|
TBIL (FSURE)
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT 82247
|
| Hospital Charge Code |
4538813
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
TBIL (FSURE)
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
CPT 82247
|
| Hospital Charge Code |
4538813
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Aetna Managed Medicare |
$5.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.78
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.33
|
| Rate for Payer: Anthem Medicaid |
$4.24
|
| Rate for Payer: Anthem Medicare Advantage |
$5.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.02
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.65
|
| Rate for Payer: Dean Health Medicaid |
$4.24
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.02
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.02
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.02
|
| Rate for Payer: Managed Health Services Medicaid |
$4.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.02
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$7.53
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4.24
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$50.70
|
| Rate for Payer: Quartz Medicare Advantage |
$5.02
|
| Rate for Payer: The Alliance Commercial |
$20.08
|
| Rate for Payer: United Healthcare Medicaid |
$4.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.02
|
| Rate for Payer: United Healthcare PPO |
$58.50
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: Wellcare Medicare |
$5.02
|
| Rate for Payer: WMAP Medicaid |
$4.24
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
TBIL (FSURE)
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
CPT 82247
|
| Hospital Charge Code |
4538813
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.72 |
| Max. Negotiated Rate |
$74.10 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.80
|
| Rate for Payer: Health EOS Commercial |
$70.98
|
| Rate for Payer: HFN Commercial |
$74.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.72
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$74.10
|
| Rate for Payer: Quartz Beloit One Network |
$34.32
|
| Rate for Payer: Quartz Commercial |
$44.46
|
| Rate for Payer: The Alliance Commercial |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
TB Intradermal Test 86580
|
Professional
|
Both
|
$56.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3382901
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.60
|
| Rate for Payer: Health EOS Commercial |
$50.96
|
| Rate for Payer: HFN Commercial |
$53.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.86
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.20
|
| Rate for Payer: Quartz Beloit One Network |
$24.64
|
| Rate for Payer: Quartz Commercial |
$31.92
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
TB Intradermal Test 86580
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3382901
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$117.72 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$29.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.85
|
| Rate for Payer: Anthem Medicare Advantage |
$29.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.43
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$29.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$29.43
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.43
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$29.43
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$29.43
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$44.14
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$29.43
|
| Rate for Payer: The Alliance Commercial |
$117.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.43
|
| Rate for Payer: United Healthcare PPO |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: Wellcare Medicare |
$29.43
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
TB Intradermal Test 86580
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3382901
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
TB Intradermal Test Dialysis
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3605546
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$46.92 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$30.60
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$30.60
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
TB Intradermal Test Dialysis
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3605546
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$117.72 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Aetna Managed Medicare |
$29.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.85
|
| Rate for Payer: Anthem Medicare Advantage |
$29.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.43
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$29.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$29.43
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.43
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$29.43
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$29.43
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$44.14
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$33.15
|
| Rate for Payer: Quartz Medicare Advantage |
$29.43
|
| Rate for Payer: The Alliance Commercial |
$117.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.43
|
| Rate for Payer: United Healthcare PPO |
$38.25
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: Wellcare Medicare |
$29.43
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
TB Intradermal Test PD
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3605547
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$46.92 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$30.60
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$30.60
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
TB Intradermal Test PD
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3605547
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$117.72 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Aetna Managed Medicare |
$29.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.85
|
| Rate for Payer: Anthem Medicare Advantage |
$29.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.43
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$29.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$29.43
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.43
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$29.43
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$29.43
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$44.14
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$33.15
|
| Rate for Payer: Quartz Medicare Advantage |
$29.43
|
| Rate for Payer: The Alliance Commercial |
$117.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.43
|
| Rate for Payer: United Healthcare PPO |
$38.25
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: Wellcare Medicare |
$29.43
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
Tc-99m bicisate(Neurolite)
|
Facility
|
OP
|
$1,793.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
1486840
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$502.04 |
| Max. Negotiated Rate |
$7,172.00 |
| Rate for Payer: Aetna Commercial |
$1,613.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.98
|
| Rate for Payer: Aetna Managed Medicare |
$502.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,165.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$896.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$860.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$950.29
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cigna Commercial |
$1,649.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,003.36
|
| Rate for Payer: Health EOS Commercial |
$1,595.77
|
| Rate for Payer: HFN Commercial |
$1,649.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,344.75
|
| Rate for Payer: Multiplan Commercial |
$1,434.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,075.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,649.56
|
| Rate for Payer: Quartz Beloit One Network |
$878.57
|
| Rate for Payer: Quartz Commercial |
$1,165.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,075.80
|
| Rate for Payer: The Alliance Commercial |
$7,172.00
|
| Rate for Payer: WEA Trust Commercial |
$986.15
|
| Rate for Payer: WPS Commercial |
$1,328.08
|
|
|
Tc-99m bicisate(Neurolite)
|
Professional
|
Both
|
$1,793.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
1486840
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$651.90 |
| Max. Negotiated Rate |
$1,703.35 |
| Rate for Payer: Aetna Commercial |
$1,703.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.98
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cigna Commercial |
$1,703.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$896.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,075.80
|
| Rate for Payer: Health EOS Commercial |
$1,631.63
|
| Rate for Payer: HFN Commercial |
$1,703.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$651.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$651.90
|
| Rate for Payer: Multiplan Commercial |
$1,434.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,703.35
|
| Rate for Payer: Quartz Beloit One Network |
$788.92
|
| Rate for Payer: Quartz Commercial |
$1,022.01
|
| Rate for Payer: The Alliance Commercial |
$896.50
|
| Rate for Payer: WEA Trust Commercial |
$986.15
|
| Rate for Payer: WPS Commercial |
$1,328.08
|
|
|
Tc-99m bicisate(Neurolite)
|
Facility
|
IP
|
$1,793.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
1486840
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$878.57 |
| Max. Negotiated Rate |
$1,649.56 |
| Rate for Payer: Aetna Commercial |
$1,613.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$950.29
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cigna Commercial |
$1,649.56
|
| Rate for Payer: Health EOS Commercial |
$1,595.77
|
| Rate for Payer: HFN Commercial |
$1,649.56
|
| Rate for Payer: Multiplan Commercial |
$1,434.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,075.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,649.56
|
| Rate for Payer: Quartz Beloit One Network |
$878.57
|
| Rate for Payer: Quartz Commercial |
$1,075.80
|
| Rate for Payer: WEA Trust Commercial |
$986.15
|
| Rate for Payer: WPS Commercial |
$1,328.08
|
|
|
Tc-99m Ceretec(HMPAO)
|
Professional
|
Both
|
$1,946.00
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
1486814
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$856.24 |
| Max. Negotiated Rate |
$2,550.85 |
| Rate for Payer: Aetna Commercial |
$1,848.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,673.56
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cigna Commercial |
$1,848.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$973.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,167.60
|
| Rate for Payer: Health EOS Commercial |
$1,770.86
|
| Rate for Payer: HFN Commercial |
$1,848.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,550.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,550.85
|
| Rate for Payer: Multiplan Commercial |
$1,556.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,848.70
|
| Rate for Payer: Quartz Beloit One Network |
$856.24
|
| Rate for Payer: Quartz Commercial |
$1,109.22
|
| Rate for Payer: The Alliance Commercial |
$973.00
|
| Rate for Payer: WEA Trust Commercial |
$1,070.30
|
| Rate for Payer: WPS Commercial |
$1,441.40
|
|
|
Tc-99m Ceretec(HMPAO)
|
Facility
|
IP
|
$1,946.00
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
1486814
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$953.54 |
| Max. Negotiated Rate |
$1,790.32 |
| Rate for Payer: Aetna Commercial |
$1,751.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,673.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,031.38
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cigna Commercial |
$1,790.32
|
| Rate for Payer: Health EOS Commercial |
$1,731.94
|
| Rate for Payer: HFN Commercial |
$1,790.32
|
| Rate for Payer: Multiplan Commercial |
$1,556.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,167.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,790.32
|
| Rate for Payer: Quartz Beloit One Network |
$953.54
|
| Rate for Payer: Quartz Commercial |
$1,167.60
|
| Rate for Payer: WEA Trust Commercial |
$1,070.30
|
| Rate for Payer: WPS Commercial |
$1,441.40
|
|
|
Tc-99m Ceretec(HMPAO)
|
Facility
|
OP
|
$1,946.00
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
1486814
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$544.88 |
| Max. Negotiated Rate |
$7,784.00 |
| Rate for Payer: Aetna Commercial |
$1,751.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,673.56
|
| Rate for Payer: Aetna Managed Medicare |
$544.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,264.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$973.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$934.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,031.38
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cigna Commercial |
$1,790.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,088.98
|
| Rate for Payer: Health EOS Commercial |
$1,731.94
|
| Rate for Payer: HFN Commercial |
$1,790.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,459.50
|
| Rate for Payer: Multiplan Commercial |
$1,556.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,167.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,790.32
|
| Rate for Payer: Quartz Beloit One Network |
$953.54
|
| Rate for Payer: Quartz Commercial |
$1,264.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,167.60
|
| Rate for Payer: The Alliance Commercial |
$7,784.00
|
| Rate for Payer: WEA Trust Commercial |
$1,070.30
|
| Rate for Payer: WPS Commercial |
$1,441.40
|
|
|
Tc-99m Ceretec Leukocytes
|
Facility
|
OP
|
$9,017.00
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
1486812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,524.76 |
| Max. Negotiated Rate |
$36,068.00 |
| Rate for Payer: Aetna Commercial |
$8,115.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,754.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,524.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,861.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,508.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,328.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,779.01
|
| Rate for Payer: Cash Price |
$2,705.10
|
| Rate for Payer: Cigna Commercial |
$8,295.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,045.91
|
| Rate for Payer: Health EOS Commercial |
$8,025.13
|
| Rate for Payer: HFN Commercial |
$8,295.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,762.75
|
| Rate for Payer: Multiplan Commercial |
$7,213.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,410.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,295.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,418.33
|
| Rate for Payer: Quartz Commercial |
$5,861.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5,410.20
|
| Rate for Payer: The Alliance Commercial |
$36,068.00
|
| Rate for Payer: WEA Trust Commercial |
$4,959.35
|
| Rate for Payer: WPS Commercial |
$6,678.89
|
|
|
Tc-99m Ceretec Leukocytes
|
Facility
|
IP
|
$9,017.00
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
1486812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,418.33 |
| Max. Negotiated Rate |
$8,295.64 |
| Rate for Payer: Aetna Commercial |
$8,115.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,754.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,779.01
|
| Rate for Payer: Cash Price |
$2,705.10
|
| Rate for Payer: Cigna Commercial |
$8,295.64
|
| Rate for Payer: Health EOS Commercial |
$8,025.13
|
| Rate for Payer: HFN Commercial |
$8,295.64
|
| Rate for Payer: Multiplan Commercial |
$7,213.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,410.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,295.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,418.33
|
| Rate for Payer: Quartz Commercial |
$5,410.20
|
| Rate for Payer: WEA Trust Commercial |
$4,959.35
|
| Rate for Payer: WPS Commercial |
$6,678.89
|
|
|
Tc-99m Ceretec Leukocytes
|
Professional
|
Both
|
$9,017.00
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
1486812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,550.85 |
| Max. Negotiated Rate |
$8,566.15 |
| Rate for Payer: Aetna Commercial |
$8,566.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,754.62
|
| Rate for Payer: Cash Price |
$2,705.10
|
| Rate for Payer: Cash Price |
$2,705.10
|
| Rate for Payer: Cigna Commercial |
$8,566.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,508.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,410.20
|
| Rate for Payer: Health EOS Commercial |
$8,205.47
|
| Rate for Payer: HFN Commercial |
$8,566.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,550.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,550.85
|
| Rate for Payer: Multiplan Commercial |
$7,213.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,566.15
|
| Rate for Payer: Quartz Beloit One Network |
$3,967.48
|
| Rate for Payer: Quartz Commercial |
$5,139.69
|
| Rate for Payer: The Alliance Commercial |
$4,508.50
|
| Rate for Payer: WEA Trust Commercial |
$4,959.35
|
| Rate for Payer: WPS Commercial |
$6,678.89
|
|
|
Tc-99m DMSA
|
Facility
|
OP
|
$1,768.00
|
|
|
Service Code
|
HCPCS A9551
|
| Hospital Charge Code |
1486818
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$495.04 |
| Max. Negotiated Rate |
$7,072.00 |
| Rate for Payer: Aetna Commercial |
$1,591.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,520.48
|
| Rate for Payer: Aetna Managed Medicare |
$495.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,149.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$884.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$848.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$937.04
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cigna Commercial |
$1,626.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$989.37
|
| Rate for Payer: Health EOS Commercial |
$1,573.52
|
| Rate for Payer: HFN Commercial |
$1,626.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,326.00
|
| Rate for Payer: Multiplan Commercial |
$1,414.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,060.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,626.56
|
| Rate for Payer: Quartz Beloit One Network |
$866.32
|
| Rate for Payer: Quartz Commercial |
$1,149.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,060.80
|
| Rate for Payer: The Alliance Commercial |
$7,072.00
|
| Rate for Payer: WEA Trust Commercial |
$972.40
|
| Rate for Payer: WPS Commercial |
$1,309.56
|
|
|
Tc-99m DMSA
|
Facility
|
IP
|
$1,768.00
|
|
|
Service Code
|
HCPCS A9551
|
| Hospital Charge Code |
1486818
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$866.32 |
| Max. Negotiated Rate |
$1,626.56 |
| Rate for Payer: Aetna Commercial |
$1,591.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,520.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$937.04
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cigna Commercial |
$1,626.56
|
| Rate for Payer: Health EOS Commercial |
$1,573.52
|
| Rate for Payer: HFN Commercial |
$1,626.56
|
| Rate for Payer: Multiplan Commercial |
$1,414.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,060.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,626.56
|
| Rate for Payer: Quartz Beloit One Network |
$866.32
|
| Rate for Payer: Quartz Commercial |
$1,060.80
|
| Rate for Payer: WEA Trust Commercial |
$972.40
|
| Rate for Payer: WPS Commercial |
$1,309.56
|
|
|
Tc-99m DMSA
|
Professional
|
Both
|
$1,768.00
|
|
|
Service Code
|
HCPCS A9551
|
| Hospital Charge Code |
1486818
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$777.92 |
| Max. Negotiated Rate |
$1,679.60 |
| Rate for Payer: Aetna Commercial |
$1,679.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,520.48
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cigna Commercial |
$1,679.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$884.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,060.80
|
| Rate for Payer: Health EOS Commercial |
$1,608.88
|
| Rate for Payer: HFN Commercial |
$1,679.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,050.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,050.18
|
| Rate for Payer: Multiplan Commercial |
$1,414.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,679.60
|
| Rate for Payer: Quartz Beloit One Network |
$777.92
|
| Rate for Payer: Quartz Commercial |
$1,007.76
|
| Rate for Payer: The Alliance Commercial |
$884.00
|
| Rate for Payer: WEA Trust Commercial |
$972.40
|
| Rate for Payer: WPS Commercial |
$1,309.56
|
|
|
TC99m DTPA
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
1158884
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$54.90 |
| Max. Negotiated Rate |
$263.15 |
| Rate for Payer: Aetna Commercial |
$263.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$263.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$138.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$166.20
|
| Rate for Payer: Health EOS Commercial |
$252.07
|
| Rate for Payer: HFN Commercial |
$263.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.90
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.15
|
| Rate for Payer: Quartz Beloit One Network |
$121.88
|
| Rate for Payer: Quartz Commercial |
$157.89
|
| Rate for Payer: The Alliance Commercial |
$138.50
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
TC99m DTPA
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
1158884
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$135.73 |
| Max. Negotiated Rate |
$254.84 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$166.20
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
TC99m DTPA
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
1158884
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$77.56 |
| Max. Negotiated Rate |
$1,108.00 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Aetna Managed Medicare |
$77.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$180.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$138.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.01
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$207.75
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$180.05
|
| Rate for Payer: Quartz Medicare Advantage |
$166.20
|
| Rate for Payer: The Alliance Commercial |
$1,108.00
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
