|
US Breast Right
|
Facility
OP
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627720
|
| 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 Right
|
Facility
IP
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2544823
|
|
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 Right
|
Facility
OP
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2544823
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$269.64 |
| Max. Negotiated Rate |
$3,852.00 |
| Rate for Payer: Aetna Commercial |
$866.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| Rate for Payer: Aetna Managed Medicare |
$269.64
|
| 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 |
$510.39
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| 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: Humana Commercial/EPO/HMO/POS/PPO |
$722.25
|
| 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 |
$625.95
|
| Rate for Payer: Quartz Medicare Advantage |
$577.80
|
| Rate for Payer: The Alliance Commercial |
$3,852.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$529.65
|
| Rate for Payer: WPS Commercial |
$713.29
|
|
|
US Breast Right
|
Facility
IP
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627720
|
| 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 Right
|
Professional
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627720
|
| 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 Right
|
Facility
OP
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2980118
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$269.64 |
| Max. Negotiated Rate |
$3,852.00 |
| Rate for Payer: Aetna Commercial |
$866.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| Rate for Payer: Aetna Managed Medicare |
$269.64
|
| 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 |
$510.39
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| 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: Humana Commercial/EPO/HMO/POS/PPO |
$722.25
|
| 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 |
$625.95
|
| Rate for Payer: Quartz Medicare Advantage |
$577.80
|
| Rate for Payer: The Alliance Commercial |
$3,852.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$529.65
|
| Rate for Payer: WPS Commercial |
$713.29
|
|
|
US Breast Right
|
Facility
IP
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2980118
|
|
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 Unilateral Right
|
Professional
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC
|
| Hospital Charge Code |
4498608
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$66.42 |
| Max. Negotiated Rate |
$914.85 |
| Rate for Payer: Aetna Commercial |
$914.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| Rate for Payer: Aetna Managed Medicare |
$66.42
|
| Rate for Payer: Anthem Medicare Advantage |
$66.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$66.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$66.42
|
| 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 |
$66.42
|
| Rate for Payer: Health EOS Commercial |
$876.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$241.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$241.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$66.42
|
| 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: Quartz Medicare Advantage |
$66.42
|
| Rate for Payer: The Alliance Commercial |
$252.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$66.42
|
| Rate for Payer: WEA Trust Commercial |
$529.65
|
| Rate for Payer: WPS Commercial |
$332.10
|
|
|
US Breast Unilateral Right
|
Facility
OP
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC
|
| Hospital Charge Code |
4498608
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$269.64 |
| Max. Negotiated Rate |
$3,852.00 |
| Rate for Payer: Aetna Commercial |
$866.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| Rate for Payer: Aetna Managed Medicare |
$269.64
|
| 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 |
$510.39
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| 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: Humana Commercial/EPO/HMO/POS/PPO |
$722.25
|
| 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 |
$625.95
|
| Rate for Payer: Quartz Medicare Advantage |
$577.80
|
| Rate for Payer: The Alliance Commercial |
$3,852.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$529.65
|
| Rate for Payer: WPS Commercial |
$713.29
|
|
|
US Breast Unilateral Right
|
Facility
IP
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC
|
| Hospital Charge Code |
4498608
|
|
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 Uni Real Time with Image 76641
|
Professional
|
$508.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
4521339
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$100.28 |
| Max. Negotiated Rate |
$501.40 |
| Rate for Payer: Aetna Commercial |
$482.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.88
|
| 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 |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$482.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$254.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.28
|
| Rate for Payer: Health EOS Commercial |
$462.28
|
| 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 |
$406.40
|
| Rate for Payer: Preferred Network Access Commercial |
$482.60
|
| Rate for Payer: Quartz Beloit One Network |
$223.52
|
| Rate for Payer: Quartz Commercial |
$289.56
|
| 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 |
$279.40
|
| Rate for Payer: WPS Commercial |
$501.40
|
|
|
US Breast Uni Real Time with Image 7664126
|
Professional
|
$508.00
|
|
|
Service Code
|
CPT 76641 26
|
| Hospital Charge Code |
4521340
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.86 |
| Max. Negotiated Rate |
$482.60 |
| Rate for Payer: Aetna Commercial |
$482.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.88
|
| Rate for Payer: Aetna Managed Medicare |
$33.86
|
| Rate for Payer: Anthem Medicare Advantage |
$33.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.86
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$482.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$254.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.86
|
| Rate for Payer: Health EOS Commercial |
$462.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$121.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.86
|
| Rate for Payer: Multiplan Commercial |
$406.40
|
| Rate for Payer: Preferred Network Access Commercial |
$482.60
|
| Rate for Payer: Quartz Beloit One Network |
$223.52
|
| Rate for Payer: Quartz Commercial |
$289.56
|
| Rate for Payer: Quartz Medicare Advantage |
$33.86
|
| Rate for Payer: The Alliance Commercial |
$128.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.86
|
| Rate for Payer: WEA Trust Commercial |
$279.40
|
| Rate for Payer: WPS Commercial |
$169.30
|
|
|
US Breast Uni Real Time with Image Limited 76642
|
Professional
|
$467.00
|
|
|
Service Code
|
CPT 76642
|
| Hospital Charge Code |
4538775
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.49 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Aetna Commercial |
$443.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$401.62
|
| Rate for Payer: Aetna Managed Medicare |
$82.49
|
| Rate for Payer: Anthem Medicare Advantage |
$82.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$82.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$82.49
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cigna Commercial |
$443.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$233.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.49
|
| Rate for Payer: Health EOS Commercial |
$424.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$299.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$299.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$82.49
|
| Rate for Payer: Multiplan Commercial |
$373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$443.65
|
| Rate for Payer: Quartz Beloit One Network |
$205.48
|
| Rate for Payer: Quartz Commercial |
$266.19
|
| Rate for Payer: Quartz Medicare Advantage |
$82.49
|
| Rate for Payer: The Alliance Commercial |
$313.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$82.49
|
| Rate for Payer: WEA Trust Commercial |
$256.85
|
| Rate for Payer: WPS Commercial |
$412.45
|
|
|
US Breast Uni Real Time with Image Limited 7664226
|
Professional
|
$467.00
|
|
|
Service Code
|
CPT 76642 26
|
| Hospital Charge Code |
4538776
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.52 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Aetna Commercial |
$443.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$401.62
|
| Rate for Payer: Aetna Managed Medicare |
$31.52
|
| Rate for Payer: Anthem Medicare Advantage |
$31.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$31.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$31.52
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cigna Commercial |
$443.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$233.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.52
|
| Rate for Payer: Health EOS Commercial |
$424.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$114.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$31.52
|
| Rate for Payer: Multiplan Commercial |
$373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$443.65
|
| Rate for Payer: Quartz Beloit One Network |
$205.48
|
| Rate for Payer: Quartz Commercial |
$266.19
|
| Rate for Payer: Quartz Medicare Advantage |
$31.52
|
| Rate for Payer: The Alliance Commercial |
$119.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31.52
|
| Rate for Payer: WEA Trust Commercial |
$256.85
|
| Rate for Payer: WPS Commercial |
$157.60
|
|
|
US Breast Uni Real Time with Image Limited 76642PP
|
Professional
|
$1,228.00
|
|
|
Service Code
|
CPT 76642
|
| Hospital Charge Code |
4780607
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.49 |
| Max. Negotiated Rate |
$1,166.60 |
| Rate for Payer: Aetna Commercial |
$1,166.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,056.08
|
| Rate for Payer: Aetna Managed Medicare |
$82.49
|
| Rate for Payer: Anthem Medicare Advantage |
$82.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$82.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$82.49
|
| Rate for Payer: Cash Price |
$368.40
|
| Rate for Payer: Cash Price |
$368.40
|
| Rate for Payer: Cigna Commercial |
$1,166.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$614.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.49
|
| Rate for Payer: Health EOS Commercial |
$1,117.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$299.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$299.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$82.49
|
| Rate for Payer: Multiplan Commercial |
$982.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,166.60
|
| Rate for Payer: Quartz Beloit One Network |
$540.32
|
| Rate for Payer: Quartz Commercial |
$699.96
|
| Rate for Payer: Quartz Medicare Advantage |
$82.49
|
| Rate for Payer: The Alliance Commercial |
$313.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$82.49
|
| Rate for Payer: WEA Trust Commercial |
$675.40
|
| Rate for Payer: WPS Commercial |
$412.45
|
|
|
US Chest
|
Facility
OP
|
$1,061.00
|
|
|
Service Code
|
CPT 76604
|
| Hospital Charge Code |
629714
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$2,089.48 |
| Rate for Payer: Aetna Commercial |
$954.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$912.46
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$689.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$530.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$509.28
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$562.33
|
| 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 |
$318.30
|
| Rate for Payer: Cash Price |
$318.30
|
| Rate for Payer: Cigna Commercial |
$976.12
|
| 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 |
$944.29
|
| Rate for Payer: HFN Commercial |
$976.12
|
| 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 |
$848.80
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$976.12
|
| Rate for Payer: Quartz Beloit One Network |
$519.89
|
| Rate for Payer: Quartz Commercial |
$689.65
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$2,089.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$583.55
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$785.88
|
|
|
US Chest
|
Professional
|
$1,061.00
|
|
|
Service Code
|
CPT 76604
|
| Hospital Charge Code |
629714
|
| Min. Negotiated Rate |
$54.65 |
| Max. Negotiated Rate |
$1,007.95 |
| Rate for Payer: Aetna Commercial |
$1,007.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$912.46
|
| Rate for Payer: Aetna Managed Medicare |
$54.65
|
| Rate for Payer: Anthem Medicare Advantage |
$54.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$54.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$54.65
|
| Rate for Payer: Cash Price |
$318.30
|
| Rate for Payer: Cash Price |
$318.30
|
| Rate for Payer: Cigna Commercial |
$1,007.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$530.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.65
|
| Rate for Payer: Health EOS Commercial |
$965.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$54.65
|
| Rate for Payer: Multiplan Commercial |
$848.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,007.95
|
| Rate for Payer: Quartz Beloit One Network |
$466.84
|
| Rate for Payer: Quartz Commercial |
$604.77
|
| Rate for Payer: Quartz Medicare Advantage |
$54.65
|
| Rate for Payer: The Alliance Commercial |
$207.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$54.65
|
| Rate for Payer: WEA Trust Commercial |
$583.55
|
| Rate for Payer: WPS Commercial |
$273.25
|
|
|
US Chest
|
Facility
IP
|
$1,061.00
|
|
|
Service Code
|
CPT 76604
|
| Hospital Charge Code |
629714
|
| Min. Negotiated Rate |
$519.89 |
| Max. Negotiated Rate |
$976.12 |
| Rate for Payer: Aetna Commercial |
$954.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$562.33
|
| Rate for Payer: Cash Price |
$318.30
|
| Rate for Payer: Cigna Commercial |
$976.12
|
| Rate for Payer: Health EOS Commercial |
$944.29
|
| Rate for Payer: HFN Commercial |
$976.12
|
| Rate for Payer: Multiplan Commercial |
$848.80
|
| Rate for Payer: NAPHCARE Commercial |
$636.60
|
| Rate for Payer: Preferred Network Access Commercial |
$976.12
|
| Rate for Payer: Quartz Beloit One Network |
$519.89
|
| Rate for Payer: Quartz Commercial |
$636.60
|
| Rate for Payer: WEA Trust Commercial |
$583.55
|
| Rate for Payer: WPS Commercial |
$785.88
|
|
|
US Chest
|
Facility
OP
|
$1,379.00
|
|
|
Service Code
|
CPT 76604 TC
|
| Hospital Charge Code |
2544825
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$386.12 |
| Max. Negotiated Rate |
$5,516.00 |
| Rate for Payer: Aetna Commercial |
$1,241.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,185.94
|
| Rate for Payer: Aetna Managed Medicare |
$386.12
|
| 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 |
$730.87
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cigna Commercial |
$1,268.68
|
| Rate for Payer: Health EOS Commercial |
$1,227.31
|
| Rate for Payer: HFN Commercial |
$1,268.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,034.25
|
| Rate for Payer: Multiplan Commercial |
$1,103.20
|
| Rate for Payer: NAPHCARE Commercial |
$827.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,268.68
|
| Rate for Payer: Quartz Beloit One Network |
$675.71
|
| Rate for Payer: Quartz Commercial |
$896.35
|
| Rate for Payer: Quartz Medicare Advantage |
$827.40
|
| Rate for Payer: The Alliance Commercial |
$5,516.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$758.45
|
| Rate for Payer: WPS Commercial |
$1,021.43
|
|
|
US Chest
|
Professional
|
$1,379.00
|
|
|
Service Code
|
CPT 76604 TC
|
| Hospital Charge Code |
2544825
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$28.11 |
| Max. Negotiated Rate |
$1,310.05 |
| Rate for Payer: Aetna Commercial |
$1,310.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,185.94
|
| Rate for Payer: Aetna Managed Medicare |
$28.11
|
| Rate for Payer: Anthem Medicare Advantage |
$28.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.11
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cigna Commercial |
$1,310.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$689.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.11
|
| Rate for Payer: Health EOS Commercial |
$1,254.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$131.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.11
|
| Rate for Payer: Multiplan Commercial |
$1,103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,310.05
|
| Rate for Payer: Quartz Beloit One Network |
$606.76
|
| Rate for Payer: Quartz Commercial |
$786.03
|
| Rate for Payer: Quartz Medicare Advantage |
$28.11
|
| Rate for Payer: The Alliance Commercial |
$106.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.11
|
| Rate for Payer: WEA Trust Commercial |
$758.45
|
| Rate for Payer: WPS Commercial |
$140.55
|
|
|
US Chest
|
Facility
IP
|
$1,379.00
|
|
|
Service Code
|
CPT 76604 TC
|
| Hospital Charge Code |
2544825
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$675.71 |
| Max. Negotiated Rate |
$1,268.68 |
| Rate for Payer: Aetna Commercial |
$1,241.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$730.87
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cigna Commercial |
$1,268.68
|
| Rate for Payer: Health EOS Commercial |
$1,227.31
|
| Rate for Payer: HFN Commercial |
$1,268.68
|
| Rate for Payer: Multiplan Commercial |
$1,103.20
|
| Rate for Payer: NAPHCARE Commercial |
$827.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,268.68
|
| Rate for Payer: Quartz Beloit One Network |
$675.71
|
| Rate for Payer: Quartz Commercial |
$827.40
|
| Rate for Payer: WEA Trust Commercial |
$758.45
|
| Rate for Payer: WPS Commercial |
$1,021.43
|
|
|
US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL 7693626
|
Professional
|
$953.00
|
|
|
Service Code
|
CPT 76936 26
|
| Hospital Charge Code |
5416647
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.48 |
| Max. Negotiated Rate |
$905.35 |
| Rate for Payer: Aetna Commercial |
$905.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$819.58
|
| Rate for Payer: Aetna Managed Medicare |
$87.48
|
| Rate for Payer: Anthem Medicare Advantage |
$87.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$87.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$87.48
|
| Rate for Payer: Cash Price |
$285.90
|
| Rate for Payer: Cash Price |
$285.90
|
| Rate for Payer: Cigna Commercial |
$905.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$476.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.48
|
| Rate for Payer: Health EOS Commercial |
$867.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$318.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$318.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$87.48
|
| Rate for Payer: Multiplan Commercial |
$762.40
|
| Rate for Payer: Preferred Network Access Commercial |
$905.35
|
| Rate for Payer: Quartz Beloit One Network |
$419.32
|
| Rate for Payer: Quartz Commercial |
$543.21
|
| Rate for Payer: Quartz Medicare Advantage |
$87.48
|
| Rate for Payer: The Alliance Commercial |
$332.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.48
|
| Rate for Payer: WEA Trust Commercial |
$524.15
|
| Rate for Payer: WPS Commercial |
$437.40
|
|
|
US Doppler
|
Facility
OP
|
$881.00
|
|
|
Service Code
|
CPT 93975 TC
|
| Hospital Charge Code |
6187358
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$246.68 |
| Max. Negotiated Rate |
$3,524.00 |
| Rate for Payer: Aetna Commercial |
$792.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$757.66
|
| Rate for Payer: Aetna Managed Medicare |
$246.68
|
| 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 |
$466.93
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cigna Commercial |
$810.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$493.01
|
| Rate for Payer: Health EOS Commercial |
$784.09
|
| Rate for Payer: HFN Commercial |
$810.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$660.75
|
| Rate for Payer: Multiplan Commercial |
$704.80
|
| Rate for Payer: NAPHCARE Commercial |
$528.60
|
| Rate for Payer: Preferred Network Access Commercial |
$810.52
|
| Rate for Payer: Quartz Beloit One Network |
$431.69
|
| Rate for Payer: Quartz Commercial |
$572.65
|
| Rate for Payer: Quartz Medicare Advantage |
$528.60
|
| Rate for Payer: The Alliance Commercial |
$3,524.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$484.55
|
| Rate for Payer: WPS Commercial |
$652.56
|
|
|
US Doppler
|
Professional
|
$881.00
|
|
|
Service Code
|
CPT 93975 TC
|
| Hospital Charge Code |
6187358
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$203.24 |
| Max. Negotiated Rate |
$836.95 |
| Rate for Payer: Aetna Commercial |
$836.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$757.66
|
| Rate for Payer: Aetna Managed Medicare |
$203.24
|
| Rate for Payer: Anthem Medicare Advantage |
$203.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$203.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$203.24
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cigna Commercial |
$836.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$440.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.24
|
| Rate for Payer: Health EOS Commercial |
$801.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$752.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$752.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$203.24
|
| Rate for Payer: Multiplan Commercial |
$704.80
|
| Rate for Payer: Preferred Network Access Commercial |
$836.95
|
| Rate for Payer: Quartz Beloit One Network |
$387.64
|
| Rate for Payer: Quartz Commercial |
$502.17
|
| Rate for Payer: Quartz Medicare Advantage |
$203.24
|
| Rate for Payer: The Alliance Commercial |
$508.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$203.24
|
| Rate for Payer: WEA Trust Commercial |
$484.55
|
| Rate for Payer: WPS Commercial |
$812.96
|
|
|
US Doppler
|
Facility
IP
|
$881.00
|
|
|
Service Code
|
CPT 93975 TC
|
| Hospital Charge Code |
6187358
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$431.69 |
| Max. Negotiated Rate |
$810.52 |
| Rate for Payer: Aetna Commercial |
$792.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$466.93
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cigna Commercial |
$810.52
|
| Rate for Payer: Health EOS Commercial |
$784.09
|
| Rate for Payer: HFN Commercial |
$810.52
|
| Rate for Payer: Multiplan Commercial |
$704.80
|
| Rate for Payer: NAPHCARE Commercial |
$528.60
|
| Rate for Payer: Preferred Network Access Commercial |
$810.52
|
| Rate for Payer: Quartz Beloit One Network |
$431.69
|
| Rate for Payer: Quartz Commercial |
$528.60
|
| Rate for Payer: WEA Trust Commercial |
$484.55
|
| Rate for Payer: WPS Commercial |
$652.56
|
|
