|
US Unilateral Breast Left
|
Professional
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC,LT
|
| Hospital Charge Code |
4444805
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$423.72 |
| Max. Negotiated Rate |
$914.85 |
| Rate for Payer: Aetna Commercial |
$914.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$914.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$481.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$577.80
|
| Rate for Payer: Health EOS Commercial |
$876.33
|
| Rate for Payer: Multiplan Commercial |
$770.40
|
| Rate for Payer: Preferred Network Access Commercial |
$914.85
|
| Rate for Payer: Quartz Beloit One Network |
$423.72
|
| Rate for Payer: Quartz Commercial |
$548.91
|
| Rate for Payer: The Alliance Commercial |
$481.50
|
| Rate for Payer: WEA Trust Commercial |
$529.65
|
| Rate for Payer: WPS Commercial |
$713.29
|
|
|
US Unilateral Breast Left
|
Facility
IP
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC,LT
|
| Hospital Charge Code |
4444805
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$471.87 |
| Max. Negotiated Rate |
$885.96 |
| Rate for Payer: Aetna Commercial |
$866.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$510.39
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$885.96
|
| Rate for Payer: Health EOS Commercial |
$857.07
|
| Rate for Payer: HFN Commercial |
$885.96
|
| Rate for Payer: Multiplan Commercial |
$770.40
|
| Rate for Payer: NAPHCARE Commercial |
$577.80
|
| Rate for Payer: Preferred Network Access Commercial |
$885.96
|
| Rate for Payer: Quartz Beloit One Network |
$471.87
|
| Rate for Payer: Quartz Commercial |
$577.80
|
| Rate for Payer: WEA Trust Commercial |
$529.65
|
| Rate for Payer: WPS Commercial |
$713.29
|
|
|
US Unilateral Breast Left
|
Facility
OP
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC,LT
|
| Hospital Charge Code |
4444805
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$269.64 |
| Max. Negotiated Rate |
$3,852.00 |
| Rate for Payer: Aetna Commercial |
$866.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| Rate for Payer: Aetna Managed Medicare |
$269.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$510.39
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$885.96
|
| Rate for Payer: Health EOS Commercial |
$857.07
|
| Rate for Payer: HFN Commercial |
$885.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$722.25
|
| Rate for Payer: Multiplan Commercial |
$770.40
|
| Rate for Payer: NAPHCARE Commercial |
$577.80
|
| Rate for Payer: Preferred Network Access Commercial |
$885.96
|
| Rate for Payer: Quartz Beloit One Network |
$471.87
|
| Rate for Payer: Quartz Commercial |
$625.95
|
| Rate for Payer: Quartz Medicare Advantage |
$577.80
|
| Rate for Payer: The Alliance Commercial |
$3,852.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$529.65
|
| Rate for Payer: WPS Commercial |
$713.29
|
|
|
US Unlisted Procedure
|
Facility
OP
|
$1,839.00
|
|
|
Service Code
|
CPT 76999 TC
|
| Hospital Charge Code |
2544985
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$514.92 |
| Max. Negotiated Rate |
$7,356.00 |
| Rate for Payer: Aetna Commercial |
$1,655.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,581.54
|
| Rate for Payer: Aetna Managed Medicare |
$514.92
|
| 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 |
$974.67
|
| Rate for Payer: Cash Price |
$551.70
|
| Rate for Payer: Cash Price |
$551.70
|
| Rate for Payer: Cash Price |
$551.70
|
| Rate for Payer: Cigna Commercial |
$1,691.88
|
| Rate for Payer: Health EOS Commercial |
$1,636.71
|
| Rate for Payer: HFN Commercial |
$1,691.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,379.25
|
| Rate for Payer: Multiplan Commercial |
$1,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,103.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,691.88
|
| Rate for Payer: Quartz Beloit One Network |
$901.11
|
| Rate for Payer: Quartz Commercial |
$1,195.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,103.40
|
| Rate for Payer: The Alliance Commercial |
$7,356.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$1,011.45
|
| Rate for Payer: WPS Commercial |
$1,362.15
|
|
|
US Unlisted Procedure
|
Facility
IP
|
$1,839.00
|
|
|
Service Code
|
CPT 76999 TC
|
| Hospital Charge Code |
2544985
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$901.11 |
| Max. Negotiated Rate |
$1,691.88 |
| Rate for Payer: Aetna Commercial |
$1,655.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.67
|
| Rate for Payer: Cash Price |
$551.70
|
| Rate for Payer: Cigna Commercial |
$1,691.88
|
| Rate for Payer: Health EOS Commercial |
$1,636.71
|
| Rate for Payer: HFN Commercial |
$1,691.88
|
| Rate for Payer: Multiplan Commercial |
$1,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,103.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,691.88
|
| Rate for Payer: Quartz Beloit One Network |
$901.11
|
| Rate for Payer: Quartz Commercial |
$1,103.40
|
| Rate for Payer: WEA Trust Commercial |
$1,011.45
|
| Rate for Payer: WPS Commercial |
$1,362.15
|
|
|
US Unlisted Procedure
|
Professional
|
$1,839.00
|
|
|
Service Code
|
CPT 76999 TC
|
| Hospital Charge Code |
2544985
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$809.16 |
| Max. Negotiated Rate |
$1,747.05 |
| Rate for Payer: Aetna Commercial |
$1,747.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,581.54
|
| Rate for Payer: Cash Price |
$551.70
|
| Rate for Payer: Cash Price |
$551.70
|
| Rate for Payer: Cigna Commercial |
$1,747.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$919.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,103.40
|
| Rate for Payer: Health EOS Commercial |
$1,673.49
|
| Rate for Payer: Multiplan Commercial |
$1,471.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,747.05
|
| Rate for Payer: Quartz Beloit One Network |
$809.16
|
| Rate for Payer: Quartz Commercial |
$1,048.23
|
| Rate for Payer: The Alliance Commercial |
$919.50
|
| Rate for Payer: WEA Trust Commercial |
$1,011.45
|
| Rate for Payer: WPS Commercial |
$1,362.15
|
|
|
US Upper Extremity Non-Vascular Bilat
|
Professional
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 LT,TC
|
| Hospital Charge Code |
2544987
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$485.32 |
| Max. Negotiated Rate |
$1,047.85 |
| Rate for Payer: Aetna Commercial |
$1,047.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,047.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$551.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$661.80
|
| Rate for Payer: Health EOS Commercial |
$1,003.73
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,047.85
|
| Rate for Payer: Quartz Beloit One Network |
$485.32
|
| Rate for Payer: Quartz Commercial |
$628.71
|
| Rate for Payer: The Alliance Commercial |
$551.50
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Upper Extremity Non-Vascular Bilat
|
Facility
OP
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 LT,TC
|
| Hospital Charge Code |
2544987
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$308.84 |
| Max. Negotiated Rate |
$4,412.00 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Aetna Managed Medicare |
$308.84
|
| 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 |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$827.25
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$716.95
|
| Rate for Payer: Quartz Medicare Advantage |
$661.80
|
| Rate for Payer: The Alliance Commercial |
$4,412.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Upper Extremity Non-Vascular Bilat
|
Facility
IP
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 LT,TC
|
| Hospital Charge Code |
2544987
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$540.47 |
| Max. Negotiated Rate |
$1,014.76 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$661.80
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Upper Extremity Non-Vascular Left
|
Facility
OP
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 TC,LT
|
| Hospital Charge Code |
2544990
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$308.84 |
| Max. Negotiated Rate |
$4,412.00 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Aetna Managed Medicare |
$308.84
|
| 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 |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$827.25
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$716.95
|
| Rate for Payer: Quartz Medicare Advantage |
$661.80
|
| Rate for Payer: The Alliance Commercial |
$4,412.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Upper Extremity Non-Vascular Left
|
Facility
OP
|
$971.00
|
|
|
Service Code
|
CPT 76881 TC,LT
|
| Hospital Charge Code |
4406577
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$271.88 |
| Max. Negotiated Rate |
$3,884.00 |
| Rate for Payer: Aetna Commercial |
$873.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$835.06
|
| Rate for Payer: Aetna Managed Medicare |
$271.88
|
| 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 |
$514.63
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cigna Commercial |
$893.32
|
| Rate for Payer: Health EOS Commercial |
$864.19
|
| Rate for Payer: HFN Commercial |
$893.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$728.25
|
| Rate for Payer: Multiplan Commercial |
$776.80
|
| Rate for Payer: NAPHCARE Commercial |
$582.60
|
| Rate for Payer: Preferred Network Access Commercial |
$893.32
|
| Rate for Payer: Quartz Beloit One Network |
$475.79
|
| Rate for Payer: Quartz Commercial |
$631.15
|
| Rate for Payer: Quartz Medicare Advantage |
$582.60
|
| Rate for Payer: The Alliance Commercial |
$3,884.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$534.05
|
| Rate for Payer: WPS Commercial |
$719.22
|
|
|
US Upper Extremity Non-Vascular Left
|
Professional
|
$971.00
|
|
|
Service Code
|
CPT 76881 TC,LT
|
| Hospital Charge Code |
4406577
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$427.24 |
| Max. Negotiated Rate |
$922.45 |
| Rate for Payer: Aetna Commercial |
$922.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$835.06
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cigna Commercial |
$922.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$485.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$582.60
|
| Rate for Payer: Health EOS Commercial |
$883.61
|
| Rate for Payer: Multiplan Commercial |
$776.80
|
| Rate for Payer: Preferred Network Access Commercial |
$922.45
|
| Rate for Payer: Quartz Beloit One Network |
$427.24
|
| Rate for Payer: Quartz Commercial |
$553.47
|
| Rate for Payer: The Alliance Commercial |
$485.50
|
| Rate for Payer: WEA Trust Commercial |
$534.05
|
| Rate for Payer: WPS Commercial |
$719.22
|
|
|
US Upper Extremity Non-Vascular Left
|
Professional
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 TC,LT
|
| Hospital Charge Code |
2544990
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$485.32 |
| Max. Negotiated Rate |
$1,047.85 |
| Rate for Payer: Aetna Commercial |
$1,047.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,047.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$551.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$661.80
|
| Rate for Payer: Health EOS Commercial |
$1,003.73
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,047.85
|
| Rate for Payer: Quartz Beloit One Network |
$485.32
|
| Rate for Payer: Quartz Commercial |
$628.71
|
| Rate for Payer: The Alliance Commercial |
$551.50
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Upper Extremity Non-Vascular Left
|
Facility
IP
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 TC,LT
|
| Hospital Charge Code |
2544990
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$540.47 |
| Max. Negotiated Rate |
$1,014.76 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$661.80
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Upper Extremity Non-Vascular Left
|
Facility
IP
|
$971.00
|
|
|
Service Code
|
CPT 76881 TC,LT
|
| Hospital Charge Code |
4406577
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$475.79 |
| Max. Negotiated Rate |
$893.32 |
| Rate for Payer: Aetna Commercial |
$873.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$514.63
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cigna Commercial |
$893.32
|
| Rate for Payer: Health EOS Commercial |
$864.19
|
| Rate for Payer: HFN Commercial |
$893.32
|
| Rate for Payer: Multiplan Commercial |
$776.80
|
| Rate for Payer: NAPHCARE Commercial |
$582.60
|
| Rate for Payer: Preferred Network Access Commercial |
$893.32
|
| Rate for Payer: Quartz Beloit One Network |
$475.79
|
| Rate for Payer: Quartz Commercial |
$582.60
|
| Rate for Payer: WEA Trust Commercial |
$534.05
|
| Rate for Payer: WPS Commercial |
$719.22
|
|
|
US Upper Extremity Non-Vascular Right
|
Facility
OP
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 TC,RT
|
| Hospital Charge Code |
4330578
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$308.84 |
| Max. Negotiated Rate |
$4,412.00 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Aetna Managed Medicare |
$308.84
|
| 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 |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$827.25
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$716.95
|
| Rate for Payer: Quartz Medicare Advantage |
$661.80
|
| Rate for Payer: The Alliance Commercial |
$4,412.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Upper Extremity Non-Vascular Right
|
Facility
IP
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 TC,RT
|
| Hospital Charge Code |
4330578
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$540.47 |
| Max. Negotiated Rate |
$1,014.76 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$661.80
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Upper Extremity Non-Vascular Right
|
Professional
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 TC,RT
|
| Hospital Charge Code |
4330578
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$485.32 |
| Max. Negotiated Rate |
$1,047.85 |
| Rate for Payer: Aetna Commercial |
$1,047.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,047.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$551.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$661.80
|
| Rate for Payer: Health EOS Commercial |
$1,003.73
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,047.85
|
| Rate for Payer: Quartz Beloit One Network |
$485.32
|
| Rate for Payer: Quartz Commercial |
$628.71
|
| Rate for Payer: The Alliance Commercial |
$551.50
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Upper Extremity Non-Vascular Right
|
Facility
IP
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 RT,TC
|
| Hospital Charge Code |
2544993
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$540.47 |
| Max. Negotiated Rate |
$1,014.76 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$661.80
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Upper Extremity Non-Vascular Right
|
Professional
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 RT,TC
|
| Hospital Charge Code |
2544993
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$485.32 |
| Max. Negotiated Rate |
$1,047.85 |
| Rate for Payer: Aetna Commercial |
$1,047.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,047.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$551.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$661.80
|
| Rate for Payer: Health EOS Commercial |
$1,003.73
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,047.85
|
| Rate for Payer: Quartz Beloit One Network |
$485.32
|
| Rate for Payer: Quartz Commercial |
$628.71
|
| Rate for Payer: The Alliance Commercial |
$551.50
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Upper Extremity Non-Vascular Right
|
Facility
OP
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 RT,TC
|
| Hospital Charge Code |
2544993
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$308.84 |
| Max. Negotiated Rate |
$4,412.00 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Aetna Managed Medicare |
$308.84
|
| 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 |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$827.25
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$716.95
|
| Rate for Payer: Quartz Medicare Advantage |
$661.80
|
| Rate for Payer: The Alliance Commercial |
$4,412.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC
|
Facility
IP
|
$47,694.00
|
|
|
Service Code
|
MS-DRG 742
|
| Min. Negotiated Rate |
$17,156.10 |
| Max. Negotiated Rate |
$47,694.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,156.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37,344.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28,624.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,194.84
|
| Rate for Payer: Anthem Medicare Advantage |
$17,156.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,156.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,156.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,156.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30,188.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,156.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,747.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,156.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,156.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,156.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,156.10
|
| Rate for Payer: NAPHCARE Commercial |
$25,734.15
|
| Rate for Payer: Quartz Medicare Advantage |
$17,156.10
|
| Rate for Payer: The Alliance Commercial |
$47,694.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,156.10
|
| Rate for Payer: United Healthcare PPO |
$27,051.02
|
| Rate for Payer: Wellcare Medicare |
$17,156.10
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC
|
Facility
IP
|
$31,213.00
|
|
|
Service Code
|
MS-DRG 743
|
| Min. Negotiated Rate |
$11,227.80 |
| Max. Negotiated Rate |
$31,213.00 |
| Rate for Payer: Aetna Managed Medicare |
$11,227.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,336.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,653.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,722.48
|
| Rate for Payer: Anthem Medicare Advantage |
$11,227.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,227.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,227.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,227.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,673.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,227.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22,659.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,227.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,227.80
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,227.80
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,227.80
|
| Rate for Payer: NAPHCARE Commercial |
$16,841.70
|
| Rate for Payer: Quartz Medicare Advantage |
$11,227.80
|
| Rate for Payer: The Alliance Commercial |
$31,213.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,227.80
|
| Rate for Payer: United Healthcare PPO |
$17,640.32
|
| Rate for Payer: Wellcare Medicare |
$11,227.80
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC
|
Facility
IP
|
$47,830.00
|
|
|
Service Code
|
MS-DRG 740
|
| Min. Negotiated Rate |
$17,204.87 |
| Max. Negotiated Rate |
$47,830.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,204.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37,554.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28,784.99
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,347.62
|
| Rate for Payer: Anthem Medicare Advantage |
$17,204.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,204.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,204.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,204.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30,358.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,204.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,846.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,204.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,204.87
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,204.87
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,204.87
|
| Rate for Payer: NAPHCARE Commercial |
$25,807.30
|
| Rate for Payer: Quartz Medicare Advantage |
$17,204.87
|
| Rate for Payer: The Alliance Commercial |
$47,830.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,204.87
|
| Rate for Payer: United Healthcare PPO |
$27,128.45
|
| Rate for Payer: Wellcare Medicare |
$17,204.87
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC
|
Facility
IP
|
$96,463.00
|
|
|
Service Code
|
MS-DRG 739
|
| Min. Negotiated Rate |
$34,699.01 |
| Max. Negotiated Rate |
$96,463.00 |
| Rate for Payer: NAPHCARE Commercial |
$52,048.52
|
| Rate for Payer: Aetna Managed Medicare |
$34,699.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$75,947.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$58,213.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55,306.36
|
| Rate for Payer: Anthem Medicare Advantage |
$34,699.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$34,699.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$34,699.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$34,699.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61,395.13
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$34,699.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70,517.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$34,699.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$34,699.01
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$34,699.01
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$34,699.01
|
| Rate for Payer: Quartz Medicare Advantage |
$34,699.01
|
| Rate for Payer: The Alliance Commercial |
$96,463.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34,699.01
|
| Rate for Payer: United Healthcare PPO |
$54,899.05
|
| Rate for Payer: Wellcare Medicare |
$34,699.01
|
|
