|
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 |
$372.96 |
| Max. Negotiated Rate |
$5,328.00 |
| Rate for Payer: Aetna Commercial |
$1,198.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,145.52
|
| Rate for Payer: Aetna Managed Medicare |
$372.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$705.96
|
| 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: Health EOS Commercial |
$1,185.48
|
| Rate for Payer: HFN Commercial |
$1,225.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$999.00
|
| 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 |
$865.80
|
| Rate for Payer: Quartz Medicare Advantage |
$799.20
|
| Rate for Payer: The Alliance Commercial |
$5,328.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| 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: 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 Right
|
Professional
|
$1,383.00
|
|
|
Service Code
|
CPT 76776 TC
|
| Hospital Charge Code |
2544913
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.70 |
| 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: Aetna Managed Medicare |
$108.70
|
| Rate for Payer: Anthem Medicare Advantage |
$108.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.70
|
| 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 |
$108.70
|
| Rate for Payer: Health EOS Commercial |
$1,258.53
|
| 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: Independent Care Health Plan Medicare |
$108.70
|
| 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: Quartz Medicare Advantage |
$108.70
|
| Rate for Payer: The Alliance Commercial |
$413.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.70
|
| Rate for Payer: WEA Trust Commercial |
$760.65
|
| Rate for Payer: WPS Commercial |
$543.50
|
|
|
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 |
$387.24 |
| Max. Negotiated Rate |
$5,532.00 |
| Rate for Payer: Aetna Commercial |
$1,244.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,189.38
|
| Rate for Payer: Aetna Managed Medicare |
$387.24
|
| 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 |
$732.99
|
| 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: Health EOS Commercial |
$1,230.87
|
| Rate for Payer: HFN Commercial |
$1,272.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,037.25
|
| 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 |
$898.95
|
| Rate for Payer: Quartz Medicare Advantage |
$829.80
|
| Rate for Payer: The Alliance Commercial |
$5,532.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$760.65
|
| Rate for Payer: WPS Commercial |
$1,024.39
|
|
|
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: 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 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: 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
|
Facility
OP
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544915
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$436.52 |
| Max. Negotiated Rate |
$6,236.00 |
| Rate for Payer: Aetna Commercial |
$1,403.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Aetna Managed Medicare |
$436.52
|
| 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 |
$826.27
|
| 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: Health EOS Commercial |
$1,387.51
|
| Rate for Payer: HFN Commercial |
$1,434.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,169.25
|
| 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 |
$1,013.35
|
| Rate for Payer: Quartz Medicare Advantage |
$935.40
|
| Rate for Payer: The Alliance Commercial |
$6,236.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
|
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: 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
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711775
|
| Min. Negotiated Rate |
$13.28 |
| 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 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 |
$13.28
|
| 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
|
Professional
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711775
|
| Min. Negotiated Rate |
$85.23 |
| 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: 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 |
$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 |
$85.23
|
| Rate for Payer: Health EOS Commercial |
$1,364.09
|
| 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 |
$1,199.20
|
| 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: 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 |
$824.45
|
| Rate for Payer: WPS Commercial |
$426.15
|
|
|
US Left Lower Quadrant
|
Professional
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544915
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$58.05 |
| 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: 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 |
$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 |
$58.05
|
| Rate for Payer: Health EOS Commercial |
$1,418.69
|
| 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 |
$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: 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 |
$857.45
|
| Rate for Payer: WPS Commercial |
$290.25
|
|
|
US Left Upper Quadrant
|
Facility
OP
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544918
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$436.52 |
| Max. Negotiated Rate |
$6,236.00 |
| Rate for Payer: Aetna Commercial |
$1,403.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Aetna Managed Medicare |
$436.52
|
| 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 |
$826.27
|
| 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: Health EOS Commercial |
$1,387.51
|
| Rate for Payer: HFN Commercial |
$1,434.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,169.25
|
| 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 |
$1,013.35
|
| Rate for Payer: Quartz Medicare Advantage |
$935.40
|
| Rate for Payer: The Alliance Commercial |
$6,236.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
|
US Left Upper Quadrant
|
Facility
OP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711776
|
| Min. Negotiated Rate |
$13.28 |
| 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 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 |
$13.28
|
| 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 Upper Quadrant
|
Facility
IP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711776
|
| Min. Negotiated Rate |
$734.51 |
| Max. Negotiated Rate |
$1,379.08 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| 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 Upper Quadrant
|
Professional
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711776
|
| Min. Negotiated Rate |
$85.23 |
| 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: 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 |
$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 |
$85.23
|
| Rate for Payer: Health EOS Commercial |
$1,364.09
|
| 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 |
$1,199.20
|
| 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: 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 |
$824.45
|
| Rate for Payer: WPS Commercial |
$426.15
|
|
|
US Left Upper Quadrant
|
Facility
IP
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544918
|
|
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: 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 Upper Quadrant
|
Professional
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544918
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$58.05 |
| 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: 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 |
$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 |
$58.05
|
| Rate for Payer: Health EOS Commercial |
$1,418.69
|
| 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 |
$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: 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 |
$857.45
|
| Rate for Payer: WPS Commercial |
$290.25
|
|
|
US Liver
|
Facility
OP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
2552807
|
| Min. Negotiated Rate |
$13.28 |
| 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 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 |
$13.28
|
| 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 Liver
|
Professional
|
$1,763.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587172
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$58.05 |
| Max. Negotiated Rate |
$1,674.85 |
| Rate for Payer: Aetna Commercial |
$1,674.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| 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 |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,674.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$881.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.05
|
| Rate for Payer: Health EOS Commercial |
$1,604.33
|
| 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 |
$1,410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,674.85
|
| Rate for Payer: Quartz Beloit One Network |
$775.72
|
| Rate for Payer: Quartz Commercial |
$1,004.91
|
| 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 |
$969.65
|
| Rate for Payer: WPS Commercial |
$290.25
|
|
|
US Liver
|
Professional
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
2552807
|
| Min. Negotiated Rate |
$85.23 |
| 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: 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 |
$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 |
$85.23
|
| Rate for Payer: Health EOS Commercial |
$1,364.09
|
| 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 |
$1,199.20
|
| 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: 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 |
$824.45
|
| Rate for Payer: WPS Commercial |
$426.15
|
|
|
US Liver
|
Facility
IP
|
$1,763.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587172
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$863.87 |
| Max. Negotiated Rate |
$1,621.96 |
| Rate for Payer: Aetna Commercial |
$1,586.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.39
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,621.96
|
| Rate for Payer: Health EOS Commercial |
$1,569.07
|
| Rate for Payer: HFN Commercial |
$1,621.96
|
| Rate for Payer: Multiplan Commercial |
$1,410.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,057.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,621.96
|
| Rate for Payer: Quartz Beloit One Network |
$863.87
|
| Rate for Payer: Quartz Commercial |
$1,057.80
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
US Liver
|
Facility
OP
|
$1,763.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587172
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$493.64 |
| Max. Negotiated Rate |
$7,052.00 |
| Rate for Payer: Aetna Commercial |
$1,586.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Aetna Managed Medicare |
$493.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.39
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,621.96
|
| Rate for Payer: Health EOS Commercial |
$1,569.07
|
| Rate for Payer: HFN Commercial |
$1,621.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,322.25
|
| Rate for Payer: Multiplan Commercial |
$1,410.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,057.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,621.96
|
| Rate for Payer: Quartz Beloit One Network |
$863.87
|
| Rate for Payer: Quartz Commercial |
$1,145.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,057.80
|
| Rate for Payer: The Alliance Commercial |
$7,052.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
US Liver
|
Facility
IP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
2552807
|
| Min. Negotiated Rate |
$734.51 |
| Max. Negotiated Rate |
$1,379.08 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| 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 Lower Extremity Non-Vascular Bilat
|
Professional
|
$1,128.00
|
|
|
Service Code
|
CPT 76882 LT,TC
|
| Hospital Charge Code |
2544921
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$496.32 |
| Max. Negotiated Rate |
$1,071.60 |
| Rate for Payer: Aetna Commercial |
$1,071.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.08
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cigna Commercial |
$1,071.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$564.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$676.80
|
| Rate for Payer: Health EOS Commercial |
$1,026.48
|
| Rate for Payer: Multiplan Commercial |
$902.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,071.60
|
| Rate for Payer: Quartz Beloit One Network |
$496.32
|
| Rate for Payer: Quartz Commercial |
$642.96
|
| Rate for Payer: The Alliance Commercial |
$564.00
|
| Rate for Payer: WEA Trust Commercial |
$620.40
|
| Rate for Payer: WPS Commercial |
$835.51
|
|
|
US Lower Extremity Non-Vascular Bilat
|
Facility
IP
|
$1,128.00
|
|
|
Service Code
|
CPT 76882 LT,TC
|
| Hospital Charge Code |
2544921
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$552.72 |
| Max. Negotiated Rate |
$1,037.76 |
| Rate for Payer: Aetna Commercial |
$1,015.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.84
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cigna Commercial |
$1,037.76
|
| Rate for Payer: Health EOS Commercial |
$1,003.92
|
| Rate for Payer: HFN Commercial |
$1,037.76
|
| Rate for Payer: Multiplan Commercial |
$902.40
|
| Rate for Payer: NAPHCARE Commercial |
$676.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.76
|
| Rate for Payer: Quartz Beloit One Network |
$552.72
|
| Rate for Payer: Quartz Commercial |
$676.80
|
| Rate for Payer: WEA Trust Commercial |
$620.40
|
| Rate for Payer: WPS Commercial |
$835.51
|
|
