|
US ED Soft Tissue Axilla
|
Facility
IP
|
$552.00
|
|
|
Service Code
|
CPT 76882 TC
|
| Hospital Charge Code |
2587124
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$270.48 |
| Max. Negotiated Rate |
$507.84 |
| Rate for Payer: Aetna Commercial |
$496.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$292.56
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$507.84
|
| Rate for Payer: Health EOS Commercial |
$491.28
|
| Rate for Payer: HFN Commercial |
$507.84
|
| Rate for Payer: Multiplan Commercial |
$441.60
|
| Rate for Payer: NAPHCARE Commercial |
$331.20
|
| Rate for Payer: Preferred Network Access Commercial |
$507.84
|
| Rate for Payer: Quartz Beloit One Network |
$270.48
|
| Rate for Payer: Quartz Commercial |
$331.20
|
| Rate for Payer: WEA Trust Commercial |
$303.60
|
| Rate for Payer: WPS Commercial |
$408.87
|
|
|
US ED Soft Tissue Axilla
|
Facility
OP
|
$964.00
|
|
|
Service Code
|
CPT 76882
|
| Hospital Charge Code |
2552820
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$886.88 |
| Rate for Payer: Aetna Commercial |
$867.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$829.04
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$626.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$482.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$462.72
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$510.92
|
| 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 |
$289.20
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Cigna Commercial |
$886.88
|
| 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 |
$857.96
|
| Rate for Payer: HFN Commercial |
$886.88
|
| 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 |
$771.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$886.88
|
| Rate for Payer: Quartz Beloit One Network |
$472.36
|
| Rate for Payer: Quartz Commercial |
$626.60
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$194.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$530.20
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$714.03
|
|
|
US ED Soft Tissue Breast
|
Facility
OP
|
$479.00
|
|
|
Service Code
|
CPT 76641 TC
|
| Hospital Charge Code |
3000469
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$134.12 |
| Max. Negotiated Rate |
$1,916.00 |
| Rate for Payer: Aetna Commercial |
$431.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Aetna Managed Medicare |
$134.12
|
| 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 |
$253.87
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$440.68
|
| Rate for Payer: Health EOS Commercial |
$426.31
|
| Rate for Payer: HFN Commercial |
$440.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$359.25
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: NAPHCARE Commercial |
$287.40
|
| Rate for Payer: Preferred Network Access Commercial |
$440.68
|
| Rate for Payer: Quartz Beloit One Network |
$234.71
|
| Rate for Payer: Quartz Commercial |
$311.35
|
| Rate for Payer: Quartz Medicare Advantage |
$287.40
|
| Rate for Payer: The Alliance Commercial |
$1,916.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
US ED Soft Tissue Breast
|
Professional
|
$479.00
|
|
|
Service Code
|
CPT 76641 TC
|
| Hospital Charge Code |
3000469
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$66.42 |
| Max. Negotiated Rate |
$455.05 |
| Rate for Payer: Aetna Commercial |
$455.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| 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 |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$455.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$239.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.42
|
| Rate for Payer: Health EOS Commercial |
$435.89
|
| 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 |
$383.20
|
| Rate for Payer: Preferred Network Access Commercial |
$455.05
|
| Rate for Payer: Quartz Beloit One Network |
$210.76
|
| Rate for Payer: Quartz Commercial |
$273.03
|
| 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 |
$263.45
|
| Rate for Payer: WPS Commercial |
$332.10
|
|
|
US ED Soft Tissue Breast
|
Facility
IP
|
$479.00
|
|
|
Service Code
|
CPT 76641 TC
|
| Hospital Charge Code |
3000469
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$234.71 |
| Max. Negotiated Rate |
$440.68 |
| Rate for Payer: Aetna Commercial |
$431.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.87
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$440.68
|
| Rate for Payer: Health EOS Commercial |
$426.31
|
| Rate for Payer: HFN Commercial |
$440.68
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: NAPHCARE Commercial |
$287.40
|
| Rate for Payer: Preferred Network Access Commercial |
$440.68
|
| Rate for Payer: Quartz Beloit One Network |
$234.71
|
| Rate for Payer: Quartz Commercial |
$287.40
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
US ED Soft Tissue Buttock
|
Professional
|
$387.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
2587127
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$24.25 |
| Max. Negotiated Rate |
$367.65 |
| Rate for Payer: Aetna Commercial |
$367.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$332.82
|
| Rate for Payer: Aetna Managed Medicare |
$24.25
|
| Rate for Payer: Anthem Medicare Advantage |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.25
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$367.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$193.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.25
|
| Rate for Payer: Health EOS Commercial |
$352.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$81.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.25
|
| Rate for Payer: Multiplan Commercial |
$309.60
|
| Rate for Payer: Preferred Network Access Commercial |
$367.65
|
| Rate for Payer: Quartz Beloit One Network |
$170.28
|
| Rate for Payer: Quartz Commercial |
$220.59
|
| Rate for Payer: Quartz Medicare Advantage |
$24.25
|
| Rate for Payer: The Alliance Commercial |
$92.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.25
|
| Rate for Payer: WEA Trust Commercial |
$212.85
|
| Rate for Payer: WPS Commercial |
$121.25
|
|
|
US ED Soft Tissue Buttock
|
Facility
OP
|
$387.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
2587127
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.36 |
| Max. Negotiated Rate |
$1,548.00 |
| Rate for Payer: Aetna Commercial |
$348.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$332.82
|
| Rate for Payer: Aetna Managed Medicare |
$108.36
|
| 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 |
$205.11
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$356.04
|
| Rate for Payer: Health EOS Commercial |
$344.43
|
| Rate for Payer: HFN Commercial |
$356.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$290.25
|
| Rate for Payer: Multiplan Commercial |
$309.60
|
| Rate for Payer: NAPHCARE Commercial |
$232.20
|
| Rate for Payer: Preferred Network Access Commercial |
$356.04
|
| Rate for Payer: Quartz Beloit One Network |
$189.63
|
| Rate for Payer: Quartz Commercial |
$251.55
|
| Rate for Payer: Quartz Medicare Advantage |
$232.20
|
| Rate for Payer: The Alliance Commercial |
$1,548.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$212.85
|
| Rate for Payer: WPS Commercial |
$286.65
|
|
|
US ED Soft Tissue Buttock
|
Facility
IP
|
$387.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
2587127
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$189.63 |
| Max. Negotiated Rate |
$356.04 |
| Rate for Payer: Aetna Commercial |
$348.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.11
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$356.04
|
| Rate for Payer: Health EOS Commercial |
$344.43
|
| Rate for Payer: HFN Commercial |
$356.04
|
| Rate for Payer: Multiplan Commercial |
$309.60
|
| Rate for Payer: NAPHCARE Commercial |
$232.20
|
| Rate for Payer: Preferred Network Access Commercial |
$356.04
|
| Rate for Payer: Quartz Beloit One Network |
$189.63
|
| Rate for Payer: Quartz Commercial |
$232.20
|
| Rate for Payer: WEA Trust Commercial |
$212.85
|
| Rate for Payer: WPS Commercial |
$286.65
|
|
|
US ED Soft Tissue Chest Wall
|
Professional
|
$1,020.00
|
|
|
Service Code
|
CPT 76604
|
| Hospital Charge Code |
2552821
|
| Min. Negotiated Rate |
$54.65 |
| Max. Negotiated Rate |
$969.00 |
| Rate for Payer: Aetna Commercial |
$969.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$877.20
|
| 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 |
$306.00
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$969.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$510.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.65
|
| Rate for Payer: Health EOS Commercial |
$928.20
|
| 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 |
$816.00
|
| Rate for Payer: Preferred Network Access Commercial |
$969.00
|
| Rate for Payer: Quartz Beloit One Network |
$448.80
|
| Rate for Payer: Quartz Commercial |
$581.40
|
| 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 |
$561.00
|
| Rate for Payer: WPS Commercial |
$273.25
|
|
|
US ED Soft Tissue Chest Wall
|
Professional
|
$483.00
|
|
|
Service Code
|
CPT 76604 TC
|
| Hospital Charge Code |
2587130
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$28.11 |
| Max. Negotiated Rate |
$458.85 |
| Rate for Payer: Aetna Commercial |
$458.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$415.38
|
| 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 |
$144.90
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cigna Commercial |
$458.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$241.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.11
|
| Rate for Payer: Health EOS Commercial |
$439.53
|
| 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 |
$386.40
|
| Rate for Payer: Preferred Network Access Commercial |
$458.85
|
| Rate for Payer: Quartz Beloit One Network |
$212.52
|
| Rate for Payer: Quartz Commercial |
$275.31
|
| 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 |
$265.65
|
| Rate for Payer: WPS Commercial |
$140.55
|
|
|
US ED Soft Tissue Chest Wall
|
Facility
IP
|
$1,020.00
|
|
|
Service Code
|
CPT 76604
|
| Hospital Charge Code |
2552821
|
| Min. Negotiated Rate |
$499.80 |
| Max. Negotiated Rate |
$938.40 |
| Rate for Payer: Aetna Commercial |
$918.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$540.60
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$938.40
|
| Rate for Payer: Health EOS Commercial |
$907.80
|
| Rate for Payer: HFN Commercial |
$938.40
|
| Rate for Payer: Multiplan Commercial |
$816.00
|
| Rate for Payer: NAPHCARE Commercial |
$612.00
|
| Rate for Payer: Preferred Network Access Commercial |
$938.40
|
| Rate for Payer: Quartz Beloit One Network |
$499.80
|
| Rate for Payer: Quartz Commercial |
$612.00
|
| Rate for Payer: WEA Trust Commercial |
$561.00
|
| Rate for Payer: WPS Commercial |
$755.51
|
|
|
US ED Soft Tissue Chest Wall
|
Facility
OP
|
$1,020.00
|
|
|
Service Code
|
CPT 76604
|
| Hospital Charge Code |
2552821
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$2,089.48 |
| Rate for Payer: Aetna Commercial |
$918.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$877.20
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$663.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$510.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$489.60
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$540.60
|
| 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 |
$306.00
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$938.40
|
| 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 |
$907.80
|
| Rate for Payer: HFN Commercial |
$938.40
|
| 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 |
$816.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$938.40
|
| Rate for Payer: Quartz Beloit One Network |
$499.80
|
| Rate for Payer: Quartz Commercial |
$663.00
|
| 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 |
$561.00
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$755.51
|
|
|
US ED Soft Tissue Chest Wall
|
Facility
IP
|
$483.00
|
|
|
Service Code
|
CPT 76604 TC
|
| Hospital Charge Code |
2587130
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$236.67 |
| Max. Negotiated Rate |
$444.36 |
| Rate for Payer: Aetna Commercial |
$434.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.99
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cigna Commercial |
$444.36
|
| Rate for Payer: Health EOS Commercial |
$429.87
|
| Rate for Payer: HFN Commercial |
$444.36
|
| Rate for Payer: Multiplan Commercial |
$386.40
|
| Rate for Payer: NAPHCARE Commercial |
$289.80
|
| Rate for Payer: Preferred Network Access Commercial |
$444.36
|
| Rate for Payer: Quartz Beloit One Network |
$236.67
|
| Rate for Payer: Quartz Commercial |
$289.80
|
| Rate for Payer: WEA Trust Commercial |
$265.65
|
| Rate for Payer: WPS Commercial |
$357.76
|
|
|
US ED Soft Tissue Chest Wall
|
Facility
OP
|
$483.00
|
|
|
Service Code
|
CPT 76604 TC
|
| Hospital Charge Code |
2587130
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$135.24 |
| Max. Negotiated Rate |
$1,932.00 |
| Rate for Payer: Aetna Commercial |
$434.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$415.38
|
| Rate for Payer: Aetna Managed Medicare |
$135.24
|
| 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 |
$255.99
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cigna Commercial |
$444.36
|
| Rate for Payer: Health EOS Commercial |
$429.87
|
| Rate for Payer: HFN Commercial |
$444.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$362.25
|
| Rate for Payer: Multiplan Commercial |
$386.40
|
| Rate for Payer: NAPHCARE Commercial |
$289.80
|
| Rate for Payer: Preferred Network Access Commercial |
$444.36
|
| Rate for Payer: Quartz Beloit One Network |
$236.67
|
| Rate for Payer: Quartz Commercial |
$313.95
|
| Rate for Payer: Quartz Medicare Advantage |
$289.80
|
| Rate for Payer: The Alliance Commercial |
$1,932.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$265.65
|
| Rate for Payer: WPS Commercial |
$357.76
|
|
|
US ED Soft Tissue Groin
|
Professional
|
$471.00
|
|
| Hospital Charge Code |
2587133
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$207.24 |
| Max. Negotiated Rate |
$447.45 |
| Rate for Payer: Aetna Commercial |
$447.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.06
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cigna Commercial |
$447.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$235.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$282.60
|
| Rate for Payer: Health EOS Commercial |
$428.61
|
| Rate for Payer: Multiplan Commercial |
$376.80
|
| Rate for Payer: Preferred Network Access Commercial |
$447.45
|
| Rate for Payer: Quartz Beloit One Network |
$207.24
|
| Rate for Payer: Quartz Commercial |
$268.47
|
| Rate for Payer: The Alliance Commercial |
$235.50
|
| Rate for Payer: WEA Trust Commercial |
$259.05
|
| Rate for Payer: WPS Commercial |
$348.87
|
|
|
US ED Soft Tissue Groin
|
Facility
IP
|
$471.00
|
|
| Hospital Charge Code |
2587133
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$230.79 |
| Max. Negotiated Rate |
$433.32 |
| Rate for Payer: Aetna Commercial |
$423.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.63
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cigna Commercial |
$433.32
|
| Rate for Payer: Health EOS Commercial |
$419.19
|
| Rate for Payer: HFN Commercial |
$433.32
|
| Rate for Payer: Multiplan Commercial |
$376.80
|
| Rate for Payer: NAPHCARE Commercial |
$282.60
|
| Rate for Payer: Preferred Network Access Commercial |
$433.32
|
| Rate for Payer: Quartz Beloit One Network |
$230.79
|
| Rate for Payer: Quartz Commercial |
$282.60
|
| Rate for Payer: WEA Trust Commercial |
$259.05
|
| Rate for Payer: WPS Commercial |
$348.87
|
|
|
US ED Soft Tissue Groin
|
Facility
OP
|
$471.00
|
|
| Hospital Charge Code |
2587133
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$131.88 |
| Max. Negotiated Rate |
$1,884.00 |
| Rate for Payer: Aetna Commercial |
$423.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.06
|
| Rate for Payer: Aetna Managed Medicare |
$131.88
|
| 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 |
$249.63
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cigna Commercial |
$433.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$263.57
|
| Rate for Payer: Health EOS Commercial |
$419.19
|
| Rate for Payer: HFN Commercial |
$433.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$353.25
|
| Rate for Payer: Multiplan Commercial |
$376.80
|
| Rate for Payer: NAPHCARE Commercial |
$282.60
|
| Rate for Payer: Preferred Network Access Commercial |
$433.32
|
| Rate for Payer: Quartz Beloit One Network |
$230.79
|
| Rate for Payer: Quartz Commercial |
$306.15
|
| Rate for Payer: Quartz Medicare Advantage |
$282.60
|
| Rate for Payer: The Alliance Commercial |
$1,884.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$259.05
|
| Rate for Payer: WPS Commercial |
$348.87
|
|
|
US ED Soft Tissue Lower Back
|
Facility
OP
|
$590.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587136
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$165.20 |
| Max. Negotiated Rate |
$2,360.00 |
| Rate for Payer: Aetna Commercial |
$531.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$507.40
|
| Rate for Payer: Aetna Managed Medicare |
$165.20
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$312.70
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$542.80
|
| Rate for Payer: Health EOS Commercial |
$525.10
|
| Rate for Payer: HFN Commercial |
$542.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$442.50
|
| Rate for Payer: Multiplan Commercial |
$472.00
|
| Rate for Payer: NAPHCARE Commercial |
$354.00
|
| Rate for Payer: Preferred Network Access Commercial |
$542.80
|
| Rate for Payer: Quartz Beloit One Network |
$289.10
|
| Rate for Payer: Quartz Commercial |
$383.50
|
| Rate for Payer: Quartz Medicare Advantage |
$354.00
|
| Rate for Payer: The Alliance Commercial |
$2,360.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$324.50
|
| Rate for Payer: WPS Commercial |
$437.01
|
|
|
US ED Soft Tissue Lower Back
|
Professional
|
$590.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587136
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$58.05 |
| Max. Negotiated Rate |
$560.50 |
| Rate for Payer: Aetna Commercial |
$560.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$507.40
|
| Rate for Payer: Aetna Managed Medicare |
$58.05
|
| Rate for Payer: Anthem Medicare Advantage |
$58.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$58.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$58.05
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$560.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$295.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.05
|
| Rate for Payer: Health EOS Commercial |
$536.90
|
| 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: Independent Care Health Plan Medicare |
$58.05
|
| Rate for Payer: Multiplan Commercial |
$472.00
|
| Rate for Payer: Preferred Network Access Commercial |
$560.50
|
| Rate for Payer: Quartz Beloit One Network |
$259.60
|
| Rate for Payer: Quartz Commercial |
$336.30
|
| Rate for Payer: Quartz Medicare Advantage |
$58.05
|
| Rate for Payer: The Alliance Commercial |
$220.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$58.05
|
| Rate for Payer: WEA Trust Commercial |
$324.50
|
| Rate for Payer: WPS Commercial |
$290.25
|
|
|
US ED Soft Tissue Lower Back
|
Facility
OP
|
$1,441.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
2552823
|
| Min. Negotiated Rate |
$13.28 |
| Max. Negotiated Rate |
$1,325.72 |
| Rate for Payer: Aetna Commercial |
$1,296.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,239.26
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$936.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$720.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$691.68
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$763.73
|
| 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 |
$432.30
|
| Rate for Payer: Cash Price |
$432.30
|
| Rate for Payer: Cigna Commercial |
$1,325.72
|
| 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 |
$1,282.49
|
| Rate for Payer: HFN Commercial |
$1,325.72
|
| 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 |
$1,152.80
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,325.72
|
| Rate for Payer: Quartz Beloit One Network |
$706.09
|
| Rate for Payer: Quartz Commercial |
$936.65
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$13.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$792.55
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,067.35
|
|
|
US ED Soft Tissue Lower Back
|
Facility
IP
|
$1,441.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
2552823
|
| Min. Negotiated Rate |
$706.09 |
| Max. Negotiated Rate |
$1,325.72 |
| Rate for Payer: Aetna Commercial |
$1,296.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$763.73
|
| Rate for Payer: Cash Price |
$432.30
|
| Rate for Payer: Cigna Commercial |
$1,325.72
|
| Rate for Payer: Health EOS Commercial |
$1,282.49
|
| Rate for Payer: HFN Commercial |
$1,325.72
|
| Rate for Payer: Multiplan Commercial |
$1,152.80
|
| Rate for Payer: NAPHCARE Commercial |
$864.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,325.72
|
| Rate for Payer: Quartz Beloit One Network |
$706.09
|
| Rate for Payer: Quartz Commercial |
$864.60
|
| Rate for Payer: WEA Trust Commercial |
$792.55
|
| Rate for Payer: WPS Commercial |
$1,067.35
|
|
|
US ED Soft Tissue Lower Back
|
Professional
|
$1,441.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
2552823
|
| Min. Negotiated Rate |
$85.23 |
| Max. Negotiated Rate |
$1,368.95 |
| Rate for Payer: Aetna Commercial |
$1,368.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,239.26
|
| Rate for Payer: Aetna Managed Medicare |
$85.23
|
| Rate for Payer: Anthem Medicare Advantage |
$85.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$85.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$85.23
|
| Rate for Payer: Cash Price |
$432.30
|
| Rate for Payer: Cash Price |
$432.30
|
| Rate for Payer: Cigna Commercial |
$1,368.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$720.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.23
|
| Rate for Payer: Health EOS Commercial |
$1,311.31
|
| 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: Independent Care Health Plan Medicare |
$85.23
|
| Rate for Payer: Multiplan Commercial |
$1,152.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,368.95
|
| Rate for Payer: Quartz Beloit One Network |
$634.04
|
| Rate for Payer: Quartz Commercial |
$821.37
|
| Rate for Payer: Quartz Medicare Advantage |
$85.23
|
| Rate for Payer: The Alliance Commercial |
$323.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$85.23
|
| Rate for Payer: WEA Trust Commercial |
$792.55
|
| Rate for Payer: WPS Commercial |
$426.15
|
|
|
US ED Soft Tissue Lower Back
|
Facility
IP
|
$590.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587136
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$289.10 |
| Max. Negotiated Rate |
$542.80 |
| Rate for Payer: Aetna Commercial |
$531.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$312.70
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$542.80
|
| Rate for Payer: Health EOS Commercial |
$525.10
|
| Rate for Payer: HFN Commercial |
$542.80
|
| Rate for Payer: Multiplan Commercial |
$472.00
|
| Rate for Payer: NAPHCARE Commercial |
$354.00
|
| Rate for Payer: Preferred Network Access Commercial |
$542.80
|
| Rate for Payer: Quartz Beloit One Network |
$289.10
|
| Rate for Payer: Quartz Commercial |
$354.00
|
| Rate for Payer: WEA Trust Commercial |
$324.50
|
| Rate for Payer: WPS Commercial |
$437.01
|
|
|
US ED Soft Tissue Lower Extremity
|
Facility
OP
|
$552.00
|
|
|
Service Code
|
CPT 76882 TC
|
| Hospital Charge Code |
2587139
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$154.56 |
| Max. Negotiated Rate |
$2,208.00 |
| Rate for Payer: Aetna Commercial |
$496.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$474.72
|
| Rate for Payer: Aetna Managed Medicare |
$154.56
|
| 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 |
$292.56
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$507.84
|
| Rate for Payer: Health EOS Commercial |
$491.28
|
| Rate for Payer: HFN Commercial |
$507.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$414.00
|
| Rate for Payer: Multiplan Commercial |
$441.60
|
| Rate for Payer: NAPHCARE Commercial |
$331.20
|
| Rate for Payer: Preferred Network Access Commercial |
$507.84
|
| Rate for Payer: Quartz Beloit One Network |
$270.48
|
| Rate for Payer: Quartz Commercial |
$358.80
|
| Rate for Payer: Quartz Medicare Advantage |
$331.20
|
| Rate for Payer: The Alliance Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$303.60
|
| Rate for Payer: WPS Commercial |
$408.87
|
|
|
US ED Soft Tissue Lower Extremity
|
Professional
|
$552.00
|
|
|
Service Code
|
CPT 76882 TC
|
| Hospital Charge Code |
2587139
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$524.40 |
| Rate for Payer: Aetna Commercial |
$524.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$474.72
|
| Rate for Payer: Aetna Managed Medicare |
$8.80
|
| Rate for Payer: Anthem Medicare Advantage |
$8.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.80
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$524.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$276.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.80
|
| Rate for Payer: Health EOS Commercial |
$502.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$111.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$111.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.80
|
| Rate for Payer: Multiplan Commercial |
$441.60
|
| Rate for Payer: Preferred Network Access Commercial |
$524.40
|
| Rate for Payer: Quartz Beloit One Network |
$242.88
|
| Rate for Payer: Quartz Commercial |
$314.64
|
| Rate for Payer: Quartz Medicare Advantage |
$8.80
|
| Rate for Payer: The Alliance Commercial |
$33.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.80
|
| Rate for Payer: WEA Trust Commercial |
$303.60
|
| Rate for Payer: WPS Commercial |
$44.00
|
|
