|
TC99m PYP
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
HCPCS A9538
|
| Hospital Charge Code |
1158913
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$124.95 |
| Max. Negotiated Rate |
$234.60 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$219.30
|
| 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: Health EOS Commercial |
$226.95
|
| Rate for Payer: HFN Commercial |
$234.60
|
| 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 |
$153.00
|
| Rate for Payer: WEA Trust Commercial |
$140.25
|
| Rate for Payer: WPS Commercial |
$188.88
|
|
|
TC99m PYP
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
5381840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.09 |
| Max. Negotiated Rate |
$221.72 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| 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: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| 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 |
$144.60
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
Tc-99m Sestamibi
|
Facility
|
OP
|
$413.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
1486838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.64 |
| Max. Negotiated Rate |
$1,652.00 |
| Rate for Payer: Aetna Commercial |
$371.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.18
|
| Rate for Payer: Aetna Managed Medicare |
$115.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$268.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$206.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$198.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.89
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cigna Commercial |
$379.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.11
|
| Rate for Payer: Health EOS Commercial |
$367.57
|
| Rate for Payer: HFN Commercial |
$379.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$309.75
|
| Rate for Payer: Multiplan Commercial |
$330.40
|
| Rate for Payer: NAPHCARE Commercial |
$247.80
|
| Rate for Payer: Preferred Network Access Commercial |
$379.96
|
| Rate for Payer: Quartz Beloit One Network |
$202.37
|
| Rate for Payer: Quartz Commercial |
$268.45
|
| Rate for Payer: Quartz Medicare Advantage |
$247.80
|
| Rate for Payer: The Alliance Commercial |
$1,652.00
|
| Rate for Payer: WEA Trust Commercial |
$227.15
|
| Rate for Payer: WPS Commercial |
$305.91
|
|
|
Tc-99m Sestamibi
|
Facility
|
OP
|
$397.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
5381841
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.16 |
| Max. Negotiated Rate |
$1,588.00 |
| Rate for Payer: Aetna Commercial |
$357.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Aetna Managed Medicare |
$111.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$258.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$198.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$190.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.41
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$365.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.16
|
| Rate for Payer: Health EOS Commercial |
$353.33
|
| Rate for Payer: HFN Commercial |
$365.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$297.75
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: NAPHCARE Commercial |
$238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$365.24
|
| Rate for Payer: Quartz Beloit One Network |
$194.53
|
| Rate for Payer: Quartz Commercial |
$258.05
|
| Rate for Payer: Quartz Medicare Advantage |
$238.20
|
| Rate for Payer: The Alliance Commercial |
$1,588.00
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
Tc-99m Sestamibi
|
Facility
|
IP
|
$413.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
1486838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$202.37 |
| Max. Negotiated Rate |
$379.96 |
| Rate for Payer: Aetna Commercial |
$371.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.89
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cigna Commercial |
$379.96
|
| Rate for Payer: Health EOS Commercial |
$367.57
|
| Rate for Payer: HFN Commercial |
$379.96
|
| Rate for Payer: Multiplan Commercial |
$330.40
|
| Rate for Payer: NAPHCARE Commercial |
$247.80
|
| Rate for Payer: Preferred Network Access Commercial |
$379.96
|
| Rate for Payer: Quartz Beloit One Network |
$202.37
|
| Rate for Payer: Quartz Commercial |
$247.80
|
| Rate for Payer: WEA Trust Commercial |
$227.15
|
| Rate for Payer: WPS Commercial |
$305.91
|
|
|
Tc-99m Sestamibi
|
Facility
|
IP
|
$397.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
5381841
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$194.53 |
| Max. Negotiated Rate |
$365.24 |
| Rate for Payer: Aetna Commercial |
$357.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.41
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$365.24
|
| Rate for Payer: Health EOS Commercial |
$353.33
|
| Rate for Payer: HFN Commercial |
$365.24
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: NAPHCARE Commercial |
$238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$365.24
|
| Rate for Payer: Quartz Beloit One Network |
$194.53
|
| Rate for Payer: Quartz Commercial |
$238.20
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
Tc-99m Sestamibi
|
Professional
|
Both
|
$413.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
1486838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$392.35 |
| Rate for Payer: Aetna Commercial |
$392.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.18
|
| Rate for Payer: Anthem Commercial |
$75.00
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cigna Commercial |
$392.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$206.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$247.80
|
| Rate for Payer: Health EOS Commercial |
$375.83
|
| Rate for Payer: HFN Commercial |
$392.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$187.58
|
| Rate for Payer: Multiplan Commercial |
$330.40
|
| Rate for Payer: Preferred Network Access Commercial |
$392.35
|
| Rate for Payer: Quartz Beloit One Network |
$181.72
|
| Rate for Payer: Quartz Commercial |
$235.41
|
| Rate for Payer: The Alliance Commercial |
$206.50
|
| Rate for Payer: WEA Trust Commercial |
$227.15
|
| Rate for Payer: WPS Commercial |
$305.91
|
|
|
Tc-99m Sestamibi
|
Professional
|
Both
|
$397.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
5381841
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$377.15 |
| Rate for Payer: Aetna Commercial |
$377.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Anthem Commercial |
$75.00
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$377.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$198.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$238.20
|
| Rate for Payer: Health EOS Commercial |
$361.27
|
| Rate for Payer: HFN Commercial |
$377.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$187.58
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: Preferred Network Access Commercial |
$377.15
|
| Rate for Payer: Quartz Beloit One Network |
$174.68
|
| Rate for Payer: Quartz Commercial |
$226.29
|
| Rate for Payer: The Alliance Commercial |
$198.50
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
Tc-99m Sulfur Colloid
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
1486850
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.96 |
| Max. Negotiated Rate |
$468.43 |
| 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 |
$468.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$468.43
|
| 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 Sulfur Colloid
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
1486850
|
|
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 Sulfur Colloid
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
1486850
|
|
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
|
|
|
T candidus
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
CPT 86609
|
| Hospital Charge Code |
2942920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.47 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.00
|
| Rate for Payer: Health EOS Commercial |
$95.55
|
| Rate for Payer: HFN Commercial |
$99.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.47
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$99.75
|
| Rate for Payer: Quartz Beloit One Network |
$46.20
|
| Rate for Payer: Quartz Commercial |
$59.85
|
| Rate for Payer: The Alliance Commercial |
$52.50
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
T candidus
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
CPT 86609
|
| Hospital Charge Code |
2942920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Aetna Managed Medicare |
$12.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.54
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.38
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.76
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.88
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.88
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.88
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.88
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.88
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$19.32
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$68.25
|
| Rate for Payer: Quartz Medicare Advantage |
$12.88
|
| Rate for Payer: The Alliance Commercial |
$51.52
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.88
|
| Rate for Payer: United Healthcare PPO |
$78.75
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: Wellcare Medicare |
$12.88
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
T candidus
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
CPT 86609
|
| Hospital Charge Code |
2942920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.45 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
T Cell Gene Receptor
|
Professional
|
Both
|
$248.00
|
|
|
Service Code
|
CPT 81342
|
| Hospital Charge Code |
4444793
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$109.12 |
| Max. Negotiated Rate |
$711.30 |
| Rate for Payer: Aetna Commercial |
$235.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$235.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$124.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.80
|
| Rate for Payer: Health EOS Commercial |
$225.68
|
| Rate for Payer: HFN Commercial |
$235.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$711.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$711.30
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: Preferred Network Access Commercial |
$235.60
|
| Rate for Payer: Quartz Beloit One Network |
$109.12
|
| Rate for Payer: Quartz Commercial |
$141.36
|
| Rate for Payer: The Alliance Commercial |
$124.00
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
T Cell Gene Receptor
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
CPT 81342
|
| Hospital Charge Code |
4444793
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.52 |
| Max. Negotiated Rate |
$228.16 |
| Rate for Payer: Aetna Commercial |
$223.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.44
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$228.16
|
| Rate for Payer: Health EOS Commercial |
$220.72
|
| Rate for Payer: HFN Commercial |
$228.16
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: NAPHCARE Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.16
|
| Rate for Payer: Quartz Beloit One Network |
$121.52
|
| Rate for Payer: Quartz Commercial |
$148.80
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
T Cell Gene Receptor
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
CPT 81342
|
| Hospital Charge Code |
4444793
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.52 |
| Max. Negotiated Rate |
$806.00 |
| Rate for Payer: Aetna Commercial |
$223.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Aetna Managed Medicare |
$201.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$755.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$352.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$334.49
|
| Rate for Payer: Anthem Medicaid |
$208.21
|
| Rate for Payer: Anthem Medicare Advantage |
$201.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$201.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$201.50
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$228.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$201.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$208.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$138.78
|
| Rate for Payer: Dean Health Medicaid |
$208.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$201.50
|
| Rate for Payer: Health EOS Commercial |
$220.72
|
| Rate for Payer: HFN Commercial |
$228.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$749.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$201.50
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$208.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$201.50
|
| Rate for Payer: Managed Health Services Medicaid |
$216.54
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$201.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$201.50
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: NAPHCARE Commercial |
$302.25
|
| Rate for Payer: Preferred Network Access Commercial |
$228.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$208.21
|
| Rate for Payer: Quartz Beloit One Network |
$121.52
|
| Rate for Payer: Quartz Commercial |
$161.20
|
| Rate for Payer: Quartz Medicare Advantage |
$201.50
|
| Rate for Payer: The Alliance Commercial |
$806.00
|
| Rate for Payer: United Healthcare Medicaid |
$208.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$201.50
|
| Rate for Payer: United Healthcare PPO |
$186.00
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: Wellcare Medicare |
$201.50
|
| Rate for Payer: WMAP Medicaid |
$208.21
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
TCM < 14 Days 99495
|
Professional
|
Both
|
$314.00
|
|
|
Service Code
|
CPT 99495
|
| Hospital Charge Code |
3096919
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$138.16 |
| Max. Negotiated Rate |
$489.01 |
| Rate for Payer: Aetna Commercial |
$298.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$270.04
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cigna Commercial |
$298.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$157.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$188.40
|
| Rate for Payer: Health EOS Commercial |
$285.74
|
| Rate for Payer: HFN Commercial |
$298.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$489.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$489.01
|
| Rate for Payer: Multiplan Commercial |
$251.20
|
| Rate for Payer: Preferred Network Access Commercial |
$298.30
|
| Rate for Payer: Quartz Beloit One Network |
$138.16
|
| Rate for Payer: Quartz Commercial |
$178.98
|
| Rate for Payer: The Alliance Commercial |
$157.00
|
| Rate for Payer: WEA Trust Commercial |
$172.70
|
| Rate for Payer: WPS Commercial |
$232.58
|
|
|
TCM < 14 days 99495RVU
|
Professional
|
Both
|
$314.00
|
|
|
Service Code
|
CPT 99495
|
| Hospital Charge Code |
4512594
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$138.16 |
| Max. Negotiated Rate |
$489.01 |
| Rate for Payer: Aetna Commercial |
$298.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$270.04
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cigna Commercial |
$298.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$157.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$188.40
|
| Rate for Payer: Health EOS Commercial |
$285.74
|
| Rate for Payer: HFN Commercial |
$298.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$489.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$489.01
|
| Rate for Payer: Multiplan Commercial |
$251.20
|
| Rate for Payer: Preferred Network Access Commercial |
$298.30
|
| Rate for Payer: Quartz Beloit One Network |
$138.16
|
| Rate for Payer: Quartz Commercial |
$178.98
|
| Rate for Payer: The Alliance Commercial |
$157.00
|
| Rate for Payer: WEA Trust Commercial |
$172.70
|
| Rate for Payer: WPS Commercial |
$232.58
|
|
|
TCM < 7 Days 99496
|
Professional
|
Both
|
$364.00
|
|
|
Service Code
|
CPT 99496
|
| Hospital Charge Code |
3096918
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$160.16 |
| Max. Negotiated Rate |
$665.51 |
| Rate for Payer: Aetna Commercial |
$345.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$345.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$182.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.40
|
| Rate for Payer: Health EOS Commercial |
$331.24
|
| Rate for Payer: HFN Commercial |
$345.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$665.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$665.51
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: Preferred Network Access Commercial |
$345.80
|
| Rate for Payer: Quartz Beloit One Network |
$160.16
|
| Rate for Payer: Quartz Commercial |
$207.48
|
| Rate for Payer: The Alliance Commercial |
$182.00
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
TCM < 7 Days 99496RVU
|
Professional
|
Both
|
$364.00
|
|
|
Service Code
|
CPT 99496
|
| Hospital Charge Code |
4512595
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$160.16 |
| Max. Negotiated Rate |
$665.51 |
| Rate for Payer: Aetna Commercial |
$345.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$345.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$182.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.40
|
| Rate for Payer: Health EOS Commercial |
$331.24
|
| Rate for Payer: HFN Commercial |
$345.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$665.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$665.51
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: Preferred Network Access Commercial |
$345.80
|
| Rate for Payer: Quartz Beloit One Network |
$160.16
|
| Rate for Payer: Quartz Commercial |
$207.48
|
| Rate for Payer: The Alliance Commercial |
$182.00
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
TCRB Result
|
Professional
|
Both
|
$694.00
|
|
|
Service Code
|
CPT 81340
|
| Hospital Charge Code |
4498644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$305.36 |
| Max. Negotiated Rate |
$737.49 |
| Rate for Payer: Aetna Commercial |
$659.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.84
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$659.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$347.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$416.40
|
| Rate for Payer: Health EOS Commercial |
$631.54
|
| Rate for Payer: HFN Commercial |
$659.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$737.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$737.49
|
| Rate for Payer: Multiplan Commercial |
$555.20
|
| Rate for Payer: Preferred Network Access Commercial |
$659.30
|
| Rate for Payer: Quartz Beloit One Network |
$305.36
|
| Rate for Payer: Quartz Commercial |
$395.58
|
| Rate for Payer: The Alliance Commercial |
$347.00
|
| Rate for Payer: WEA Trust Commercial |
$381.70
|
| Rate for Payer: WPS Commercial |
$514.05
|
|
|
TCRB Result
|
Facility
|
IP
|
$694.00
|
|
|
Service Code
|
CPT 81340
|
| Hospital Charge Code |
4498644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$340.06 |
| Max. Negotiated Rate |
$638.48 |
| Rate for Payer: Aetna Commercial |
$624.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.82
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$638.48
|
| Rate for Payer: Health EOS Commercial |
$617.66
|
| Rate for Payer: HFN Commercial |
$638.48
|
| Rate for Payer: Multiplan Commercial |
$555.20
|
| Rate for Payer: NAPHCARE Commercial |
$416.40
|
| Rate for Payer: Preferred Network Access Commercial |
$638.48
|
| Rate for Payer: Quartz Beloit One Network |
$340.06
|
| Rate for Payer: Quartz Commercial |
$416.40
|
| Rate for Payer: WEA Trust Commercial |
$381.70
|
| Rate for Payer: WPS Commercial |
$514.05
|
|
|
TCRB Result
|
Facility
|
OP
|
$694.00
|
|
|
Service Code
|
CPT 81340
|
| Hospital Charge Code |
4498644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$208.92 |
| Max. Negotiated Rate |
$835.68 |
| Rate for Payer: Aetna Commercial |
$624.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.84
|
| Rate for Payer: Aetna Managed Medicare |
$208.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$783.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$365.61
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$346.81
|
| Rate for Payer: Anthem Medicaid |
$215.88
|
| Rate for Payer: Anthem Medicare Advantage |
$208.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$208.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$208.92
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$638.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$208.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$215.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$388.36
|
| Rate for Payer: Dean Health Medicaid |
$215.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$208.92
|
| Rate for Payer: Health EOS Commercial |
$617.66
|
| Rate for Payer: HFN Commercial |
$638.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$777.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$208.92
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$215.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$208.92
|
| Rate for Payer: Managed Health Services Medicaid |
$224.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$208.92
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$208.92
|
| Rate for Payer: Multiplan Commercial |
$555.20
|
| Rate for Payer: NAPHCARE Commercial |
$313.38
|
| Rate for Payer: Preferred Network Access Commercial |
$638.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$215.88
|
| Rate for Payer: Quartz Beloit One Network |
$340.06
|
| Rate for Payer: Quartz Commercial |
$451.10
|
| Rate for Payer: Quartz Medicare Advantage |
$208.92
|
| Rate for Payer: The Alliance Commercial |
$835.68
|
| Rate for Payer: United Healthcare Medicaid |
$215.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$208.92
|
| Rate for Payer: United Healthcare PPO |
$520.50
|
| Rate for Payer: WEA Trust Commercial |
$381.70
|
| Rate for Payer: Wellcare Medicare |
$208.92
|
| Rate for Payer: WMAP Medicaid |
$215.88
|
| Rate for Payer: WPS Commercial |
$514.05
|
|
|
TCRG Result
|
Facility
|
OP
|
$694.00
|
|
|
Service Code
|
CPT 81342
|
| Hospital Charge Code |
4498643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$201.50 |
| Max. Negotiated Rate |
$806.00 |
| Rate for Payer: Aetna Commercial |
$624.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.84
|
| Rate for Payer: Aetna Managed Medicare |
$201.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$755.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$352.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$334.49
|
| Rate for Payer: Anthem Medicaid |
$208.21
|
| Rate for Payer: Anthem Medicare Advantage |
$201.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$201.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$201.50
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$638.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$201.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$208.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$388.36
|
| Rate for Payer: Dean Health Medicaid |
$208.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$201.50
|
| Rate for Payer: Health EOS Commercial |
$617.66
|
| Rate for Payer: HFN Commercial |
$638.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$749.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$201.50
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$208.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$201.50
|
| Rate for Payer: Managed Health Services Medicaid |
$216.54
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$201.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$201.50
|
| Rate for Payer: Multiplan Commercial |
$555.20
|
| Rate for Payer: NAPHCARE Commercial |
$302.25
|
| Rate for Payer: Preferred Network Access Commercial |
$638.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$208.21
|
| Rate for Payer: Quartz Beloit One Network |
$340.06
|
| Rate for Payer: Quartz Commercial |
$451.10
|
| Rate for Payer: Quartz Medicare Advantage |
$201.50
|
| Rate for Payer: The Alliance Commercial |
$806.00
|
| Rate for Payer: United Healthcare Medicaid |
$208.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$201.50
|
| Rate for Payer: United Healthcare PPO |
$520.50
|
| Rate for Payer: WEA Trust Commercial |
$381.70
|
| Rate for Payer: Wellcare Medicare |
$201.50
|
| Rate for Payer: WMAP Medicaid |
$208.21
|
| Rate for Payer: WPS Commercial |
$514.05
|
|
