|
TB Intradermal Test Dialysis
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3605546
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$48.80 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$31.82
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
TB Intradermal Test PD
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3605547
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$121.76 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Aetna Managed Medicare |
$30.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$114.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.81
|
| Rate for Payer: Anthem Medicare Advantage |
$30.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.44
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30.44
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30.44
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: NAPHCARE Commercial |
$45.66
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$34.48
|
| Rate for Payer: Quartz Medicare Advantage |
$30.44
|
| Rate for Payer: The Alliance Commercial |
$121.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.44
|
| Rate for Payer: United Healthcare PPO |
$39.78
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: Wellcare Medicare |
$30.44
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
TB Intradermal Test PD
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3605547
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$48.80 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$31.82
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
Tc-99m bicisate(Neurolite)
|
Facility
|
IP
|
$1,793.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
1486840
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$913.71 |
| Max. Negotiated Rate |
$1,715.54 |
| Rate for Payer: Aetna Commercial |
$1,678.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,603.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$988.30
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cigna Commercial |
$1,715.54
|
| Rate for Payer: Health EOS Commercial |
$1,659.60
|
| Rate for Payer: HFN Commercial |
$1,715.54
|
| Rate for Payer: Multiplan Commercial |
$1,491.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,715.54
|
| Rate for Payer: Quartz Beloit One Network |
$913.71
|
| Rate for Payer: Quartz Commercial |
$1,118.83
|
| Rate for Payer: WEA Trust Commercial |
$1,025.60
|
| Rate for Payer: WPS Commercial |
$1,381.15
|
|
|
Tc-99m bicisate(Neurolite)
|
Facility
|
OP
|
$1,793.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
1486840
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$806.54 |
| Max. Negotiated Rate |
$3,226.16 |
| Rate for Payer: Aetna Commercial |
$1,678.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,603.66
|
| Rate for Payer: Aetna Managed Medicare |
$806.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,212.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$932.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$895.07
|
| Rate for Payer: Anthem Medicare Advantage |
$806.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$988.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$806.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$806.54
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cigna Commercial |
$1,715.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$806.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,043.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$806.54
|
| Rate for Payer: Health EOS Commercial |
$1,659.60
|
| Rate for Payer: HFN Commercial |
$1,715.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,000.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$806.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$806.54
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$806.54
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$806.54
|
| Rate for Payer: Multiplan Commercial |
$1,491.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,209.81
|
| Rate for Payer: Preferred Network Access Commercial |
$1,715.54
|
| Rate for Payer: Quartz Beloit One Network |
$913.71
|
| Rate for Payer: Quartz Commercial |
$1,212.07
|
| Rate for Payer: Quartz Medicare Advantage |
$806.54
|
| Rate for Payer: The Alliance Commercial |
$3,226.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$806.54
|
| Rate for Payer: WEA Trust Commercial |
$1,025.60
|
| Rate for Payer: Wellcare Medicare |
$806.54
|
| Rate for Payer: WPS Commercial |
$1,381.15
|
|
|
Tc-99m bicisate(Neurolite)
|
Professional
|
Both
|
$1,793.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
1486840
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$352.91 |
| Max. Negotiated Rate |
$1,771.48 |
| Rate for Payer: Aetna Commercial |
$1,771.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,603.66
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cash Price |
$537.90
|
| Rate for Payer: Cigna Commercial |
$1,771.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$352.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,118.83
|
| Rate for Payer: Health EOS Commercial |
$1,696.90
|
| Rate for Payer: HFN Commercial |
$1,771.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$677.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$677.98
|
| Rate for Payer: Multiplan Commercial |
$1,491.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,771.48
|
| Rate for Payer: Quartz Beloit One Network |
$820.48
|
| Rate for Payer: Quartz Commercial |
$1,062.89
|
| Rate for Payer: The Alliance Commercial |
$932.36
|
| Rate for Payer: United Healthcare Medicaid |
$352.91
|
| Rate for Payer: WEA Trust Commercial |
$1,025.60
|
| Rate for Payer: WPS Commercial |
$1,381.15
|
|
|
Tc-99m Ceretec(HMPAO)
|
Facility
|
OP
|
$1,946.00
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
1486814
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$964.82 |
| Max. Negotiated Rate |
$3,859.27 |
| Rate for Payer: Aetna Commercial |
$1,821.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.50
|
| Rate for Payer: Aetna Managed Medicare |
$964.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,315.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,011.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.44
|
| Rate for Payer: Anthem Medicare Advantage |
$964.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$964.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$964.82
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cigna Commercial |
$1,861.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$964.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$964.82
|
| Rate for Payer: Health EOS Commercial |
$1,801.22
|
| Rate for Payer: HFN Commercial |
$1,861.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,589.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$964.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$964.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$964.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$964.82
|
| Rate for Payer: Multiplan Commercial |
$1,619.07
|
| Rate for Payer: NAPHCARE Commercial |
$1,447.23
|
| Rate for Payer: Preferred Network Access Commercial |
$1,861.93
|
| Rate for Payer: Quartz Beloit One Network |
$991.68
|
| Rate for Payer: Quartz Commercial |
$1,315.50
|
| Rate for Payer: Quartz Medicare Advantage |
$964.82
|
| Rate for Payer: The Alliance Commercial |
$3,859.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$964.82
|
| Rate for Payer: WEA Trust Commercial |
$1,113.11
|
| Rate for Payer: Wellcare Medicare |
$964.82
|
| Rate for Payer: WPS Commercial |
$1,499.00
|
|
|
Tc-99m Ceretec(HMPAO)
|
Facility
|
IP
|
$1,946.00
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
1486814
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$991.68 |
| Max. Negotiated Rate |
$1,861.93 |
| Rate for Payer: Aetna Commercial |
$1,821.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.64
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cigna Commercial |
$1,861.93
|
| Rate for Payer: Health EOS Commercial |
$1,801.22
|
| Rate for Payer: HFN Commercial |
$1,861.93
|
| Rate for Payer: Multiplan Commercial |
$1,619.07
|
| Rate for Payer: Preferred Network Access Commercial |
$1,861.93
|
| Rate for Payer: Quartz Beloit One Network |
$991.68
|
| Rate for Payer: Quartz Commercial |
$1,214.30
|
| Rate for Payer: WEA Trust Commercial |
$1,113.11
|
| Rate for Payer: WPS Commercial |
$1,499.00
|
|
|
Tc-99m Ceretec(HMPAO)
|
Professional
|
Both
|
$1,946.00
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
1486814
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$472.25 |
| Max. Negotiated Rate |
$2,652.88 |
| Rate for Payer: Aetna Commercial |
$1,922.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.50
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cigna Commercial |
$1,922.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$472.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,214.30
|
| Rate for Payer: Health EOS Commercial |
$1,841.69
|
| Rate for Payer: HFN Commercial |
$1,922.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,652.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,652.88
|
| Rate for Payer: Multiplan Commercial |
$1,619.07
|
| Rate for Payer: Preferred Network Access Commercial |
$1,922.65
|
| Rate for Payer: Quartz Beloit One Network |
$890.49
|
| Rate for Payer: Quartz Commercial |
$1,153.59
|
| Rate for Payer: The Alliance Commercial |
$1,011.92
|
| Rate for Payer: United Healthcare Medicaid |
$472.25
|
| Rate for Payer: WEA Trust Commercial |
$1,113.11
|
| Rate for Payer: WPS Commercial |
$1,499.00
|
|
|
Tc-99m Ceretec Leukocytes
|
Facility
|
IP
|
$9,017.00
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
1486812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,595.06 |
| Max. Negotiated Rate |
$8,627.47 |
| Rate for Payer: Aetna Commercial |
$8,439.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,064.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,970.17
|
| Rate for Payer: Cash Price |
$2,705.10
|
| Rate for Payer: Cigna Commercial |
$8,627.47
|
| Rate for Payer: Health EOS Commercial |
$8,346.14
|
| Rate for Payer: HFN Commercial |
$8,627.47
|
| Rate for Payer: Multiplan Commercial |
$7,502.14
|
| Rate for Payer: Preferred Network Access Commercial |
$8,627.47
|
| Rate for Payer: Quartz Beloit One Network |
$4,595.06
|
| Rate for Payer: Quartz Commercial |
$5,626.61
|
| Rate for Payer: WEA Trust Commercial |
$5,157.72
|
| Rate for Payer: WPS Commercial |
$6,945.80
|
|
|
Tc-99m Ceretec Leukocytes
|
Professional
|
Both
|
$9,017.00
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
1486812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,652.88 |
| Max. Negotiated Rate |
$8,908.80 |
| Rate for Payer: Aetna Commercial |
$8,908.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,064.80
|
| Rate for Payer: Cash Price |
$2,705.10
|
| Rate for Payer: Cash Price |
$2,705.10
|
| Rate for Payer: Cigna Commercial |
$8,908.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,688.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,626.61
|
| Rate for Payer: Health EOS Commercial |
$8,533.69
|
| Rate for Payer: HFN Commercial |
$8,908.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,652.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,652.88
|
| Rate for Payer: Multiplan Commercial |
$7,502.14
|
| Rate for Payer: Preferred Network Access Commercial |
$8,908.80
|
| Rate for Payer: Quartz Beloit One Network |
$4,126.18
|
| Rate for Payer: Quartz Commercial |
$5,345.28
|
| Rate for Payer: The Alliance Commercial |
$4,688.84
|
| Rate for Payer: WEA Trust Commercial |
$5,157.72
|
| Rate for Payer: WPS Commercial |
$6,945.80
|
|
|
Tc-99m Ceretec Leukocytes
|
Facility
|
OP
|
$9,017.00
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
1486812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$971.50 |
| Max. Negotiated Rate |
$8,627.47 |
| Rate for Payer: Aetna Commercial |
$8,439.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,064.80
|
| Rate for Payer: Aetna Managed Medicare |
$971.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,095.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,688.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,501.29
|
| Rate for Payer: Anthem Medicare Advantage |
$971.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,970.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$971.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$971.50
|
| Rate for Payer: Cash Price |
$2,705.10
|
| Rate for Payer: Cash Price |
$2,705.10
|
| Rate for Payer: Cigna Commercial |
$8,627.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$971.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,247.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$971.50
|
| Rate for Payer: Health EOS Commercial |
$8,346.14
|
| Rate for Payer: HFN Commercial |
$8,627.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,613.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$971.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$971.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$971.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$971.50
|
| Rate for Payer: Multiplan Commercial |
$7,502.14
|
| Rate for Payer: NAPHCARE Commercial |
$1,457.24
|
| Rate for Payer: Preferred Network Access Commercial |
$8,627.47
|
| Rate for Payer: Quartz Beloit One Network |
$4,595.06
|
| Rate for Payer: Quartz Commercial |
$6,095.49
|
| Rate for Payer: Quartz Medicare Advantage |
$971.50
|
| Rate for Payer: The Alliance Commercial |
$3,885.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$971.50
|
| Rate for Payer: WEA Trust Commercial |
$5,157.72
|
| Rate for Payer: Wellcare Medicare |
$971.50
|
| Rate for Payer: WPS Commercial |
$6,945.80
|
|
|
Tc-99m DMSA
|
Professional
|
Both
|
$1,768.00
|
|
|
Service Code
|
HCPCS A9551
|
| Hospital Charge Code |
1486818
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$105.35 |
| Max. Negotiated Rate |
$1,746.78 |
| Rate for Payer: Aetna Commercial |
$1,746.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,581.30
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cigna Commercial |
$1,746.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$105.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,103.23
|
| Rate for Payer: Health EOS Commercial |
$1,673.24
|
| Rate for Payer: HFN Commercial |
$1,746.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,092.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,092.19
|
| Rate for Payer: Multiplan Commercial |
$1,470.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,746.78
|
| Rate for Payer: Quartz Beloit One Network |
$809.04
|
| Rate for Payer: Quartz Commercial |
$1,048.07
|
| Rate for Payer: The Alliance Commercial |
$919.36
|
| Rate for Payer: United Healthcare Medicaid |
$105.35
|
| Rate for Payer: WEA Trust Commercial |
$1,011.30
|
| Rate for Payer: WPS Commercial |
$1,361.89
|
|
|
Tc-99m DMSA
|
Facility
|
IP
|
$1,768.00
|
|
|
Service Code
|
HCPCS A9551
|
| Hospital Charge Code |
1486818
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$900.97 |
| Max. Negotiated Rate |
$1,691.62 |
| Rate for Payer: Aetna Commercial |
$1,654.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,581.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.52
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cigna Commercial |
$1,691.62
|
| Rate for Payer: Health EOS Commercial |
$1,636.46
|
| Rate for Payer: HFN Commercial |
$1,691.62
|
| Rate for Payer: Multiplan Commercial |
$1,470.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,691.62
|
| Rate for Payer: Quartz Beloit One Network |
$900.97
|
| Rate for Payer: Quartz Commercial |
$1,103.23
|
| Rate for Payer: WEA Trust Commercial |
$1,011.30
|
| Rate for Payer: WPS Commercial |
$1,361.89
|
|
|
Tc-99m DMSA
|
Facility
|
OP
|
$1,768.00
|
|
|
Service Code
|
HCPCS A9551
|
| Hospital Charge Code |
1486818
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$686.33 |
| Max. Negotiated Rate |
$2,745.31 |
| Rate for Payer: Aetna Commercial |
$1,654.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,581.30
|
| Rate for Payer: Aetna Managed Medicare |
$686.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,195.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$919.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$882.59
|
| Rate for Payer: Anthem Medicare Advantage |
$686.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$686.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$686.33
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cigna Commercial |
$1,691.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$686.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,028.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$686.33
|
| Rate for Payer: Health EOS Commercial |
$1,636.46
|
| Rate for Payer: HFN Commercial |
$1,691.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,553.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$686.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$686.33
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$686.33
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$686.33
|
| Rate for Payer: Multiplan Commercial |
$1,470.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,029.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,691.62
|
| Rate for Payer: Quartz Beloit One Network |
$900.97
|
| Rate for Payer: Quartz Commercial |
$1,195.17
|
| Rate for Payer: Quartz Medicare Advantage |
$686.33
|
| Rate for Payer: The Alliance Commercial |
$2,745.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$686.33
|
| Rate for Payer: WEA Trust Commercial |
$1,011.30
|
| Rate for Payer: Wellcare Medicare |
$686.33
|
| Rate for Payer: WPS Commercial |
$1,361.89
|
|
|
TC99m DTPA
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
1158884
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$13.52 |
| Max. Negotiated Rate |
$273.68 |
| Rate for Payer: Aetna Commercial |
$273.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$273.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$172.85
|
| Rate for Payer: Health EOS Commercial |
$262.15
|
| Rate for Payer: HFN Commercial |
$273.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.10
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: Preferred Network Access Commercial |
$273.68
|
| Rate for Payer: Quartz Beloit One Network |
$126.76
|
| Rate for Payer: Quartz Commercial |
$164.21
|
| Rate for Payer: The Alliance Commercial |
$144.04
|
| Rate for Payer: United Healthcare Medicaid |
$13.52
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
TC99m DTPA
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
1158884
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$80.66 |
| Max. Negotiated Rate |
$265.03 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Aetna Managed Medicare |
$80.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$187.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$144.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$138.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.21
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$216.06
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: NAPHCARE Commercial |
$172.85
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$187.25
|
| Rate for Payer: Quartz Medicare Advantage |
$172.85
|
| Rate for Payer: The Alliance Commercial |
$144.04
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
TC99m DTPA
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
1158884
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$141.16 |
| Max. Negotiated Rate |
$265.03 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$172.85
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
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 |
$595.21 |
| Max. Negotiated Rate |
$1,955.70 |
| Rate for Payer: Aetna Commercial |
$1,913.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,828.15
|
| Rate for Payer: Aetna Managed Medicare |
$595.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,381.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,062.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,020.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,126.65
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cigna Commercial |
$1,955.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,189.61
|
| Rate for Payer: Health EOS Commercial |
$1,891.93
|
| Rate for Payer: HFN Commercial |
$1,955.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,594.32
|
| Rate for Payer: Multiplan Commercial |
$1,700.61
|
| Rate for Payer: NAPHCARE Commercial |
$1,275.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,955.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,041.62
|
| Rate for Payer: Quartz Commercial |
$1,381.74
|
| Rate for Payer: Quartz Medicare Advantage |
$1,275.46
|
| Rate for Payer: The Alliance Commercial |
$1,062.88
|
| Rate for Payer: WEA Trust Commercial |
$1,169.17
|
| Rate for Payer: WPS Commercial |
$1,574.49
|
|
|
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 |
$1,041.62 |
| Max. Negotiated Rate |
$1,955.70 |
| Rate for Payer: Aetna Commercial |
$1,913.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,828.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,126.65
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cigna Commercial |
$1,955.70
|
| Rate for Payer: Health EOS Commercial |
$1,891.93
|
| Rate for Payer: HFN Commercial |
$1,955.70
|
| Rate for Payer: Multiplan Commercial |
$1,700.61
|
| Rate for Payer: Preferred Network Access Commercial |
$1,955.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,041.62
|
| Rate for Payer: Quartz Commercial |
$1,275.46
|
| Rate for Payer: WEA Trust Commercial |
$1,169.17
|
| Rate for Payer: WPS Commercial |
$1,574.49
|
|
|
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 |
$44.26 |
| Max. Negotiated Rate |
$2,019.47 |
| Rate for Payer: Aetna Commercial |
$2,019.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,828.15
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cigna Commercial |
$2,019.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,275.46
|
| Rate for Payer: Health EOS Commercial |
$1,934.44
|
| Rate for Payer: HFN Commercial |
$2,019.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$487.17
|
| Rate for Payer: Multiplan Commercial |
$1,700.61
|
| Rate for Payer: Preferred Network Access Commercial |
$2,019.47
|
| Rate for Payer: Quartz Beloit One Network |
$935.33
|
| Rate for Payer: Quartz Commercial |
$1,211.68
|
| Rate for Payer: The Alliance Commercial |
$1,062.88
|
| Rate for Payer: United Healthcare Medicaid |
$44.26
|
| Rate for Payer: WEA Trust Commercial |
$1,169.17
|
| Rate for Payer: WPS Commercial |
$1,574.49
|
|
|
Tc 99m Lymphoseek
|
Professional
|
Both
|
$3,168.00
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
4538667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,449.68 |
| Max. Negotiated Rate |
$3,129.98 |
| Rate for Payer: Aetna Commercial |
$3,129.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,833.46
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$3,129.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,647.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,976.83
|
| Rate for Payer: Health EOS Commercial |
$2,998.20
|
| Rate for Payer: HFN Commercial |
$3,129.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,069.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,069.67
|
| Rate for Payer: Multiplan Commercial |
$2,635.78
|
| Rate for Payer: Preferred Network Access Commercial |
$3,129.98
|
| Rate for Payer: Quartz Beloit One Network |
$1,449.68
|
| Rate for Payer: Quartz Commercial |
$1,877.99
|
| Rate for Payer: The Alliance Commercial |
$1,647.36
|
| Rate for Payer: WEA Trust Commercial |
$1,812.10
|
| Rate for Payer: WPS Commercial |
$2,440.31
|
|
|
Tc 99m Lymphoseek
|
Facility
|
OP
|
$3,168.00
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
4538667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$922.52 |
| Max. Negotiated Rate |
$3,031.14 |
| Rate for Payer: Aetna Commercial |
$2,965.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,833.46
|
| Rate for Payer: Aetna Managed Medicare |
$922.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,141.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,647.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,581.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,746.20
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$3,031.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,843.78
|
| Rate for Payer: Health EOS Commercial |
$2,932.30
|
| Rate for Payer: HFN Commercial |
$3,031.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,471.04
|
| Rate for Payer: Multiplan Commercial |
$2,635.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,976.83
|
| Rate for Payer: Preferred Network Access Commercial |
$3,031.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,614.41
|
| Rate for Payer: Quartz Commercial |
$2,141.57
|
| Rate for Payer: Quartz Medicare Advantage |
$1,976.83
|
| Rate for Payer: The Alliance Commercial |
$1,647.36
|
| Rate for Payer: WEA Trust Commercial |
$1,812.10
|
| Rate for Payer: WPS Commercial |
$2,440.31
|
|
|
Tc 99m Lymphoseek
|
Facility
|
IP
|
$3,168.00
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
4538667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,614.41 |
| Max. Negotiated Rate |
$3,031.14 |
| Rate for Payer: Aetna Commercial |
$2,965.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,833.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,746.20
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$3,031.14
|
| Rate for Payer: Health EOS Commercial |
$2,932.30
|
| Rate for Payer: HFN Commercial |
$3,031.14
|
| Rate for Payer: Multiplan Commercial |
$2,635.78
|
| Rate for Payer: Preferred Network Access Commercial |
$3,031.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,614.41
|
| Rate for Payer: Quartz Commercial |
$1,976.83
|
| Rate for Payer: WEA Trust Commercial |
$1,812.10
|
| Rate for Payer: WPS Commercial |
$2,440.31
|
|
|
Tc-99m Macroaggregated Albumin(MAA)
|
Professional
|
Both
|
$212.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
1486832
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.91 |
| Max. Negotiated Rate |
$209.46 |
| Rate for Payer: Aetna Commercial |
$209.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.61
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$209.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.29
|
| Rate for Payer: Health EOS Commercial |
$200.64
|
| Rate for Payer: HFN Commercial |
$209.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.66
|
| Rate for Payer: Multiplan Commercial |
$176.38
|
| Rate for Payer: Preferred Network Access Commercial |
$209.46
|
| Rate for Payer: Quartz Beloit One Network |
$97.01
|
| Rate for Payer: Quartz Commercial |
$125.67
|
| Rate for Payer: The Alliance Commercial |
$110.24
|
| Rate for Payer: United Healthcare Medicaid |
$17.91
|
| Rate for Payer: WEA Trust Commercial |
$121.26
|
| Rate for Payer: WPS Commercial |
$163.30
|
|
