|
US Parotid
|
Facility
|
IP
|
$1,374.00
|
|
|
Service Code
|
CPT 76536
|
| Hospital Charge Code |
631477
|
| Min. Negotiated Rate |
$673.26 |
| Max. Negotiated Rate |
$1,264.08 |
| Rate for Payer: Aetna Commercial |
$1,236.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.22
|
| Rate for Payer: Cash Price |
$412.20
|
| Rate for Payer: Cigna Commercial |
$1,264.08
|
| Rate for Payer: Health EOS Commercial |
$1,222.86
|
| Rate for Payer: HFN Commercial |
$1,264.08
|
| Rate for Payer: Multiplan Commercial |
$1,099.20
|
| Rate for Payer: NAPHCARE Commercial |
$824.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,264.08
|
| Rate for Payer: Quartz Beloit One Network |
$673.26
|
| Rate for Payer: Quartz Commercial |
$824.40
|
| Rate for Payer: WEA Trust Commercial |
$755.70
|
| Rate for Payer: WPS Commercial |
$1,017.72
|
|
|
US Parotid
|
Facility
|
OP
|
$1,374.00
|
|
|
Service Code
|
CPT 76536
|
| Hospital Charge Code |
631477
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,264.08 |
| Rate for Payer: Aetna Commercial |
$1,236.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.64
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$893.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$687.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$659.52
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.22
|
| 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 |
$412.20
|
| Rate for Payer: Cash Price |
$412.20
|
| Rate for Payer: Cigna Commercial |
$1,264.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$768.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,222.86
|
| Rate for Payer: HFN Commercial |
$1,264.08
|
| 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 |
$1,099.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,264.08
|
| Rate for Payer: Quartz Beloit One Network |
$673.26
|
| Rate for Payer: Quartz Commercial |
$893.10
|
| 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 |
$755.70
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,017.72
|
|
|
US Pelvis Non-Ob Complete
|
Facility
|
IP
|
$1,789.00
|
|
|
Service Code
|
CPT 76856 TC
|
| Hospital Charge Code |
3072733
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$876.61 |
| Max. Negotiated Rate |
$1,645.88 |
| Rate for Payer: Aetna Commercial |
$1,610.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,538.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$948.17
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cigna Commercial |
$1,645.88
|
| Rate for Payer: Health EOS Commercial |
$1,592.21
|
| Rate for Payer: HFN Commercial |
$1,645.88
|
| Rate for Payer: Multiplan Commercial |
$1,431.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,073.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,645.88
|
| Rate for Payer: Quartz Beloit One Network |
$876.61
|
| Rate for Payer: Quartz Commercial |
$1,073.40
|
| Rate for Payer: WEA Trust Commercial |
$983.95
|
| Rate for Payer: WPS Commercial |
$1,325.11
|
|
|
US Pelvis Non-Ob Complete
|
Facility
|
OP
|
$1,789.00
|
|
|
Service Code
|
CPT 76856 TC
|
| Hospital Charge Code |
3072733
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,645.88 |
| Rate for Payer: Aetna Commercial |
$1,610.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,538.54
|
| 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 |
$948.17
|
| 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 |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cigna Commercial |
$1,645.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,001.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,592.21
|
| Rate for Payer: HFN Commercial |
$1,645.88
|
| 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 |
$1,431.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,645.88
|
| Rate for Payer: Quartz Beloit One Network |
$876.61
|
| Rate for Payer: Quartz Commercial |
$1,162.85
|
| 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 |
$983.95
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,325.11
|
|
|
US Pelvis Non-Ob Complete
|
Professional
|
Both
|
$1,789.00
|
|
|
Service Code
|
CPT 76856 TC
|
| Hospital Charge Code |
3072733
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$259.10 |
| Max. Negotiated Rate |
$1,699.55 |
| Rate for Payer: Aetna Commercial |
$1,699.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,538.54
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cigna Commercial |
$1,699.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$894.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,073.40
|
| Rate for Payer: Health EOS Commercial |
$1,627.99
|
| Rate for Payer: HFN Commercial |
$1,699.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$259.10
|
| Rate for Payer: Multiplan Commercial |
$1,431.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,699.55
|
| Rate for Payer: Quartz Beloit One Network |
$787.16
|
| Rate for Payer: Quartz Commercial |
$1,019.73
|
| Rate for Payer: The Alliance Commercial |
$894.50
|
| Rate for Payer: WEA Trust Commercial |
$983.95
|
| Rate for Payer: WPS Commercial |
$1,325.11
|
|
|
US Pelvis Non-OB Complete
|
Professional
|
Both
|
$1,513.00
|
|
|
Service Code
|
CPT 76856
|
| Hospital Charge Code |
630929
|
| Min. Negotiated Rate |
$374.57 |
| Max. Negotiated Rate |
$1,437.35 |
| Rate for Payer: Aetna Commercial |
$1,437.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,301.18
|
| Rate for Payer: Cash Price |
$453.90
|
| Rate for Payer: Cash Price |
$453.90
|
| Rate for Payer: Cash Price |
$453.90
|
| Rate for Payer: Cigna Commercial |
$1,437.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$756.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$907.80
|
| Rate for Payer: Health EOS Commercial |
$1,376.83
|
| Rate for Payer: HFN Commercial |
$1,437.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$374.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$374.57
|
| Rate for Payer: Multiplan Commercial |
$1,210.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,437.35
|
| Rate for Payer: Quartz Beloit One Network |
$665.72
|
| Rate for Payer: Quartz Commercial |
$862.41
|
| Rate for Payer: The Alliance Commercial |
$756.50
|
| Rate for Payer: WEA Trust Commercial |
$832.15
|
| Rate for Payer: WPS Commercial |
$1,120.68
|
|
|
US Pelvis Non-OB Complete
|
Facility
|
IP
|
$1,513.00
|
|
|
Service Code
|
CPT 76856
|
| Hospital Charge Code |
630929
|
| Min. Negotiated Rate |
$741.37 |
| Max. Negotiated Rate |
$1,391.96 |
| Rate for Payer: Aetna Commercial |
$1,361.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,301.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$801.89
|
| Rate for Payer: Cash Price |
$453.90
|
| Rate for Payer: Cigna Commercial |
$1,391.96
|
| Rate for Payer: Health EOS Commercial |
$1,346.57
|
| Rate for Payer: HFN Commercial |
$1,391.96
|
| Rate for Payer: Multiplan Commercial |
$1,210.40
|
| Rate for Payer: NAPHCARE Commercial |
$907.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,391.96
|
| Rate for Payer: Quartz Beloit One Network |
$741.37
|
| Rate for Payer: Quartz Commercial |
$907.80
|
| Rate for Payer: WEA Trust Commercial |
$832.15
|
| Rate for Payer: WPS Commercial |
$1,120.68
|
|
|
US Pelvis Non-OB Complete
|
Professional
|
Both
|
$1,789.00
|
|
|
Service Code
|
CPT 76856 TC
|
| Hospital Charge Code |
2544942
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$259.10 |
| Max. Negotiated Rate |
$1,699.55 |
| Rate for Payer: Aetna Commercial |
$1,699.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,538.54
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cigna Commercial |
$1,699.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$894.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,073.40
|
| Rate for Payer: Health EOS Commercial |
$1,627.99
|
| Rate for Payer: HFN Commercial |
$1,699.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$259.10
|
| Rate for Payer: Multiplan Commercial |
$1,431.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,699.55
|
| Rate for Payer: Quartz Beloit One Network |
$787.16
|
| Rate for Payer: Quartz Commercial |
$1,019.73
|
| Rate for Payer: The Alliance Commercial |
$894.50
|
| Rate for Payer: WEA Trust Commercial |
$983.95
|
| Rate for Payer: WPS Commercial |
$1,325.11
|
|
|
US Pelvis Non-OB Complete
|
Facility
|
OP
|
$1,789.00
|
|
|
Service Code
|
CPT 76856 TC
|
| Hospital Charge Code |
2544942
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,645.88 |
| Rate for Payer: Aetna Commercial |
$1,610.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,538.54
|
| 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 |
$948.17
|
| 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 |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cigna Commercial |
$1,645.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,001.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,592.21
|
| Rate for Payer: HFN Commercial |
$1,645.88
|
| 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 |
$1,431.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,645.88
|
| Rate for Payer: Quartz Beloit One Network |
$876.61
|
| Rate for Payer: Quartz Commercial |
$1,162.85
|
| 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 |
$983.95
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,325.11
|
|
|
US Pelvis Non-OB Complete
|
Facility
|
OP
|
$1,513.00
|
|
|
Service Code
|
CPT 76856
|
| Hospital Charge Code |
630929
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,391.96 |
| Rate for Payer: Aetna Commercial |
$1,361.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,301.18
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$983.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$756.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$726.24
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$801.89
|
| 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 |
$453.90
|
| Rate for Payer: Cash Price |
$453.90
|
| Rate for Payer: Cigna Commercial |
$1,391.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$846.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,346.57
|
| Rate for Payer: HFN Commercial |
$1,391.96
|
| 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 |
$1,210.40
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,391.96
|
| Rate for Payer: Quartz Beloit One Network |
$741.37
|
| Rate for Payer: Quartz Commercial |
$983.45
|
| 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 |
$832.15
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,120.68
|
|
|
US Pelvis Non-OB Complete
|
Facility
|
IP
|
$1,789.00
|
|
|
Service Code
|
CPT 76856 TC
|
| Hospital Charge Code |
2544942
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$876.61 |
| Max. Negotiated Rate |
$1,645.88 |
| Rate for Payer: Aetna Commercial |
$1,610.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,538.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$948.17
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cigna Commercial |
$1,645.88
|
| Rate for Payer: Health EOS Commercial |
$1,592.21
|
| Rate for Payer: HFN Commercial |
$1,645.88
|
| Rate for Payer: Multiplan Commercial |
$1,431.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,073.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,645.88
|
| Rate for Payer: Quartz Beloit One Network |
$876.61
|
| Rate for Payer: Quartz Commercial |
$1,073.40
|
| Rate for Payer: WEA Trust Commercial |
$983.95
|
| Rate for Payer: WPS Commercial |
$1,325.11
|
|
|
US Pelvis Non-OB Limited
|
Professional
|
Both
|
$1,221.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
2544944
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.58 |
| Max. Negotiated Rate |
$1,159.95 |
| Rate for Payer: Aetna Commercial |
$1,159.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.06
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,159.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$610.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$732.60
|
| Rate for Payer: Health EOS Commercial |
$1,111.11
|
| Rate for Payer: HFN Commercial |
$1,159.95
|
| 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: Multiplan Commercial |
$976.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.95
|
| Rate for Payer: Quartz Beloit One Network |
$537.24
|
| Rate for Payer: Quartz Commercial |
$695.97
|
| Rate for Payer: The Alliance Commercial |
$610.50
|
| Rate for Payer: WEA Trust Commercial |
$671.55
|
| Rate for Payer: WPS Commercial |
$904.39
|
|
|
US Pelvis Non-OB Limited
|
Facility
|
OP
|
$1,221.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
2544944
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,123.32 |
| Rate for Payer: Aetna Commercial |
$1,098.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.06
|
| 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 |
$647.13
|
| 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 |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,123.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$683.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,086.69
|
| Rate for Payer: HFN Commercial |
$1,123.32
|
| 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 |
$976.80
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,123.32
|
| Rate for Payer: Quartz Beloit One Network |
$598.29
|
| Rate for Payer: Quartz Commercial |
$793.65
|
| 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 |
$671.55
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$904.39
|
|
|
US Pelvis Non-OB Limited
|
Professional
|
Both
|
$1,144.00
|
|
|
Service Code
|
CPT 76857
|
| Hospital Charge Code |
630925
|
| Min. Negotiated Rate |
$163.62 |
| Max. Negotiated Rate |
$1,086.80 |
| Rate for Payer: Aetna Commercial |
$1,086.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$983.84
|
| Rate for Payer: Cash Price |
$343.20
|
| Rate for Payer: Cash Price |
$343.20
|
| Rate for Payer: Cash Price |
$343.20
|
| Rate for Payer: Cigna Commercial |
$1,086.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$572.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$686.40
|
| Rate for Payer: Health EOS Commercial |
$1,041.04
|
| Rate for Payer: HFN Commercial |
$1,086.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$163.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$163.62
|
| Rate for Payer: Multiplan Commercial |
$915.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,086.80
|
| Rate for Payer: Quartz Beloit One Network |
$503.36
|
| Rate for Payer: Quartz Commercial |
$652.08
|
| Rate for Payer: The Alliance Commercial |
$572.00
|
| Rate for Payer: WEA Trust Commercial |
$629.20
|
| Rate for Payer: WPS Commercial |
$847.36
|
|
|
US Pelvis Non-OB Limited
|
Facility
|
IP
|
$1,144.00
|
|
|
Service Code
|
CPT 76857
|
| Hospital Charge Code |
630925
|
| Min. Negotiated Rate |
$560.56 |
| Max. Negotiated Rate |
$1,052.48 |
| Rate for Payer: Aetna Commercial |
$1,029.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$983.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$606.32
|
| Rate for Payer: Cash Price |
$343.20
|
| Rate for Payer: Cigna Commercial |
$1,052.48
|
| Rate for Payer: Health EOS Commercial |
$1,018.16
|
| Rate for Payer: HFN Commercial |
$1,052.48
|
| Rate for Payer: Multiplan Commercial |
$915.20
|
| Rate for Payer: NAPHCARE Commercial |
$686.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,052.48
|
| Rate for Payer: Quartz Beloit One Network |
$560.56
|
| Rate for Payer: Quartz Commercial |
$686.40
|
| Rate for Payer: WEA Trust Commercial |
$629.20
|
| Rate for Payer: WPS Commercial |
$847.36
|
|
|
US Pelvis Non-OB Limited
|
Facility
|
OP
|
$1,144.00
|
|
|
Service Code
|
CPT 76857
|
| Hospital Charge Code |
630925
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,052.48 |
| Rate for Payer: Aetna Commercial |
$1,029.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$983.84
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$743.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$572.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$549.12
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$606.32
|
| 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 |
$343.20
|
| Rate for Payer: Cash Price |
$343.20
|
| Rate for Payer: Cigna Commercial |
$1,052.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$640.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,018.16
|
| Rate for Payer: HFN Commercial |
$1,052.48
|
| 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 |
$915.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,052.48
|
| Rate for Payer: Quartz Beloit One Network |
$560.56
|
| Rate for Payer: Quartz Commercial |
$743.60
|
| 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 |
$629.20
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$847.36
|
|
|
US Pelvis Non-OB Limited
|
Facility
|
IP
|
$1,221.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
2544944
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$598.29 |
| Max. Negotiated Rate |
$1,123.32 |
| Rate for Payer: Aetna Commercial |
$1,098.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$647.13
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,123.32
|
| Rate for Payer: Health EOS Commercial |
$1,086.69
|
| Rate for Payer: HFN Commercial |
$1,123.32
|
| Rate for Payer: Multiplan Commercial |
$976.80
|
| Rate for Payer: NAPHCARE Commercial |
$732.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,123.32
|
| Rate for Payer: Quartz Beloit One Network |
$598.29
|
| Rate for Payer: Quartz Commercial |
$732.60
|
| Rate for Payer: WEA Trust Commercial |
$671.55
|
| Rate for Payer: WPS Commercial |
$904.39
|
|
|
US Pelvis, Transvaginal
|
Facility
|
IP
|
$1,789.00
|
|
|
Service Code
|
CPT 76856 TC
|
| Hospital Charge Code |
2587178
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$876.61 |
| Max. Negotiated Rate |
$1,645.88 |
| Rate for Payer: Aetna Commercial |
$1,610.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,538.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$948.17
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cigna Commercial |
$1,645.88
|
| Rate for Payer: Health EOS Commercial |
$1,592.21
|
| Rate for Payer: HFN Commercial |
$1,645.88
|
| Rate for Payer: Multiplan Commercial |
$1,431.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,073.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,645.88
|
| Rate for Payer: Quartz Beloit One Network |
$876.61
|
| Rate for Payer: Quartz Commercial |
$1,073.40
|
| Rate for Payer: WEA Trust Commercial |
$983.95
|
| Rate for Payer: WPS Commercial |
$1,325.11
|
|
|
US Pelvis, Transvaginal
|
Professional
|
Both
|
$1,789.00
|
|
|
Service Code
|
CPT 76856 TC
|
| Hospital Charge Code |
2587178
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$259.10 |
| Max. Negotiated Rate |
$1,699.55 |
| Rate for Payer: Aetna Commercial |
$1,699.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,538.54
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cigna Commercial |
$1,699.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$894.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,073.40
|
| Rate for Payer: Health EOS Commercial |
$1,627.99
|
| Rate for Payer: HFN Commercial |
$1,699.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$259.10
|
| Rate for Payer: Multiplan Commercial |
$1,431.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,699.55
|
| Rate for Payer: Quartz Beloit One Network |
$787.16
|
| Rate for Payer: Quartz Commercial |
$1,019.73
|
| Rate for Payer: The Alliance Commercial |
$894.50
|
| Rate for Payer: WEA Trust Commercial |
$983.95
|
| Rate for Payer: WPS Commercial |
$1,325.11
|
|
|
US Pelvis, Transvaginal
|
Facility
|
OP
|
$1,789.00
|
|
|
Service Code
|
CPT 76856 TC
|
| Hospital Charge Code |
2587178
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,645.88 |
| Rate for Payer: Aetna Commercial |
$1,610.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,538.54
|
| 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 |
$948.17
|
| 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 |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cash Price |
$536.70
|
| Rate for Payer: Cigna Commercial |
$1,645.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,001.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,592.21
|
| Rate for Payer: HFN Commercial |
$1,645.88
|
| 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 |
$1,431.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,645.88
|
| Rate for Payer: Quartz Beloit One Network |
$876.61
|
| Rate for Payer: Quartz Commercial |
$1,162.85
|
| 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 |
$983.95
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,325.11
|
|
|
US Placenta Localization
|
Professional
|
Both
|
$1,121.00
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
2552811
|
| Min. Negotiated Rate |
$287.27 |
| Max. Negotiated Rate |
$1,064.95 |
| Rate for Payer: Aetna Commercial |
$1,064.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$964.06
|
| Rate for Payer: Cash Price |
$336.30
|
| Rate for Payer: Cash Price |
$336.30
|
| Rate for Payer: Cash Price |
$336.30
|
| Rate for Payer: Cigna Commercial |
$1,064.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$560.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$672.60
|
| Rate for Payer: Health EOS Commercial |
$1,020.11
|
| Rate for Payer: HFN Commercial |
$1,064.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$287.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$287.27
|
| Rate for Payer: Multiplan Commercial |
$896.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,064.95
|
| Rate for Payer: Quartz Beloit One Network |
$493.24
|
| Rate for Payer: Quartz Commercial |
$638.97
|
| Rate for Payer: The Alliance Commercial |
$560.50
|
| Rate for Payer: WEA Trust Commercial |
$616.55
|
| Rate for Payer: WPS Commercial |
$830.32
|
|
|
US Placenta Localization
|
Facility
|
OP
|
$1,166.00
|
|
|
Service Code
|
CPT 76815 TC
|
| Hospital Charge Code |
2587181
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,072.72 |
| Rate for Payer: Aetna Commercial |
$1,049.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,002.76
|
| 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 |
$617.98
|
| 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 |
$349.80
|
| Rate for Payer: Cash Price |
$349.80
|
| Rate for Payer: Cash Price |
$349.80
|
| Rate for Payer: Cigna Commercial |
$1,072.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$652.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,037.74
|
| Rate for Payer: HFN Commercial |
$1,072.72
|
| 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 |
$932.80
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,072.72
|
| Rate for Payer: Quartz Beloit One Network |
$571.34
|
| Rate for Payer: Quartz Commercial |
$757.90
|
| 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 |
$641.30
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$863.66
|
|
|
US Placenta Localization
|
Facility
|
IP
|
$1,166.00
|
|
|
Service Code
|
CPT 76815 TC
|
| Hospital Charge Code |
2587181
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$571.34 |
| Max. Negotiated Rate |
$1,072.72 |
| Rate for Payer: Aetna Commercial |
$1,049.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,002.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$617.98
|
| Rate for Payer: Cash Price |
$349.80
|
| Rate for Payer: Cigna Commercial |
$1,072.72
|
| Rate for Payer: Health EOS Commercial |
$1,037.74
|
| Rate for Payer: HFN Commercial |
$1,072.72
|
| Rate for Payer: Multiplan Commercial |
$932.80
|
| Rate for Payer: NAPHCARE Commercial |
$699.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,072.72
|
| Rate for Payer: Quartz Beloit One Network |
$571.34
|
| Rate for Payer: Quartz Commercial |
$699.60
|
| Rate for Payer: WEA Trust Commercial |
$641.30
|
| Rate for Payer: WPS Commercial |
$863.66
|
|
|
US Placenta Localization
|
Professional
|
Both
|
$1,166.00
|
|
|
Service Code
|
CPT 76815 TC
|
| Hospital Charge Code |
2587181
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$177.91 |
| Max. Negotiated Rate |
$1,107.70 |
| Rate for Payer: Aetna Commercial |
$1,107.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,002.76
|
| Rate for Payer: Cash Price |
$349.80
|
| Rate for Payer: Cash Price |
$349.80
|
| Rate for Payer: Cash Price |
$349.80
|
| Rate for Payer: Cigna Commercial |
$1,107.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$583.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$699.60
|
| Rate for Payer: Health EOS Commercial |
$1,061.06
|
| Rate for Payer: HFN Commercial |
$1,107.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$177.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$177.91
|
| Rate for Payer: Multiplan Commercial |
$932.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,107.70
|
| Rate for Payer: Quartz Beloit One Network |
$513.04
|
| Rate for Payer: Quartz Commercial |
$664.62
|
| Rate for Payer: The Alliance Commercial |
$583.00
|
| Rate for Payer: WEA Trust Commercial |
$641.30
|
| Rate for Payer: WPS Commercial |
$863.66
|
|
|
US Placenta Localization
|
Facility
|
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
2552811
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,031.32 |
| Rate for Payer: Aetna Commercial |
$1,008.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$964.06
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$728.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$560.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.08
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$594.13
|
| 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 |
$336.30
|
| Rate for Payer: Cash Price |
$336.30
|
| Rate for Payer: Cigna Commercial |
$1,031.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$627.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$997.69
|
| Rate for Payer: HFN Commercial |
$1,031.32
|
| 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 |
$896.80
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,031.32
|
| Rate for Payer: Quartz Beloit One Network |
$549.29
|
| Rate for Payer: Quartz Commercial |
$728.65
|
| 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 |
$616.55
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$830.32
|
|
