|
US Hips Infant Dynamic
|
Facility
|
IP
|
$1,249.00
|
|
|
Service Code
|
CPT 76885
|
| Hospital Charge Code |
631145
|
| Min. Negotiated Rate |
$612.01 |
| Max. Negotiated Rate |
$1,149.08 |
| Rate for Payer: Aetna Commercial |
$1,124.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,074.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$661.97
|
| Rate for Payer: Cash Price |
$374.70
|
| Rate for Payer: Cigna Commercial |
$1,149.08
|
| Rate for Payer: Health EOS Commercial |
$1,111.61
|
| Rate for Payer: HFN Commercial |
$1,149.08
|
| Rate for Payer: Multiplan Commercial |
$999.20
|
| Rate for Payer: NAPHCARE Commercial |
$749.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,149.08
|
| Rate for Payer: Quartz Beloit One Network |
$612.01
|
| Rate for Payer: Quartz Commercial |
$749.40
|
| Rate for Payer: WEA Trust Commercial |
$686.95
|
| Rate for Payer: WPS Commercial |
$925.13
|
|
|
US Hips Infant Dynamic
|
Facility
|
IP
|
$1,350.00
|
|
|
Service Code
|
CPT 76885 TC
|
| Hospital Charge Code |
2544893
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$661.50 |
| Max. Negotiated Rate |
$1,242.00 |
| Rate for Payer: Aetna Commercial |
$1,215.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,161.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$715.50
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$1,242.00
|
| Rate for Payer: Health EOS Commercial |
$1,201.50
|
| Rate for Payer: HFN Commercial |
$1,242.00
|
| Rate for Payer: Multiplan Commercial |
$1,080.00
|
| Rate for Payer: NAPHCARE Commercial |
$810.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,242.00
|
| Rate for Payer: Quartz Beloit One Network |
$661.50
|
| Rate for Payer: Quartz Commercial |
$810.00
|
| Rate for Payer: WEA Trust Commercial |
$742.50
|
| Rate for Payer: WPS Commercial |
$999.94
|
|
|
US Hips Infant Dynamic
|
Facility
|
OP
|
$1,350.00
|
|
|
Service Code
|
CPT 76885 TC
|
| Hospital Charge Code |
2544893
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$1,242.00 |
| Rate for Payer: Aetna Commercial |
$1,215.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,161.00
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| 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: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$715.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$1,242.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$755.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$1,201.50
|
| Rate for Payer: HFN Commercial |
$1,242.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$1,080.00
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,242.00
|
| Rate for Payer: Quartz Beloit One Network |
$661.50
|
| Rate for Payer: Quartz Commercial |
$877.50
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$742.50
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$999.94
|
|
|
US Hips Infant Static Limited
|
Professional
|
Both
|
$899.00
|
|
|
Service Code
|
CPT 76886 TC
|
| Hospital Charge Code |
2544895
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$253.31 |
| Max. Negotiated Rate |
$854.05 |
| Rate for Payer: Aetna Commercial |
$854.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$773.14
|
| Rate for Payer: Cash Price |
$269.70
|
| Rate for Payer: Cash Price |
$269.70
|
| Rate for Payer: Cash Price |
$269.70
|
| Rate for Payer: Cigna Commercial |
$854.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$449.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$539.40
|
| Rate for Payer: Health EOS Commercial |
$818.09
|
| Rate for Payer: HFN Commercial |
$854.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$253.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$253.31
|
| Rate for Payer: Multiplan Commercial |
$719.20
|
| Rate for Payer: Preferred Network Access Commercial |
$854.05
|
| Rate for Payer: Quartz Beloit One Network |
$395.56
|
| Rate for Payer: Quartz Commercial |
$512.43
|
| Rate for Payer: The Alliance Commercial |
$449.50
|
| Rate for Payer: WEA Trust Commercial |
$494.45
|
| Rate for Payer: WPS Commercial |
$665.89
|
|
|
US Hips Infant Static Limited
|
Facility
|
IP
|
$899.00
|
|
|
Service Code
|
CPT 76886 TC
|
| Hospital Charge Code |
2544895
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$440.51 |
| Max. Negotiated Rate |
$827.08 |
| Rate for Payer: Aetna Commercial |
$809.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$773.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$476.47
|
| Rate for Payer: Cash Price |
$269.70
|
| Rate for Payer: Cigna Commercial |
$827.08
|
| Rate for Payer: Health EOS Commercial |
$800.11
|
| Rate for Payer: HFN Commercial |
$827.08
|
| Rate for Payer: Multiplan Commercial |
$719.20
|
| Rate for Payer: NAPHCARE Commercial |
$539.40
|
| Rate for Payer: Preferred Network Access Commercial |
$827.08
|
| Rate for Payer: Quartz Beloit One Network |
$440.51
|
| Rate for Payer: Quartz Commercial |
$539.40
|
| Rate for Payer: WEA Trust Commercial |
$494.45
|
| Rate for Payer: WPS Commercial |
$665.89
|
|
|
US Hips Infant Static Limited
|
Facility
|
OP
|
$899.00
|
|
|
Service Code
|
CPT 76886 TC
|
| Hospital Charge Code |
2544895
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$827.08 |
| Rate for Payer: Aetna Commercial |
$809.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$773.14
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| 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: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$476.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$269.70
|
| Rate for Payer: Cash Price |
$269.70
|
| Rate for Payer: Cash Price |
$269.70
|
| Rate for Payer: Cigna Commercial |
$827.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$503.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$800.11
|
| Rate for Payer: HFN Commercial |
$827.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$719.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$827.08
|
| Rate for Payer: Quartz Beloit One Network |
$440.51
|
| Rate for Payer: Quartz Commercial |
$584.35
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$494.45
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$665.89
|
|
|
US Inferior Vena Cava Duplex Complete
|
Facility
|
IP
|
$1,288.00
|
|
|
Service Code
|
CPT 93978 TC
|
| Hospital Charge Code |
2544903
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$631.12 |
| Max. Negotiated Rate |
$1,184.96 |
| Rate for Payer: Aetna Commercial |
$1,159.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,107.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$682.64
|
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: Cigna Commercial |
$1,184.96
|
| Rate for Payer: Health EOS Commercial |
$1,146.32
|
| Rate for Payer: HFN Commercial |
$1,184.96
|
| Rate for Payer: Multiplan Commercial |
$1,030.40
|
| Rate for Payer: NAPHCARE Commercial |
$772.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,184.96
|
| Rate for Payer: Quartz Beloit One Network |
$631.12
|
| Rate for Payer: Quartz Commercial |
$772.80
|
| Rate for Payer: WEA Trust Commercial |
$708.40
|
| Rate for Payer: WPS Commercial |
$954.02
|
|
|
US Inferior Vena Cava Duplex Complete
|
Professional
|
Both
|
$1,288.00
|
|
|
Service Code
|
CPT 93978 TC
|
| Hospital Charge Code |
2544903
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$163.95 |
| Max. Negotiated Rate |
$1,223.60 |
| Rate for Payer: Aetna Commercial |
$1,223.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,107.68
|
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: Cigna Commercial |
$1,223.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$772.80
|
| Rate for Payer: Health EOS Commercial |
$1,172.08
|
| Rate for Payer: HFN Commercial |
$1,223.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$508.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$508.92
|
| Rate for Payer: Multiplan Commercial |
$1,030.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,223.60
|
| Rate for Payer: Quartz Beloit One Network |
$566.72
|
| Rate for Payer: Quartz Commercial |
$734.16
|
| Rate for Payer: The Alliance Commercial |
$644.00
|
| Rate for Payer: United Healthcare Medicaid |
$163.95
|
| Rate for Payer: WEA Trust Commercial |
$708.40
|
| Rate for Payer: WPS Commercial |
$954.02
|
|
|
US Inferior Vena Cava Duplex Complete
|
Facility
|
OP
|
$1,288.00
|
|
|
Service Code
|
CPT 93978 TC
|
| Hospital Charge Code |
2544903
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$1,184.96 |
| Rate for Payer: Aetna Commercial |
$1,159.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,107.68
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| 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: Anthem Medicare Advantage |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$682.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: Cigna Commercial |
$1,184.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$720.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$1,146.32
|
| Rate for Payer: HFN Commercial |
$1,184.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$1,030.40
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,184.96
|
| Rate for Payer: Quartz Beloit One Network |
$631.12
|
| Rate for Payer: Quartz Commercial |
$837.20
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$708.40
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$954.02
|
|
|
US Inferior Vena Cava Duplex Limited
|
Professional
|
Both
|
$766.00
|
|
|
Service Code
|
CPT 93979 TC
|
| Hospital Charge Code |
2544905
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$118.89 |
| Max. Negotiated Rate |
$727.70 |
| Rate for Payer: Aetna Commercial |
$727.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$658.76
|
| Rate for Payer: Cash Price |
$229.80
|
| Rate for Payer: Cash Price |
$229.80
|
| Rate for Payer: Cash Price |
$229.80
|
| Rate for Payer: Cigna Commercial |
$727.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$118.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$459.60
|
| Rate for Payer: Health EOS Commercial |
$697.06
|
| Rate for Payer: HFN Commercial |
$727.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$332.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$332.60
|
| Rate for Payer: Multiplan Commercial |
$612.80
|
| Rate for Payer: Preferred Network Access Commercial |
$727.70
|
| Rate for Payer: Quartz Beloit One Network |
$337.04
|
| Rate for Payer: Quartz Commercial |
$436.62
|
| Rate for Payer: The Alliance Commercial |
$383.00
|
| Rate for Payer: United Healthcare Medicaid |
$118.89
|
| Rate for Payer: WEA Trust Commercial |
$421.30
|
| Rate for Payer: WPS Commercial |
$567.38
|
|
|
US Inferior Vena Cava Duplex Limited
|
Facility
|
IP
|
$766.00
|
|
|
Service Code
|
CPT 93979 TC
|
| Hospital Charge Code |
2544905
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$375.34 |
| Max. Negotiated Rate |
$704.72 |
| Rate for Payer: Aetna Commercial |
$689.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$658.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.98
|
| Rate for Payer: Cash Price |
$229.80
|
| Rate for Payer: Cigna Commercial |
$704.72
|
| Rate for Payer: Health EOS Commercial |
$681.74
|
| Rate for Payer: HFN Commercial |
$704.72
|
| Rate for Payer: Multiplan Commercial |
$612.80
|
| Rate for Payer: NAPHCARE Commercial |
$459.60
|
| Rate for Payer: Preferred Network Access Commercial |
$704.72
|
| Rate for Payer: Quartz Beloit One Network |
$375.34
|
| Rate for Payer: Quartz Commercial |
$459.60
|
| Rate for Payer: WEA Trust Commercial |
$421.30
|
| Rate for Payer: WPS Commercial |
$567.38
|
|
|
US Inferior Vena Cava Duplex Limited
|
Facility
|
OP
|
$766.00
|
|
|
Service Code
|
CPT 93979 TC
|
| Hospital Charge Code |
2544905
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$689.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$658.76
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| 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: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.98
|
| 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 |
$229.80
|
| Rate for Payer: Cash Price |
$229.80
|
| Rate for Payer: Cash Price |
$229.80
|
| Rate for Payer: Cigna Commercial |
$704.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$428.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$681.74
|
| Rate for Payer: HFN Commercial |
$704.72
|
| 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 |
$612.80
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$704.72
|
| Rate for Payer: Quartz Beloit One Network |
$375.34
|
| Rate for Payer: Quartz Commercial |
$497.90
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$421.30
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$567.38
|
|
|
US Kidney Transplant Left
|
Professional
|
Both
|
$1,332.00
|
|
|
Service Code
|
CPT 76776 TC
|
| Hospital Charge Code |
2544911
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$403.34 |
| Max. Negotiated Rate |
$1,265.40 |
| Rate for Payer: Aetna Commercial |
$1,265.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,145.52
|
| Rate for Payer: Cash Price |
$399.60
|
| Rate for Payer: Cash Price |
$399.60
|
| Rate for Payer: Cash Price |
$399.60
|
| Rate for Payer: Cigna Commercial |
$1,265.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$666.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$799.20
|
| Rate for Payer: Health EOS Commercial |
$1,212.12
|
| Rate for Payer: HFN Commercial |
$1,265.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$403.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$403.34
|
| Rate for Payer: Multiplan Commercial |
$1,065.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,265.40
|
| Rate for Payer: Quartz Beloit One Network |
$586.08
|
| Rate for Payer: Quartz Commercial |
$759.24
|
| Rate for Payer: The Alliance Commercial |
$666.00
|
| Rate for Payer: WEA Trust Commercial |
$732.60
|
| Rate for Payer: WPS Commercial |
$986.61
|
|
|
US Kidney Transplant Left
|
Facility
|
IP
|
$1,332.00
|
|
|
Service Code
|
CPT 76776 TC
|
| Hospital Charge Code |
2544911
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$652.68 |
| Max. Negotiated Rate |
$1,225.44 |
| Rate for Payer: Aetna Commercial |
$1,198.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,145.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$705.96
|
| Rate for Payer: Cash Price |
$399.60
|
| Rate for Payer: Cigna Commercial |
$1,225.44
|
| Rate for Payer: Health EOS Commercial |
$1,185.48
|
| Rate for Payer: HFN Commercial |
$1,225.44
|
| Rate for Payer: Multiplan Commercial |
$1,065.60
|
| Rate for Payer: NAPHCARE Commercial |
$799.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,225.44
|
| Rate for Payer: Quartz Beloit One Network |
$652.68
|
| Rate for Payer: Quartz Commercial |
$799.20
|
| Rate for Payer: WEA Trust Commercial |
$732.60
|
| Rate for Payer: WPS Commercial |
$986.61
|
|
|
US Kidney Transplant Left
|
Facility
|
OP
|
$1,332.00
|
|
|
Service Code
|
CPT 76776 TC
|
| Hospital Charge Code |
2544911
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,225.44 |
| Rate for Payer: Aetna Commercial |
$1,198.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,145.52
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| 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: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$705.96
|
| 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 |
$399.60
|
| Rate for Payer: Cash Price |
$399.60
|
| Rate for Payer: Cash Price |
$399.60
|
| Rate for Payer: Cigna Commercial |
$1,225.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$745.39
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,185.48
|
| Rate for Payer: HFN Commercial |
$1,225.44
|
| 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 |
$1,065.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,225.44
|
| Rate for Payer: Quartz Beloit One Network |
$652.68
|
| Rate for Payer: Quartz Commercial |
$865.80
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$732.60
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$986.61
|
|
|
US Kidney Transplant Right
|
Facility
|
IP
|
$1,383.00
|
|
|
Service Code
|
CPT 76776 TC
|
| Hospital Charge Code |
2544913
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$677.67 |
| Max. Negotiated Rate |
$1,272.36 |
| Rate for Payer: Aetna Commercial |
$1,244.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,189.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$732.99
|
| Rate for Payer: Cash Price |
$414.90
|
| Rate for Payer: Cigna Commercial |
$1,272.36
|
| Rate for Payer: Health EOS Commercial |
$1,230.87
|
| Rate for Payer: HFN Commercial |
$1,272.36
|
| Rate for Payer: Multiplan Commercial |
$1,106.40
|
| Rate for Payer: NAPHCARE Commercial |
$829.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,272.36
|
| Rate for Payer: Quartz Beloit One Network |
$677.67
|
| Rate for Payer: Quartz Commercial |
$829.80
|
| Rate for Payer: WEA Trust Commercial |
$760.65
|
| Rate for Payer: WPS Commercial |
$1,024.39
|
|
|
US Kidney Transplant Right
|
Professional
|
Both
|
$1,383.00
|
|
|
Service Code
|
CPT 76776 TC
|
| Hospital Charge Code |
2544913
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$403.34 |
| Max. Negotiated Rate |
$1,313.85 |
| Rate for Payer: Aetna Commercial |
$1,313.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,189.38
|
| Rate for Payer: Cash Price |
$414.90
|
| Rate for Payer: Cash Price |
$414.90
|
| Rate for Payer: Cash Price |
$414.90
|
| Rate for Payer: Cigna Commercial |
$1,313.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$691.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$829.80
|
| Rate for Payer: Health EOS Commercial |
$1,258.53
|
| Rate for Payer: HFN Commercial |
$1,313.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$403.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$403.34
|
| Rate for Payer: Multiplan Commercial |
$1,106.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,313.85
|
| Rate for Payer: Quartz Beloit One Network |
$608.52
|
| Rate for Payer: Quartz Commercial |
$788.31
|
| Rate for Payer: The Alliance Commercial |
$691.50
|
| Rate for Payer: WEA Trust Commercial |
$760.65
|
| Rate for Payer: WPS Commercial |
$1,024.39
|
|
|
US Kidney Transplant Right
|
Facility
|
OP
|
$1,383.00
|
|
|
Service Code
|
CPT 76776 TC
|
| Hospital Charge Code |
2544913
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,272.36 |
| Rate for Payer: Aetna Commercial |
$1,244.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,189.38
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| 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: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$732.99
|
| 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 |
$414.90
|
| Rate for Payer: Cash Price |
$414.90
|
| Rate for Payer: Cash Price |
$414.90
|
| Rate for Payer: Cigna Commercial |
$1,272.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$773.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,230.87
|
| Rate for Payer: HFN Commercial |
$1,272.36
|
| 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 |
$1,106.40
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,272.36
|
| Rate for Payer: Quartz Beloit One Network |
$677.67
|
| Rate for Payer: Quartz Commercial |
$898.95
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$760.65
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,024.39
|
|
|
US Left Lower Quadrant
|
Professional
|
Both
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711775
|
| Min. Negotiated Rate |
$310.04 |
| Max. Negotiated Rate |
$1,424.05 |
| Rate for Payer: Aetna Commercial |
$1,424.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,424.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$749.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$899.40
|
| Rate for Payer: Health EOS Commercial |
$1,364.09
|
| Rate for Payer: HFN Commercial |
$1,424.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$310.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$310.04
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,424.05
|
| Rate for Payer: Quartz Beloit One Network |
$659.56
|
| Rate for Payer: Quartz Commercial |
$854.43
|
| Rate for Payer: The Alliance Commercial |
$749.50
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Left Lower Quadrant
|
Facility
|
IP
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544915
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$763.91 |
| Max. Negotiated Rate |
$1,434.28 |
| Rate for Payer: Aetna Commercial |
$1,403.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$826.27
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cigna Commercial |
$1,434.28
|
| Rate for Payer: Health EOS Commercial |
$1,387.51
|
| Rate for Payer: HFN Commercial |
$1,434.28
|
| Rate for Payer: Multiplan Commercial |
$1,247.20
|
| Rate for Payer: NAPHCARE Commercial |
$935.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,434.28
|
| Rate for Payer: Quartz Beloit One Network |
$763.91
|
| Rate for Payer: Quartz Commercial |
$935.40
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
|
US Left Lower Quadrant
|
Facility
|
OP
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544915
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,434.28 |
| Rate for Payer: Aetna Commercial |
$1,403.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| 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: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$826.27
|
| 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 |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cigna Commercial |
$1,434.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$872.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,387.51
|
| Rate for Payer: HFN Commercial |
$1,434.28
|
| 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 |
$1,247.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,434.28
|
| Rate for Payer: Quartz Beloit One Network |
$763.91
|
| Rate for Payer: Quartz Commercial |
$1,013.35
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
|
US Left Lower Quadrant
|
Facility
|
OP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711775
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,379.08 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$974.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$749.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$719.52
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$794.47
|
| 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 |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,379.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$838.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,334.11
|
| Rate for Payer: HFN Commercial |
$1,379.08
|
| 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 |
$1,199.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,379.08
|
| Rate for Payer: Quartz Beloit One Network |
$734.51
|
| Rate for Payer: Quartz Commercial |
$974.35
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Left Lower Quadrant
|
Facility
|
IP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711775
|
| Min. Negotiated Rate |
$734.51 |
| Max. Negotiated Rate |
$1,379.08 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$794.47
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,379.08
|
| Rate for Payer: Health EOS Commercial |
$1,334.11
|
| Rate for Payer: HFN Commercial |
$1,379.08
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: NAPHCARE Commercial |
$899.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,379.08
|
| Rate for Payer: Quartz Beloit One Network |
$734.51
|
| Rate for Payer: Quartz Commercial |
$899.40
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Left Lower Quadrant
|
Professional
|
Both
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544915
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$211.55 |
| Max. Negotiated Rate |
$1,481.05 |
| Rate for Payer: Aetna Commercial |
$1,481.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cigna Commercial |
$1,481.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$779.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$935.40
|
| Rate for Payer: Health EOS Commercial |
$1,418.69
|
| Rate for Payer: HFN Commercial |
$1,481.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$211.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.55
|
| Rate for Payer: Multiplan Commercial |
$1,247.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,481.05
|
| Rate for Payer: Quartz Beloit One Network |
$685.96
|
| Rate for Payer: Quartz Commercial |
$888.63
|
| Rate for Payer: The Alliance Commercial |
$779.50
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
|
US Left Upper Quadrant
|
Professional
|
Both
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544918
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$211.55 |
| Max. Negotiated Rate |
$1,481.05 |
| Rate for Payer: Aetna Commercial |
$1,481.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cigna Commercial |
$1,481.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$779.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$935.40
|
| Rate for Payer: Health EOS Commercial |
$1,418.69
|
| Rate for Payer: HFN Commercial |
$1,481.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$211.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.55
|
| Rate for Payer: Multiplan Commercial |
$1,247.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,481.05
|
| Rate for Payer: Quartz Beloit One Network |
$685.96
|
| Rate for Payer: Quartz Commercial |
$888.63
|
| Rate for Payer: The Alliance Commercial |
$779.50
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
