Advantage |
$2,808.55
|
| Rate for Payer: The Alliance Commercial |
$11,234.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,808.55
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$2,808.55
|
|
|
RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FACE OR SCALP; 2 CM OR GREATER
|
Facility
|
OP
|
$11,234.20
|
|
|
Service Code
|
CPT 21016
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,808.55 |
| Max. Negotiated Rate |
$11,234.20 |
| Rate for Payer: Aetna Managed Medicare |
$2,808.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$2,808.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,808.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,808.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,808.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,808.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,447.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,808.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,808.55
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,808.55
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,808.55
|
| Rate for Payer: NAPHCARE Commercial |
$4,212.82
|
| Rate for Payer: Quartz Medicare Advantage |
$2,808.55
|
| Rate for Payer: The Alliance Commercial |
$11,234.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,808.55
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$2,808.55
|
|
|
RADIOFREQUENCY VEIN ABLATION
|
Facility
|
OP
|
$4,238.00
|
|
| Hospital Charge Code |
4494794
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,186.64 |
| Max. Negotiated Rate |
$16,952.00 |
| Rate for Payer: Aetna Commercial |
$3,814.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,644.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,186.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,754.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,119.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,034.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,246.14
|
| Rate for Payer: Cash Price |
$1,271.40
|
| Rate for Payer: Cigna Commercial |
$3,898.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,371.58
|
| Rate for Payer: Health EOS Commercial |
$3,771.82
|
| Rate for Payer: HFN Commercial |
$3,898.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,178.50
|
| Rate for Payer: Multiplan Commercial |
$3,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,542.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,898.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,076.62
|
| Rate for Payer: Quartz Commercial |
$2,754.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,542.80
|
| Rate for Payer: The Alliance Commercial |
$16,952.00
|
| Rate for Payer: WEA Trust Commercial |
$2,330.90
|
| Rate for Payer: WPS Commercial |
$3,139.09
|
|
|
RADIOFREQUENCY VEIN ABLATION
|
Facility
|
IP
|
$4,238.00
|
|
| Hospital Charge Code |
4494794
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,076.62 |
| Max. Negotiated Rate |
$3,898.96 |
| Rate for Payer: Aetna Commercial |
$3,814.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,644.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,246.14
|
| Rate for Payer: Cash Price |
$1,271.40
|
| Rate for Payer: Cigna Commercial |
$3,898.96
|
| Rate for Payer: Health EOS Commercial |
$3,771.82
|
| Rate for Payer: HFN Commercial |
$3,898.96
|
| Rate for Payer: Multiplan Commercial |
$3,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,542.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,898.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,076.62
|
| Rate for Payer: Quartz Commercial |
$2,542.80
|
| Rate for Payer: WEA Trust Commercial |
$2,330.90
|
| Rate for Payer: WPS Commercial |
$3,139.09
|
|
|
Radiographic Guidance
|
Facility
|
IP
|
$3,338.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
2944295
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,635.62 |
| Max. Negotiated Rate |
$3,070.96 |
| Rate for Payer: Aetna Commercial |
$3,004.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,870.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,769.14
|
| Rate for Payer: Cash Price |
$1,001.40
|
| Rate for Payer: Cigna Commercial |
$3,070.96
|
| Rate for Payer: Health EOS Commercial |
$2,970.82
|
| Rate for Payer: HFN Commercial |
$3,070.96
|
| Rate for Payer: Multiplan Commercial |
$2,670.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,002.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,070.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,635.62
|
| Rate for Payer: Quartz Commercial |
$2,002.80
|
| Rate for Payer: WEA Trust Commercial |
$1,835.90
|
| Rate for Payer: WPS Commercial |
$2,472.46
|
|
|
Radiographic Guidance
|
Facility
|
OP
|
$3,338.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
2944295
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$13,352.00 |
| Rate for Payer: Aetna Commercial |
$3,004.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,870.68
|
| Rate for Payer: Aetna Managed Medicare |
$934.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,169.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,669.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,602.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,769.14
|
| Rate for Payer: Cash Price |
$1,001.40
|
| Rate for Payer: Cash Price |
$1,001.40
|
| Rate for Payer: Cigna Commercial |
$3,070.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,867.94
|
| Rate for Payer: Health EOS Commercial |
$2,970.82
|
| Rate for Payer: HFN Commercial |
$3,070.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,503.50
|
| Rate for Payer: Multiplan Commercial |
$2,670.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,002.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,070.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,635.62
|
| Rate for Payer: Quartz Commercial |
$2,169.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,002.80
|
| Rate for Payer: The Alliance Commercial |
$13,352.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$1,835.90
|
| Rate for Payer: WPS Commercial |
$2,472.46
|
|
|
Radiographic Guidance
|
Professional
|
Both
|
$3,338.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
2944295
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$406.73 |
| Max. Negotiated Rate |
$3,171.10 |
| Rate for Payer: Aetna Commercial |
$3,171.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,870.68
|
| Rate for Payer: Cash Price |
$1,001.40
|
| Rate for Payer: Cash Price |
$1,001.40
|
| Rate for Payer: Cigna Commercial |
$3,171.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,669.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,002.80
|
| Rate for Payer: Health EOS Commercial |
$3,037.58
|
| Rate for Payer: HFN Commercial |
$3,171.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$406.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$406.73
|
| Rate for Payer: Multiplan Commercial |
$2,670.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,171.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,468.72
|
| Rate for Payer: Quartz Commercial |
$1,902.66
|
| Rate for Payer: The Alliance Commercial |
$1,669.00
|
| Rate for Payer: WEA Trust Commercial |
$1,835.90
|
| Rate for Payer: WPS Commercial |
$2,472.46
|
|
|
RADIOTHERAPY
|
Facility
|
IP
|
$71,874.00
|
|
|
Service Code
|
MSDRG 849
|
| Min. Negotiated Rate |
$25,853.91 |
| Max. Negotiated Rate |
$71,874.00 |
| Rate for Payer: Aetna Managed Medicare |
$25,853.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56,436.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43,257.89
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41,097.82
|
| Rate for Payer: Anthem Medicare Advantage |
$25,853.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25,853.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25,853.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25,853.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45,622.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25,853.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52,482.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25,853.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25,853.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25,853.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25,853.91
|
| Rate for Payer: NAPHCARE Commercial |
$38,780.86
|
| Rate for Payer: Quartz Medicare Advantage |
$25,853.91
|
| Rate for Payer: The Alliance Commercial |
$71,874.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25,853.91
|
| Rate for Payer: United Healthcare PPO |
$40,858.14
|
| Rate for Payer: Wellcare Medicare |
$25,853.91
|
|
|
Radium 223 (Xofigo)
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
HCPCS A9606
|
| Hospital Charge Code |
3790004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.82 |
| Max. Negotiated Rate |
$200.56 |
| Rate for Payer: Aetna Commercial |
$196.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.54
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$200.56
|
| Rate for Payer: Health EOS Commercial |
$194.02
|
| Rate for Payer: HFN Commercial |
$200.56
|
| Rate for Payer: Multiplan Commercial |
$174.40
|
| Rate for Payer: NAPHCARE Commercial |
$130.80
|
| Rate for Payer: Preferred Network Access Commercial |
$200.56
|
| Rate for Payer: Quartz Beloit One Network |
$106.82
|
| Rate for Payer: Quartz Commercial |
$130.80
|
| Rate for Payer: WEA Trust Commercial |
$119.90
|
| Rate for Payer: WPS Commercial |
$161.47
|
|
|
Radium 223 (Xofigo)
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
HCPCS A9606
|
| Hospital Charge Code |
3790004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.64 |
| Max. Negotiated Rate |
$644.65 |
| Rate for Payer: Aetna Commercial |
$196.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.48
|
| Rate for Payer: Aetna Managed Medicare |
$161.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$141.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$109.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.64
|
| Rate for Payer: Anthem Medicare Advantage |
$161.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$161.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$161.16
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$200.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$161.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$161.16
|
| Rate for Payer: Health EOS Commercial |
$194.02
|
| Rate for Payer: HFN Commercial |
$200.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$599.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$161.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$161.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$161.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$161.16
|
| Rate for Payer: Multiplan Commercial |
$174.40
|
| Rate for Payer: NAPHCARE Commercial |
$241.74
|
| Rate for Payer: Preferred Network Access Commercial |
$200.56
|
| Rate for Payer: Quartz Beloit One Network |
$106.82
|
| Rate for Payer: Quartz Commercial |
$141.70
|
| Rate for Payer: Quartz Medicare Advantage |
$161.16
|
| Rate for Payer: The Alliance Commercial |
$644.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$161.16
|
| Rate for Payer: WEA Trust Commercial |
$119.90
|
| Rate for Payer: Wellcare Medicare |
$161.16
|
| Rate for Payer: WPS Commercial |
$161.47
|
|
|
Radium 223 (Xofigo)
|
Professional
|
Both
|
$218.00
|
|
|
Service Code
|
HCPCS A9606
|
| Hospital Charge Code |
3790004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.92 |
| Max. Negotiated Rate |
$596.89 |
| Rate for Payer: Aetna Commercial |
$207.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.48
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$207.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$109.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.80
|
| Rate for Payer: Health EOS Commercial |
$198.38
|
| Rate for Payer: HFN Commercial |
$207.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$596.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$596.89
|
| Rate for Payer: Multiplan Commercial |
$174.40
|
| Rate for Payer: Preferred Network Access Commercial |
$207.10
|
| Rate for Payer: Quartz Beloit One Network |
$95.92
|
| Rate for Payer: Quartz Commercial |
$124.26
|
| Rate for Payer: The Alliance Commercial |
$109.00
|
| Rate for Payer: WEA Trust Commercial |
$119.90
|
| Rate for Payer: WPS Commercial |
$161.47
|
|
|
Rad Therapy Mgmt 5 Treatments 77427
|
Professional
|
Both
|
$2,716.00
|
|
|
Service Code
|
CPT 77427
|
| Hospital Charge Code |
5258642
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$642.35 |
| Max. Negotiated Rate |
$2,580.20 |
| Rate for Payer: Aetna Commercial |
$2,580.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,335.76
|
| Rate for Payer: Cash Price |
$814.80
|
| Rate for Payer: Cash Price |
$814.80
|
| Rate for Payer: Cigna Commercial |
$2,580.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,358.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,629.60
|
| Rate for Payer: Health EOS Commercial |
$2,471.56
|
| Rate for Payer: HFN Commercial |
$2,580.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$642.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$642.35
|
| Rate for Payer: Multiplan Commercial |
$2,172.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,580.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,195.04
|
| Rate for Payer: Quartz Commercial |
$1,548.12
|
| Rate for Payer: The Alliance Commercial |
$1,358.00
|
| Rate for Payer: WEA Trust Commercial |
$1,493.80
|
| Rate for Payer: WPS Commercial |
$2,011.74
|
|
|
Rad Therapy Mgmt-Complete 77431
|
Professional
|
Both
|
$1,426.00
|
|
|
Service Code
|
CPT 77431
|
| Hospital Charge Code |
5258643
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$360.31 |
| Max. Negotiated Rate |
$1,354.70 |
| Rate for Payer: Aetna Commercial |
$1,354.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,226.36
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cigna Commercial |
$1,354.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$713.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$855.60
|
| Rate for Payer: Health EOS Commercial |
$1,297.66
|
| Rate for Payer: HFN Commercial |
$1,354.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$360.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$360.31
|
| Rate for Payer: Multiplan Commercial |
$1,140.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,354.70
|
| Rate for Payer: Quartz Beloit One Network |
$627.44
|
| Rate for Payer: Quartz Commercial |
$812.82
|
| Rate for Payer: The Alliance Commercial |
$713.00
|
| Rate for Payer: WEA Trust Commercial |
$784.30
|
| Rate for Payer: WPS Commercial |
$1,056.24
|
|
|
Rad Therapy Tx Plan-Complex 77263
|
Professional
|
Both
|
$2,776.00
|
|
|
Service Code
|
CPT 77263
|
| Hospital Charge Code |
5258623
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$569.99 |
| Max. Negotiated Rate |
$2,637.20 |
| Rate for Payer: Aetna Commercial |
$2,637.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,387.36
|
| Rate for Payer: Cash Price |
$832.80
|
| Rate for Payer: Cash Price |
$832.80
|
| Rate for Payer: Cigna Commercial |
$2,637.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,388.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,665.60
|
| Rate for Payer: Health EOS Commercial |
$2,526.16
|
| Rate for Payer: HFN Commercial |
$2,637.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$569.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$569.99
|
| Rate for Payer: Multiplan Commercial |
$2,220.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,637.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,221.44
|
| Rate for Payer: Quartz Commercial |
$1,582.32
|
| Rate for Payer: The Alliance Commercial |
$1,388.00
|
| Rate for Payer: WEA Trust Commercial |
$1,526.80
|
| Rate for Payer: WPS Commercial |
$2,056.18
|
|
|
Rad Therapy Tx Plan-Intermediate 77262
|
Professional
|
Both
|
$1,849.00
|
|
|
Service Code
|
CPT 77262
|
| Hospital Charge Code |
5258622
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$366.31 |
| Max. Negotiated Rate |
$1,756.55 |
| Rate for Payer: Aetna Commercial |
$1,756.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,590.14
|
| Rate for Payer: Cash Price |
$554.70
|
| Rate for Payer: Cash Price |
$554.70
|
| Rate for Payer: Cigna Commercial |
$1,756.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$924.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,109.40
|
| Rate for Payer: Health EOS Commercial |
$1,682.59
|
| Rate for Payer: HFN Commercial |
$1,756.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$366.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$366.31
|
| Rate for Payer: Multiplan Commercial |
$1,479.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,756.55
|
| Rate for Payer: Quartz Beloit One Network |
$813.56
|
| Rate for Payer: Quartz Commercial |
$1,053.93
|
| Rate for Payer: The Alliance Commercial |
$924.50
|
| Rate for Payer: WEA Trust Commercial |
$1,016.95
|
| Rate for Payer: WPS Commercial |
$1,369.55
|
|
|
Rad Therapy Tx Plan-Simple 77261
|
Professional
|
Both
|
$1,248.00
|
|
|
Service Code
|
CPT 77261
|
| Hospital Charge Code |
5258621
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$241.13 |
| Max. Negotiated Rate |
$1,185.60 |
| Rate for Payer: Aetna Commercial |
$1,185.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,073.28
|
| Rate for Payer: Cash Price |
$374.40
|
| Rate for Payer: Cash Price |
$374.40
|
| Rate for Payer: Cigna Commercial |
$1,185.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$624.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$748.80
|
| Rate for Payer: Health EOS Commercial |
$1,135.68
|
| Rate for Payer: HFN Commercial |
$1,185.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$241.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$241.13
|
| Rate for Payer: Multiplan Commercial |
$998.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,185.60
|
| Rate for Payer: Quartz Beloit One Network |
$549.12
|
| Rate for Payer: Quartz Commercial |
$711.36
|
| Rate for Payer: The Alliance Commercial |
$624.00
|
| Rate for Payer: WEA Trust Commercial |
$686.40
|
| Rate for Payer: WPS Commercial |
$924.39
|
|
|
RAID
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
CPT 87086
|
| Hospital Charge Code |
6209192
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$76.36 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Aetna Managed Medicare |
$8.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.40
|
| Rate for Payer: Anthem Medicaid |
$8.34
|
| Rate for Payer: Anthem Medicare Advantage |
$8.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.07
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.45
|
| Rate for Payer: Dean Health Medicaid |
$8.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.07
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.07
|
| Rate for Payer: Managed Health Services Medicaid |
$8.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.07
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$12.10
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.34
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$53.95
|
| Rate for Payer: Quartz Medicare Advantage |
$8.07
|
| Rate for Payer: The Alliance Commercial |
$32.28
|
| Rate for Payer: United Healthcare Medicaid |
$8.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.07
|
| Rate for Payer: United Healthcare PPO |
$62.25
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: Wellcare Medicare |
$8.07
|
| Rate for Payer: WMAP Medicaid |
$8.34
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
RAID
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
CPT 87086
|
| Hospital Charge Code |
6209192
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.67 |
| Max. Negotiated Rate |
$76.36 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$49.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$49.80
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
RAID
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
CPT 87086
|
| Hospital Charge Code |
6209192
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Health EOS Commercial |
$75.53
|
| Rate for Payer: HFN Commercial |
$78.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.49
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: Preferred Network Access Commercial |
$78.85
|
| Rate for Payer: Quartz Beloit One Network |
$36.52
|
| Rate for Payer: Quartz Commercial |
$47.31
|
| Rate for Payer: The Alliance Commercial |
$41.50
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
Range of Motion Measurements 95851
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
CPT 95851
|
| Hospital Charge Code |
3015468
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$17.24 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Aetna Commercial |
$50.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.80
|
| Rate for Payer: Health EOS Commercial |
$48.23
|
| Rate for Payer: HFN Commercial |
$50.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.87
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: Preferred Network Access Commercial |
$50.35
|
| Rate for Payer: Quartz Beloit One Network |
$23.32
|
| Rate for Payer: Quartz Commercial |
$30.21
|
| Rate for Payer: The Alliance Commercial |
$26.50
|
| Rate for Payer: United Healthcare Medicaid |
$17.24
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
Ranibizumab Injection J2778
|
Facility
|
IP
|
$1,124.00
|
|
|
Service Code
|
HCPCS J2778
|
| Hospital Charge Code |
5246757
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$550.76 |
| Max. Negotiated Rate |
$1,034.08 |
| Rate for Payer: Aetna Commercial |
$1,011.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$966.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$595.72
|
| Rate for Payer: Cash Price |
$337.20
|
| Rate for Payer: Cigna Commercial |
$1,034.08
|
| Rate for Payer: Health EOS Commercial |
$1,000.36
|
| Rate for Payer: HFN Commercial |
$1,034.08
|
| Rate for Payer: Multiplan Commercial |
$899.20
|
| Rate for Payer: NAPHCARE Commercial |
$674.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,034.08
|
| Rate for Payer: Quartz Beloit One Network |
$550.76
|
| Rate for Payer: Quartz Commercial |
$674.40
|
| Rate for Payer: WEA Trust Commercial |
$618.20
|
| Rate for Payer: WPS Commercial |
$832.55
|
|
