|
Tc-99m filtered Sulfur Colloid
|
Facility
|
IP
|
$2,044.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
1486848
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,001.56 |
| Max. Negotiated Rate |
$1,880.48 |
| Rate for Payer: Aetna Commercial |
$1,839.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,757.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,083.32
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cigna Commercial |
$1,880.48
|
| Rate for Payer: Health EOS Commercial |
$1,819.16
|
| Rate for Payer: HFN Commercial |
$1,880.48
|
| Rate for Payer: Multiplan Commercial |
$1,635.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,226.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,880.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,001.56
|
| Rate for Payer: Quartz Commercial |
$1,226.40
|
| Rate for Payer: WEA Trust Commercial |
$1,124.20
|
| Rate for Payer: WPS Commercial |
$1,513.99
|
|
|
Tc-99m filtered Sulfur Colloid
|
Facility
|
OP
|
$2,044.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
1486848
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$572.32 |
| Max. Negotiated Rate |
$8,176.00 |
| Rate for Payer: Aetna Commercial |
$1,839.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,757.84
|
| Rate for Payer: Aetna Managed Medicare |
$572.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,328.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,022.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$981.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,083.32
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cigna Commercial |
$1,880.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,143.82
|
| Rate for Payer: Health EOS Commercial |
$1,819.16
|
| Rate for Payer: HFN Commercial |
$1,880.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,533.00
|
| Rate for Payer: Multiplan Commercial |
$1,635.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,226.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,880.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,001.56
|
| Rate for Payer: Quartz Commercial |
$1,328.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,226.40
|
| Rate for Payer: The Alliance Commercial |
$8,176.00
|
| Rate for Payer: WEA Trust Commercial |
$1,124.20
|
| Rate for Payer: WPS Commercial |
$1,513.99
|
|
|
Tc-99m filtered Sulfur Colloid
|
Professional
|
Both
|
$2,044.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
1486848
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$468.43 |
| Max. Negotiated Rate |
$1,941.80 |
| Rate for Payer: Aetna Commercial |
$1,941.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,757.84
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cigna Commercial |
$1,941.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,022.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,226.40
|
| Rate for Payer: Health EOS Commercial |
$1,860.04
|
| Rate for Payer: HFN Commercial |
$1,941.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$468.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$468.43
|
| Rate for Payer: Multiplan Commercial |
$1,635.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,941.80
|
| Rate for Payer: Quartz Beloit One Network |
$899.36
|
| Rate for Payer: Quartz Commercial |
$1,165.08
|
| Rate for Payer: The Alliance Commercial |
$1,022.00
|
| Rate for Payer: WEA Trust Commercial |
$1,124.20
|
| Rate for Payer: WPS Commercial |
$1,513.99
|
|
|
Tc 99m Lymphoseek
|
Facility
|
IP
|
$3,168.00
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
4538667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,552.32 |
| Max. Negotiated Rate |
$2,914.56 |
| Rate for Payer: Aetna Commercial |
$2,851.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,724.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,679.04
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$2,914.56
|
| Rate for Payer: Health EOS Commercial |
$2,819.52
|
| Rate for Payer: HFN Commercial |
$2,914.56
|
| Rate for Payer: Multiplan Commercial |
$2,534.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,900.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,914.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,552.32
|
| Rate for Payer: Quartz Commercial |
$1,900.80
|
| Rate for Payer: WEA Trust Commercial |
$1,742.40
|
| Rate for Payer: WPS Commercial |
$2,346.54
|
|
|
Tc 99m Lymphoseek
|
Facility
|
OP
|
$3,168.00
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
4538667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$887.04 |
| Max. Negotiated Rate |
$12,672.00 |
| Rate for Payer: Aetna Commercial |
$2,851.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,724.48
|
| Rate for Payer: Aetna Managed Medicare |
$887.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,059.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,584.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,520.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,679.04
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$2,914.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,772.81
|
| Rate for Payer: Health EOS Commercial |
$2,819.52
|
| Rate for Payer: HFN Commercial |
$2,914.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,376.00
|
| Rate for Payer: Multiplan Commercial |
$2,534.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,900.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,914.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,552.32
|
| Rate for Payer: Quartz Commercial |
$2,059.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,900.80
|
| Rate for Payer: The Alliance Commercial |
$12,672.00
|
| Rate for Payer: WEA Trust Commercial |
$1,742.40
|
| Rate for Payer: WPS Commercial |
$2,346.54
|
|
|
Tc 99m Lymphoseek
|
Professional
|
Both
|
$3,168.00
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
4538667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,393.92 |
| Max. Negotiated Rate |
$3,009.60 |
| Rate for Payer: Aetna Commercial |
$3,009.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,724.48
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$3,009.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,584.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,900.80
|
| Rate for Payer: Health EOS Commercial |
$2,882.88
|
| Rate for Payer: HFN Commercial |
$3,009.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,990.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,990.07
|
| Rate for Payer: Multiplan Commercial |
$2,534.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,009.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,393.92
|
| Rate for Payer: Quartz Commercial |
$1,805.76
|
| Rate for Payer: The Alliance Commercial |
$1,584.00
|
| Rate for Payer: WEA Trust Commercial |
$1,742.40
|
| Rate for Payer: WPS Commercial |
$2,346.54
|
|
|
Tc-99m Macroaggregated Albumin(MAA)
|
Facility
|
OP
|
$212.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
1486832
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.36 |
| Max. Negotiated Rate |
$848.00 |
| Rate for Payer: Aetna Commercial |
$190.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$182.32
|
| Rate for Payer: Aetna Managed Medicare |
$59.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$137.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$101.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.36
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$195.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$118.64
|
| Rate for Payer: Health EOS Commercial |
$188.68
|
| Rate for Payer: HFN Commercial |
$195.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$159.00
|
| Rate for Payer: Multiplan Commercial |
$169.60
|
| Rate for Payer: NAPHCARE Commercial |
$127.20
|
| Rate for Payer: Preferred Network Access Commercial |
$195.04
|
| Rate for Payer: Quartz Beloit One Network |
$103.88
|
| Rate for Payer: Quartz Commercial |
$137.80
|
| Rate for Payer: Quartz Medicare Advantage |
$127.20
|
| Rate for Payer: The Alliance Commercial |
$848.00
|
| Rate for Payer: WEA Trust Commercial |
$116.60
|
| Rate for Payer: WPS Commercial |
$157.03
|
|
|
Tc-99m Macroaggregated Albumin(MAA)
|
Facility
|
IP
|
$212.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
1486832
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.88 |
| Max. Negotiated Rate |
$195.04 |
| Rate for Payer: Aetna Commercial |
$190.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$182.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.36
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$195.04
|
| Rate for Payer: Health EOS Commercial |
$188.68
|
| Rate for Payer: HFN Commercial |
$195.04
|
| Rate for Payer: Multiplan Commercial |
$169.60
|
| Rate for Payer: NAPHCARE Commercial |
$127.20
|
| Rate for Payer: Preferred Network Access Commercial |
$195.04
|
| Rate for Payer: Quartz Beloit One Network |
$103.88
|
| Rate for Payer: Quartz Commercial |
$127.20
|
| Rate for Payer: WEA Trust Commercial |
$116.60
|
| Rate for Payer: WPS Commercial |
$157.03
|
|
|
Tc-99m Macroaggregated Albumin(MAA)
|
Professional
|
Both
|
$212.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
1486832
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.56 |
| Max. Negotiated Rate |
$201.40 |
| Rate for Payer: Aetna Commercial |
$201.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$182.32
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$201.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$106.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.20
|
| Rate for Payer: Health EOS Commercial |
$192.92
|
| Rate for Payer: HFN Commercial |
$201.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.56
|
| Rate for Payer: Multiplan Commercial |
$169.60
|
| Rate for Payer: Preferred Network Access Commercial |
$201.40
|
| Rate for Payer: Quartz Beloit One Network |
$93.28
|
| Rate for Payer: Quartz Commercial |
$120.84
|
| Rate for Payer: The Alliance Commercial |
$106.00
|
| Rate for Payer: WEA Trust Commercial |
$116.60
|
| Rate for Payer: WPS Commercial |
$157.03
|
|
|
Tc-99m Mebrofenin
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
1486816
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
Tc-99m Mebrofenin
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
1486816
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.36 |
| Max. Negotiated Rate |
$748.00 |
| Rate for Payer: Aetna Commercial |
$168.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.82
|
| Rate for Payer: Aetna Managed Medicare |
$52.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$121.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$89.76
|
| 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: Dean Health DHI/DHP/ASO |
$104.65
|
| Rate for Payer: Health EOS Commercial |
$166.43
|
| Rate for Payer: HFN Commercial |
$172.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$140.25
|
| 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 |
$121.55
|
| Rate for Payer: Quartz Medicare Advantage |
$112.20
|
| Rate for Payer: The Alliance Commercial |
$748.00
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
Tc-99m Mebrofenin
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
1486816
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.28 |
| 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 |
$87.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$87.31
|
| 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
|
|
|
Tc-99m Medronate(MDP)
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
1486834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Tc-99m Medronate(MDP)
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
1486834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Tc-99m Medronate(MDP)
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
1486834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.82 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Aetna Commercial |
$79.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$79.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.40
|
| Rate for Payer: Health EOS Commercial |
$76.44
|
| Rate for Payer: HFN Commercial |
$79.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.82
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Preferred Network Access Commercial |
$79.80
|
| Rate for Payer: Quartz Beloit One Network |
$36.96
|
| Rate for Payer: Quartz Commercial |
$47.88
|
| Rate for Payer: The Alliance Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Tc-99m NaTcO4
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
1486852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Tc-99m NaTcO4
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
1486852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.12 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Aetna Commercial |
$79.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$79.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.40
|
| Rate for Payer: Health EOS Commercial |
$76.44
|
| Rate for Payer: HFN Commercial |
$79.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.12
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Preferred Network Access Commercial |
$79.80
|
| Rate for Payer: Quartz Beloit One Network |
$36.96
|
| Rate for Payer: Quartz Commercial |
$47.88
|
| Rate for Payer: The Alliance Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Tc-99m NaTcO4
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
1486852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
TC99m PYP
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
5381840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.48 |
| Max. Negotiated Rate |
$964.00 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Aetna Managed Medicare |
$67.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$156.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$120.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$115.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.86
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.75
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$156.65
|
| Rate for Payer: Quartz Medicare Advantage |
$144.60
|
| Rate for Payer: The Alliance Commercial |
$964.00
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
TC99m PYP
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
1158914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$230.00 |
| Rate for Payer: Aetna Commercial |
$225.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.50
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$230.00
|
| Rate for Payer: Health EOS Commercial |
$222.50
|
| Rate for Payer: HFN Commercial |
$230.00
|
| Rate for Payer: Multiplan Commercial |
$200.00
|
| Rate for Payer: NAPHCARE Commercial |
$150.00
|
| Rate for Payer: Preferred Network Access Commercial |
$230.00
|
| Rate for Payer: Quartz Beloit One Network |
$122.50
|
| Rate for Payer: Quartz Commercial |
$150.00
|
| Rate for Payer: WEA Trust Commercial |
$137.50
|
| Rate for Payer: WPS Commercial |
$185.18
|
|
|
TC99m PYP
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
1158914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$225.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.00
|
| Rate for Payer: Aetna Managed Medicare |
$70.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$162.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$125.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$120.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.50
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$230.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$139.90
|
| Rate for Payer: Health EOS Commercial |
$222.50
|
| Rate for Payer: HFN Commercial |
$230.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.50
|
| Rate for Payer: Multiplan Commercial |
$200.00
|
| Rate for Payer: NAPHCARE Commercial |
$150.00
|
| Rate for Payer: Preferred Network Access Commercial |
$230.00
|
| Rate for Payer: Quartz Beloit One Network |
$122.50
|
| Rate for Payer: Quartz Commercial |
$162.50
|
| Rate for Payer: Quartz Medicare Advantage |
$150.00
|
| Rate for Payer: The Alliance Commercial |
$1,000.00
|
| Rate for Payer: WEA Trust Commercial |
$137.50
|
| Rate for Payer: WPS Commercial |
$185.18
|
|
|
TC99m PYP
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
HCPCS A9538
|
| Hospital Charge Code |
1158913
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$40.11 |
| Max. Negotiated Rate |
$242.25 |
| Rate for Payer: Aetna Commercial |
$242.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$219.30
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$242.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$127.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.00
|
| Rate for Payer: Health EOS Commercial |
$232.05
|
| Rate for Payer: HFN Commercial |
$242.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.11
|
| Rate for Payer: Multiplan Commercial |
$204.00
|
| Rate for Payer: Preferred Network Access Commercial |
$242.25
|
| Rate for Payer: Quartz Beloit One Network |
$112.20
|
| Rate for Payer: Quartz Commercial |
$145.35
|
| Rate for Payer: The Alliance Commercial |
$127.50
|
| Rate for Payer: WEA Trust Commercial |
$140.25
|
| Rate for Payer: WPS Commercial |
$188.88
|
|
|
TC99m PYP
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
1158914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.00 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Aetna Commercial |
$237.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$237.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$125.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.00
|
| Rate for Payer: Health EOS Commercial |
$227.50
|
| Rate for Payer: HFN Commercial |
$237.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$155.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$155.81
|
| Rate for Payer: Multiplan Commercial |
$200.00
|
| Rate for Payer: Preferred Network Access Commercial |
$237.50
|
| Rate for Payer: Quartz Beloit One Network |
$110.00
|
| Rate for Payer: Quartz Commercial |
$142.50
|
| Rate for Payer: The Alliance Commercial |
$125.00
|
| Rate for Payer: WEA Trust Commercial |
$137.50
|
| Rate for Payer: WPS Commercial |
$185.18
|
|
|
TC99m PYP
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
5381840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.04 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Aetna Commercial |
$228.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$228.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.60
|
| Rate for Payer: Health EOS Commercial |
$219.31
|
| Rate for Payer: HFN Commercial |
$228.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$155.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$155.81
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.95
|
| Rate for Payer: Quartz Beloit One Network |
$106.04
|
| Rate for Payer: Quartz Commercial |
$137.37
|
| Rate for Payer: The Alliance Commercial |
$120.50
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
TC99m PYP
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
HCPCS A9538
|
| Hospital Charge Code |
1158913
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$71.40 |
| Max. Negotiated Rate |
$1,020.00 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$219.30
|
| Rate for Payer: Aetna Managed Medicare |
$71.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$165.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$127.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$122.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.15
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.70
|
| Rate for Payer: Health EOS Commercial |
$226.95
|
| Rate for Payer: HFN Commercial |
$234.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.25
|
| Rate for Payer: Multiplan Commercial |
$204.00
|
| Rate for Payer: NAPHCARE Commercial |
$153.00
|
| Rate for Payer: Preferred Network Access Commercial |
$234.60
|
| Rate for Payer: Quartz Beloit One Network |
$124.95
|
| Rate for Payer: Quartz Commercial |
$165.75
|
| Rate for Payer: Quartz Medicare Advantage |
$153.00
|
| Rate for Payer: The Alliance Commercial |
$1,020.00
|
| Rate for Payer: WEA Trust Commercial |
$140.25
|
| Rate for Payer: WPS Commercial |
$188.88
|
|
