|
US Breast Left
|
Facility
IP
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627718
|
| Min. Negotiated Rate |
$798.70 |
| Max. Negotiated Rate |
$1,499.60 |
| Rate for Payer: Aetna Commercial |
$1,467.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$863.90
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cigna Commercial |
$1,499.60
|
| Rate for Payer: Health EOS Commercial |
$1,450.70
|
| Rate for Payer: HFN Commercial |
$1,499.60
|
| Rate for Payer: Multiplan Commercial |
$1,304.00
|
| Rate for Payer: NAPHCARE Commercial |
$978.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,499.60
|
| Rate for Payer: Quartz Beloit One Network |
$798.70
|
| Rate for Payer: Quartz Commercial |
$978.00
|
| Rate for Payer: WEA Trust Commercial |
$896.50
|
| Rate for Payer: WPS Commercial |
$1,207.34
|
|
|
US Breast Left
|
Professional
|
$963.00
|
|
|
Service Code
|
CPT 76641 LT,TC
|
| Hospital Charge Code |
2544821
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$423.72 |
| Max. Negotiated Rate |
$914.85 |
| Rate for Payer: Aetna Commercial |
$914.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$914.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$481.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$577.80
|
| Rate for Payer: Health EOS Commercial |
$876.33
|
| Rate for Payer: Multiplan Commercial |
$770.40
|
| Rate for Payer: Preferred Network Access Commercial |
$914.85
|
| Rate for Payer: Quartz Beloit One Network |
$423.72
|
| Rate for Payer: Quartz Commercial |
$548.91
|
| Rate for Payer: The Alliance Commercial |
$481.50
|
| Rate for Payer: WEA Trust Commercial |
$529.65
|
| Rate for Payer: WPS Commercial |
$713.29
|
|
|
US Breast Left
|
Facility
OP
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627718
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$2,846.16 |
| Rate for Payer: Aetna Commercial |
$1,467.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,401.80
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,059.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$815.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$782.40
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$863.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cigna Commercial |
$1,499.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,450.70
|
| Rate for Payer: HFN Commercial |
$1,499.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$1,304.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,499.60
|
| Rate for Payer: Quartz Beloit One Network |
$798.70
|
| Rate for Payer: Quartz Commercial |
$1,059.50
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$2,846.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$896.50
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,207.34
|
|
|
US Breast Left
|
Facility
IP
|
$963.00
|
|
|
Service Code
|
CPT 76641 LT,TC
|
| Hospital Charge Code |
2544821
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$471.87 |
| Max. Negotiated Rate |
$885.96 |
| Rate for Payer: Aetna Commercial |
$866.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$510.39
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$885.96
|
| Rate for Payer: Health EOS Commercial |
$857.07
|
| Rate for Payer: HFN Commercial |
$885.96
|
| Rate for Payer: Multiplan Commercial |
$770.40
|
| Rate for Payer: NAPHCARE Commercial |
$577.80
|
| Rate for Payer: Preferred Network Access Commercial |
$885.96
|
| Rate for Payer: Quartz Beloit One Network |
$471.87
|
| Rate for Payer: Quartz Commercial |
$577.80
|
| Rate for Payer: WEA Trust Commercial |
$529.65
|
| Rate for Payer: WPS Commercial |
$713.29
|
|
|
US Breast Left
|
Professional
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627718
|
| Min. Negotiated Rate |
$100.28 |
| Max. Negotiated Rate |
$1,548.50 |
| Rate for Payer: Aetna Commercial |
$1,548.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,401.80
|
| Rate for Payer: Aetna Managed Medicare |
$100.28
|
| Rate for Payer: Anthem Medicare Advantage |
$100.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$100.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$100.28
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cigna Commercial |
$1,548.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$815.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.28
|
| Rate for Payer: Health EOS Commercial |
$1,483.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$363.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$363.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$100.28
|
| Rate for Payer: Multiplan Commercial |
$1,304.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,548.50
|
| Rate for Payer: Quartz Beloit One Network |
$717.20
|
| Rate for Payer: Quartz Commercial |
$929.10
|
| Rate for Payer: Quartz Medicare Advantage |
$100.28
|
| Rate for Payer: The Alliance Commercial |
$381.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.28
|
| Rate for Payer: WEA Trust Commercial |
$896.50
|
| Rate for Payer: WPS Commercial |
$501.40
|
|
|
US Breast Limited
|
Facility
OP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
5102616
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$225.96 |
| Max. Negotiated Rate |
$3,228.00 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Aetna Managed Medicare |
$225.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$605.25
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$524.55
|
| Rate for Payer: Quartz Medicare Advantage |
$484.20
|
| Rate for Payer: The Alliance Commercial |
$3,228.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited
|
Professional
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
5102616
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$355.08 |
| Max. Negotiated Rate |
$766.65 |
| Rate for Payer: Aetna Commercial |
$766.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$766.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$403.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$484.20
|
| Rate for Payer: Health EOS Commercial |
$734.37
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: Preferred Network Access Commercial |
$766.65
|
| Rate for Payer: Quartz Beloit One Network |
$355.08
|
| Rate for Payer: Quartz Commercial |
$459.99
|
| Rate for Payer: The Alliance Commercial |
$403.50
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited
|
Facility
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
5102616
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$395.43 |
| Max. Negotiated Rate |
$742.44 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$484.20
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Bilateral
|
Facility
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 LT,LT
|
| Hospital Charge Code |
6196521
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$395.43 |
| Max. Negotiated Rate |
$742.44 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$484.20
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Bilateral
|
Facility
OP
|
$807.00
|
|
|
Service Code
|
CPT 76642 LT,LT
|
| Hospital Charge Code |
6196521
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$225.96 |
| Max. Negotiated Rate |
$3,228.00 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Aetna Managed Medicare |
$225.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$605.25
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$524.55
|
| Rate for Payer: Quartz Medicare Advantage |
$484.20
|
| Rate for Payer: The Alliance Commercial |
$3,228.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Bilateral
|
Professional
|
$807.00
|
|
|
Service Code
|
CPT 76642 LT,LT
|
| Hospital Charge Code |
6196521
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$355.08 |
| Max. Negotiated Rate |
$766.65 |
| Rate for Payer: Aetna Commercial |
$766.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$766.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$403.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$484.20
|
| Rate for Payer: Health EOS Commercial |
$734.37
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: Preferred Network Access Commercial |
$766.65
|
| Rate for Payer: Quartz Beloit One Network |
$355.08
|
| Rate for Payer: Quartz Commercial |
$459.99
|
| Rate for Payer: The Alliance Commercial |
$403.50
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Left
|
Facility
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
6196524
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$395.43 |
| Max. Negotiated Rate |
$742.44 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$484.20
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Left
|
Facility
OP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
6196524
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$225.96 |
| Max. Negotiated Rate |
$3,228.00 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Aetna Managed Medicare |
$225.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$605.25
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$524.55
|
| Rate for Payer: Quartz Medicare Advantage |
$484.20
|
| Rate for Payer: The Alliance Commercial |
$3,228.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Left
|
Professional
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
6196524
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$355.08 |
| Max. Negotiated Rate |
$766.65 |
| Rate for Payer: Quartz Commercial |
$459.99
|
| Rate for Payer: Aetna Commercial |
$766.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$766.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$403.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$484.20
|
| Rate for Payer: Health EOS Commercial |
$734.37
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: Preferred Network Access Commercial |
$766.65
|
| Rate for Payer: Quartz Beloit One Network |
$355.08
|
| Rate for Payer: The Alliance Commercial |
$403.50
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Right
|
Facility
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6208968
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$395.43 |
| Max. Negotiated Rate |
$742.44 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$484.20
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Right
|
Professional
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6196527
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$355.08 |
| Max. Negotiated Rate |
$766.65 |
| Rate for Payer: Aetna Commercial |
$766.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$766.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$403.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$484.20
|
| Rate for Payer: Health EOS Commercial |
$734.37
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: Preferred Network Access Commercial |
$766.65
|
| Rate for Payer: Quartz Beloit One Network |
$355.08
|
| Rate for Payer: Quartz Commercial |
$459.99
|
| Rate for Payer: The Alliance Commercial |
$403.50
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Right
|
Facility
OP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6208968
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$225.96 |
| Max. Negotiated Rate |
$3,228.00 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Aetna Managed Medicare |
$225.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$605.25
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$524.55
|
| Rate for Payer: Quartz Medicare Advantage |
$484.20
|
| Rate for Payer: The Alliance Commercial |
$3,228.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Right
|
Facility
OP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6196527
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$225.96 |
| Max. Negotiated Rate |
$3,228.00 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Aetna Managed Medicare |
$225.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$605.25
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$524.55
|
| Rate for Payer: Quartz Medicare Advantage |
$484.20
|
| Rate for Payer: The Alliance Commercial |
$3,228.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Right
|
Professional
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6208968
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$355.08 |
| Max. Negotiated Rate |
$766.65 |
| Rate for Payer: Aetna Commercial |
$766.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$766.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$403.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$484.20
|
| Rate for Payer: Health EOS Commercial |
$734.37
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: Preferred Network Access Commercial |
$766.65
|
| Rate for Payer: Quartz Beloit One Network |
$355.08
|
| Rate for Payer: Quartz Commercial |
$459.99
|
| Rate for Payer: The Alliance Commercial |
$403.50
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited & Axillary Right
|
Facility
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6196527
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$395.43 |
| Max. Negotiated Rate |
$742.44 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$484.20
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited Left
|
Facility
OP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
5102620
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$225.96 |
| Max. Negotiated Rate |
$3,228.00 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Aetna Managed Medicare |
$225.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$605.25
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$524.55
|
| Rate for Payer: Quartz Medicare Advantage |
$484.20
|
| Rate for Payer: The Alliance Commercial |
$3,228.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited Left
|
Facility
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
5102620
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$395.43 |
| Max. Negotiated Rate |
$742.44 |
| Rate for Payer: Aetna Commercial |
$726.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.71
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$742.44
|
| Rate for Payer: Health EOS Commercial |
$718.23
|
| Rate for Payer: HFN Commercial |
$742.44
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: NAPHCARE Commercial |
$484.20
|
| Rate for Payer: Preferred Network Access Commercial |
$742.44
|
| Rate for Payer: Quartz Beloit One Network |
$395.43
|
| Rate for Payer: Quartz Commercial |
$484.20
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Limited Left
|
Professional
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
5102620
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$355.08 |
| Max. Negotiated Rate |
$766.65 |
| Rate for Payer: Aetna Commercial |
$766.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.02
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$766.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$403.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$484.20
|
| Rate for Payer: Health EOS Commercial |
$734.37
|
| Rate for Payer: Multiplan Commercial |
$645.60
|
| Rate for Payer: Preferred Network Access Commercial |
$766.65
|
| Rate for Payer: Quartz Beloit One Network |
$355.08
|
| Rate for Payer: Quartz Commercial |
$459.99
|
| Rate for Payer: The Alliance Commercial |
$403.50
|
| Rate for Payer: WEA Trust Commercial |
$443.85
|
| Rate for Payer: WPS Commercial |
$597.74
|
|
|
US Breast Right
|
Professional
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2544823
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$423.72 |
| Max. Negotiated Rate |
$914.85 |
| Rate for Payer: Aetna Commercial |
$914.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$914.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$481.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$577.80
|
| Rate for Payer: Health EOS Commercial |
$876.33
|
| Rate for Payer: Multiplan Commercial |
$770.40
|
| Rate for Payer: Preferred Network Access Commercial |
$914.85
|
| Rate for Payer: Quartz Beloit One Network |
$423.72
|
| Rate for Payer: Quartz Commercial |
$548.91
|
| Rate for Payer: The Alliance Commercial |
$481.50
|
| Rate for Payer: WEA Trust Commercial |
$529.65
|
| Rate for Payer: WPS Commercial |
$713.29
|
|
|
US Breast Right
|
Professional
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2980118
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$423.72 |
| Max. Negotiated Rate |
$914.85 |
| Rate for Payer: Aetna Commercial |
$914.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$914.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$481.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$577.80
|
| Rate for Payer: Health EOS Commercial |
$876.33
|
| Rate for Payer: Multiplan Commercial |
$770.40
|
| Rate for Payer: Preferred Network Access Commercial |
$914.85
|
| Rate for Payer: Quartz Beloit One Network |
$423.72
|
| Rate for Payer: Quartz Commercial |
$548.91
|
| Rate for Payer: The Alliance Commercial |
$481.50
|
| Rate for Payer: WEA Trust Commercial |
$529.65
|
| Rate for Payer: WPS Commercial |
$713.29
|
|
