|
Tc-99m Macroaggregated Albumin(MAA)
|
Facility
|
OP
|
$212.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
1486832
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.73 |
| Max. Negotiated Rate |
$202.84 |
| Rate for Payer: Aetna Commercial |
$198.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.61
|
| Rate for Payer: Aetna Managed Medicare |
$61.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$143.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$105.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.85
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$202.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.38
|
| Rate for Payer: Health EOS Commercial |
$196.23
|
| Rate for Payer: HFN Commercial |
$202.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$165.36
|
| Rate for Payer: Multiplan Commercial |
$176.38
|
| Rate for Payer: NAPHCARE Commercial |
$132.29
|
| Rate for Payer: Preferred Network Access Commercial |
$202.84
|
| Rate for Payer: Quartz Beloit One Network |
$108.04
|
| Rate for Payer: Quartz Commercial |
$143.31
|
| Rate for Payer: Quartz Medicare Advantage |
$132.29
|
| Rate for Payer: The Alliance Commercial |
$110.24
|
| Rate for Payer: WEA Trust Commercial |
$121.26
|
| Rate for Payer: WPS Commercial |
$163.30
|
|
|
Tc-99m Macroaggregated Albumin(MAA)
|
Facility
|
IP
|
$212.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
1486832
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.04 |
| Max. Negotiated Rate |
$202.84 |
| Rate for Payer: Aetna Commercial |
$198.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.85
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$202.84
|
| Rate for Payer: Health EOS Commercial |
$196.23
|
| Rate for Payer: HFN Commercial |
$202.84
|
| Rate for Payer: Multiplan Commercial |
$176.38
|
| Rate for Payer: Preferred Network Access Commercial |
$202.84
|
| Rate for Payer: Quartz Beloit One Network |
$108.04
|
| Rate for Payer: Quartz Commercial |
$132.29
|
| Rate for Payer: WEA Trust Commercial |
$121.26
|
| Rate for Payer: WPS Commercial |
$163.30
|
|
|
Tc-99m Mebrofenin
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
1486816
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.45 |
| Max. Negotiated Rate |
$178.92 |
| Rate for Payer: Aetna Commercial |
$175.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Aetna Managed Medicare |
$54.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.07
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$178.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.83
|
| Rate for Payer: Health EOS Commercial |
$173.09
|
| Rate for Payer: HFN Commercial |
$178.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.86
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: NAPHCARE Commercial |
$116.69
|
| Rate for Payer: Preferred Network Access Commercial |
$178.92
|
| Rate for Payer: Quartz Beloit One Network |
$95.30
|
| Rate for Payer: Quartz Commercial |
$126.41
|
| Rate for Payer: Quartz Medicare Advantage |
$116.69
|
| Rate for Payer: The Alliance Commercial |
$97.24
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
Tc-99m Mebrofenin
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
1486816
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.30 |
| Max. Negotiated Rate |
$178.92 |
| Rate for Payer: Aetna Commercial |
$175.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.07
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$178.92
|
| Rate for Payer: Health EOS Commercial |
$173.09
|
| Rate for Payer: HFN Commercial |
$178.92
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: Preferred Network Access Commercial |
$178.92
|
| Rate for Payer: Quartz Beloit One Network |
$95.30
|
| Rate for Payer: Quartz Commercial |
$116.69
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
Tc-99m Mebrofenin
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
1486816
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.47 |
| Max. Negotiated Rate |
$184.76 |
| Rate for Payer: Aetna Commercial |
$184.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$184.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.69
|
| Rate for Payer: Health EOS Commercial |
$176.98
|
| Rate for Payer: HFN Commercial |
$184.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$90.80
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: Preferred Network Access Commercial |
$184.76
|
| Rate for Payer: Quartz Beloit One Network |
$85.57
|
| Rate for Payer: Quartz Commercial |
$110.85
|
| Rate for Payer: The Alliance Commercial |
$97.24
|
| Rate for Payer: United Healthcare Medicaid |
$52.47
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
Tc-99m Medronate(MDP)
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
1486834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Aetna Managed Medicare |
$24.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.89
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: NAPHCARE Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$56.78
|
| Rate for Payer: Quartz Medicare Advantage |
$52.42
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
Tc-99m Medronate(MDP)
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
1486834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$52.42
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
Tc-99m Medronate(MDP)
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
1486834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.96 |
| Max. Negotiated Rate |
$82.99 |
| Rate for Payer: Aetna Commercial |
$82.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$82.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.42
|
| Rate for Payer: Health EOS Commercial |
$79.50
|
| Rate for Payer: HFN Commercial |
$82.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.97
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$82.99
|
| Rate for Payer: Quartz Beloit One Network |
$38.44
|
| Rate for Payer: Quartz Commercial |
$49.80
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: United Healthcare Medicaid |
$19.96
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
Tc-99m NaTcO4
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
1486852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Aetna Managed Medicare |
$24.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.89
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: NAPHCARE Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$56.78
|
| Rate for Payer: Quartz Medicare Advantage |
$52.42
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
Tc-99m NaTcO4
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
1486852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$82.99 |
| Rate for Payer: Aetna Commercial |
$82.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$82.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.42
|
| Rate for Payer: Health EOS Commercial |
$79.50
|
| Rate for Payer: HFN Commercial |
$82.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33.40
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$82.99
|
| Rate for Payer: Quartz Beloit One Network |
$38.44
|
| Rate for Payer: Quartz Commercial |
$49.80
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: United Healthcare Medicaid |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
Tc-99m NaTcO4
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
1486852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$52.42
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
TC99m PYP
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
HCPCS A9538
|
| Hospital Charge Code |
1158913
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$20.55 |
| Max. Negotiated Rate |
$251.94 |
| Rate for Payer: Aetna Commercial |
$251.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.07
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$251.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.12
|
| Rate for Payer: Health EOS Commercial |
$241.33
|
| Rate for Payer: HFN Commercial |
$251.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$41.71
|
| Rate for Payer: Multiplan Commercial |
$212.16
|
| Rate for Payer: Preferred Network Access Commercial |
$251.94
|
| Rate for Payer: Quartz Beloit One Network |
$116.69
|
| Rate for Payer: Quartz Commercial |
$151.16
|
| Rate for Payer: The Alliance Commercial |
$132.60
|
| Rate for Payer: United Healthcare Medicaid |
$20.55
|
| Rate for Payer: WEA Trust Commercial |
$145.86
|
| Rate for Payer: WPS Commercial |
$196.43
|
|
|
TC99m PYP
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
5381840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.81 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$150.38
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
TC99m PYP
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
5381840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.59 |
| Max. Negotiated Rate |
$238.11 |
| Rate for Payer: Aetna Commercial |
$238.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$238.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$88.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.38
|
| Rate for Payer: Health EOS Commercial |
$228.08
|
| Rate for Payer: HFN Commercial |
$238.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$162.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$162.04
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: Preferred Network Access Commercial |
$238.11
|
| Rate for Payer: Quartz Beloit One Network |
$110.28
|
| Rate for Payer: Quartz Commercial |
$142.86
|
| Rate for Payer: The Alliance Commercial |
$125.32
|
| Rate for Payer: United Healthcare Medicaid |
$88.59
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
TC99m PYP
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
1158914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.59 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Aetna Commercial |
$247.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$223.60
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$247.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$88.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$156.00
|
| Rate for Payer: Health EOS Commercial |
$236.60
|
| Rate for Payer: HFN Commercial |
$247.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$162.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$162.04
|
| Rate for Payer: Multiplan Commercial |
$208.00
|
| Rate for Payer: Preferred Network Access Commercial |
$247.00
|
| Rate for Payer: Quartz Beloit One Network |
$114.40
|
| Rate for Payer: Quartz Commercial |
$148.20
|
| Rate for Payer: The Alliance Commercial |
$130.00
|
| Rate for Payer: United Healthcare Medicaid |
$88.59
|
| Rate for Payer: WEA Trust Commercial |
$143.00
|
| Rate for Payer: WPS Commercial |
$192.57
|
|
|
TC99m PYP
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
HCPCS A9538
|
| Hospital Charge Code |
1158913
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$129.95 |
| Max. Negotiated Rate |
$243.98 |
| Rate for Payer: Aetna Commercial |
$238.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.56
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$243.98
|
| Rate for Payer: Health EOS Commercial |
$236.03
|
| Rate for Payer: HFN Commercial |
$243.98
|
| Rate for Payer: Multiplan Commercial |
$212.16
|
| Rate for Payer: Preferred Network Access Commercial |
$243.98
|
| Rate for Payer: Quartz Beloit One Network |
$129.95
|
| Rate for Payer: Quartz Commercial |
$159.12
|
| Rate for Payer: WEA Trust Commercial |
$145.86
|
| Rate for Payer: WPS Commercial |
$196.43
|
|
|
TC99m PYP
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
5381840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.18 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$70.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$162.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$125.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$120.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.26
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.98
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$150.38
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$162.92
|
| Rate for Payer: Quartz Medicare Advantage |
$150.38
|
| Rate for Payer: The Alliance Commercial |
$125.32
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
TC99m PYP
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
1158914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$239.20 |
| Rate for Payer: Aetna Commercial |
$234.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$223.60
|
| Rate for Payer: Aetna Managed Medicare |
$72.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$169.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$130.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$124.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$137.80
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$239.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$145.50
|
| Rate for Payer: Health EOS Commercial |
$231.40
|
| Rate for Payer: HFN Commercial |
$239.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.00
|
| Rate for Payer: Multiplan Commercial |
$208.00
|
| Rate for Payer: NAPHCARE Commercial |
$156.00
|
| Rate for Payer: Preferred Network Access Commercial |
$239.20
|
| Rate for Payer: Quartz Beloit One Network |
$127.40
|
| Rate for Payer: Quartz Commercial |
$169.00
|
| Rate for Payer: Quartz Medicare Advantage |
$156.00
|
| Rate for Payer: The Alliance Commercial |
$130.00
|
| Rate for Payer: WEA Trust Commercial |
$143.00
|
| Rate for Payer: WPS Commercial |
$192.57
|
|
|
TC99m PYP
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
1158914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$239.20 |
| Rate for Payer: Aetna Commercial |
$234.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$223.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$137.80
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$239.20
|
| Rate for Payer: Health EOS Commercial |
$231.40
|
| Rate for Payer: HFN Commercial |
$239.20
|
| Rate for Payer: Multiplan Commercial |
$208.00
|
| Rate for Payer: Preferred Network Access Commercial |
$239.20
|
| Rate for Payer: Quartz Beloit One Network |
$127.40
|
| Rate for Payer: Quartz Commercial |
$156.00
|
| Rate for Payer: WEA Trust Commercial |
$143.00
|
| Rate for Payer: WPS Commercial |
$192.57
|
|
|
TC99m PYP
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
HCPCS A9538
|
| Hospital Charge Code |
1158913
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$74.26 |
| Max. Negotiated Rate |
$243.98 |
| Rate for Payer: Aetna Commercial |
$238.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.07
|
| Rate for Payer: Aetna Managed Medicare |
$74.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$172.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$132.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$127.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.56
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$243.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.41
|
| Rate for Payer: Health EOS Commercial |
$236.03
|
| Rate for Payer: HFN Commercial |
$243.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$198.90
|
| Rate for Payer: Multiplan Commercial |
$212.16
|
| Rate for Payer: NAPHCARE Commercial |
$159.12
|
| Rate for Payer: Preferred Network Access Commercial |
$243.98
|
| Rate for Payer: Quartz Beloit One Network |
$129.95
|
| Rate for Payer: Quartz Commercial |
$172.38
|
| Rate for Payer: Quartz Medicare Advantage |
$159.12
|
| Rate for Payer: The Alliance Commercial |
$132.60
|
| Rate for Payer: WEA Trust Commercial |
$145.86
|
| Rate for Payer: WPS Commercial |
$196.43
|
|
|
Tc-99m Sestamibi
|
Facility
|
IP
|
$413.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
1486838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.46 |
| Max. Negotiated Rate |
$395.16 |
| Rate for Payer: Aetna Commercial |
$386.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.65
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cigna Commercial |
$395.16
|
| Rate for Payer: Health EOS Commercial |
$382.27
|
| Rate for Payer: HFN Commercial |
$395.16
|
| Rate for Payer: Multiplan Commercial |
$343.62
|
| Rate for Payer: Preferred Network Access Commercial |
$395.16
|
| Rate for Payer: Quartz Beloit One Network |
$210.46
|
| Rate for Payer: Quartz Commercial |
$257.71
|
| Rate for Payer: WEA Trust Commercial |
$236.24
|
| Rate for Payer: WPS Commercial |
$318.13
|
|
|
Tc-99m Sestamibi
|
Facility
|
IP
|
$397.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
5381841
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$202.31 |
| Max. Negotiated Rate |
$379.85 |
| Rate for Payer: Aetna Commercial |
$371.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.83
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$379.85
|
| Rate for Payer: Health EOS Commercial |
$367.46
|
| Rate for Payer: HFN Commercial |
$379.85
|
| Rate for Payer: Multiplan Commercial |
$330.30
|
| Rate for Payer: Preferred Network Access Commercial |
$379.85
|
| Rate for Payer: Quartz Beloit One Network |
$202.31
|
| Rate for Payer: Quartz Commercial |
$247.73
|
| Rate for Payer: WEA Trust Commercial |
$227.08
|
| Rate for Payer: WPS Commercial |
$305.81
|
|
|
Tc-99m Sestamibi
|
Professional
|
Both
|
$413.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
1486838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$408.04 |
| Rate for Payer: Aetna Commercial |
$408.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.39
|
| Rate for Payer: Anthem Commercial |
$78.00
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cigna Commercial |
$408.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$257.71
|
| Rate for Payer: Health EOS Commercial |
$390.86
|
| Rate for Payer: HFN Commercial |
$408.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$195.08
|
| Rate for Payer: Multiplan Commercial |
$343.62
|
| Rate for Payer: Preferred Network Access Commercial |
$408.04
|
| Rate for Payer: Quartz Beloit One Network |
$188.99
|
| Rate for Payer: Quartz Commercial |
$244.83
|
| Rate for Payer: The Alliance Commercial |
$214.76
|
| Rate for Payer: United Healthcare Medicaid |
$120.54
|
| Rate for Payer: WEA Trust Commercial |
$236.24
|
| Rate for Payer: WPS Commercial |
$318.13
|
|
|
Tc-99m Sestamibi
|
Facility
|
OP
|
$413.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
1486838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$395.16 |
| Rate for Payer: Aetna Commercial |
$386.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.39
|
| Rate for Payer: Aetna Managed Medicare |
$120.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$279.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$214.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$206.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.65
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cigna Commercial |
$395.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.37
|
| Rate for Payer: Health EOS Commercial |
$382.27
|
| Rate for Payer: HFN Commercial |
$395.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$322.14
|
| Rate for Payer: Multiplan Commercial |
$343.62
|
| Rate for Payer: NAPHCARE Commercial |
$257.71
|
| Rate for Payer: Preferred Network Access Commercial |
$395.16
|
| Rate for Payer: Quartz Beloit One Network |
$210.46
|
| Rate for Payer: Quartz Commercial |
$279.19
|
| Rate for Payer: Quartz Medicare Advantage |
$257.71
|
| Rate for Payer: The Alliance Commercial |
$214.76
|
| Rate for Payer: WEA Trust Commercial |
$236.24
|
| Rate for Payer: WPS Commercial |
$318.13
|
|
|
Tc-99m Sestamibi
|
Professional
|
Both
|
$397.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
5381841
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$392.24 |
| Rate for Payer: Aetna Commercial |
$392.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.08
|
| Rate for Payer: Anthem Commercial |
$78.00
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$392.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$247.73
|
| Rate for Payer: Health EOS Commercial |
$375.72
|
| Rate for Payer: HFN Commercial |
$392.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$195.08
|
| Rate for Payer: Multiplan Commercial |
$330.30
|
| Rate for Payer: Preferred Network Access Commercial |
$392.24
|
| Rate for Payer: Quartz Beloit One Network |
$181.67
|
| Rate for Payer: Quartz Commercial |
$235.34
|
| Rate for Payer: The Alliance Commercial |
$206.44
|
| Rate for Payer: United Healthcare Medicaid |
$120.54
|
| Rate for Payer: WEA Trust Commercial |
$227.08
|
| Rate for Payer: WPS Commercial |
$305.81
|
|
