|
US Breast Limited
|
Facility
|
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
5102616
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$411.25 |
| Max. Negotiated Rate |
$772.14 |
| Rate for Payer: Aetna Commercial |
$755.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.82
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$772.14
|
| Rate for Payer: Health EOS Commercial |
$746.96
|
| Rate for Payer: HFN Commercial |
$772.14
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: Preferred Network Access Commercial |
$772.14
|
| Rate for Payer: Quartz Beloit One Network |
$411.25
|
| Rate for Payer: Quartz Commercial |
$503.57
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Bilateral
|
Facility
|
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 LT,LT
|
| Hospital Charge Code |
6196521
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$411.25 |
| Max. Negotiated Rate |
$772.14 |
| Rate for Payer: Aetna Commercial |
$755.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.82
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$772.14
|
| Rate for Payer: Health EOS Commercial |
$746.96
|
| Rate for Payer: HFN Commercial |
$772.14
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: Preferred Network Access Commercial |
$772.14
|
| Rate for Payer: Quartz Beloit One Network |
$411.25
|
| Rate for Payer: Quartz Commercial |
$503.57
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Bilateral
|
Facility
|
OP
|
$807.00
|
|
|
Service Code
|
CPT 76642 LT,LT
|
| Hospital Charge Code |
6196521
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$848.64 |
| Rate for Payer: Aetna Commercial |
$755.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Aetna Managed Medicare |
$235.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$848.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$681.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.82
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$772.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$469.67
|
| Rate for Payer: Health EOS Commercial |
$746.96
|
| Rate for Payer: HFN Commercial |
$772.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$629.46
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: NAPHCARE Commercial |
$503.57
|
| Rate for Payer: Preferred Network Access Commercial |
$772.14
|
| Rate for Payer: Quartz Beloit One Network |
$411.25
|
| Rate for Payer: Quartz Commercial |
$545.53
|
| Rate for Payer: Quartz Medicare Advantage |
$503.57
|
| Rate for Payer: The Alliance Commercial |
$419.64
|
| Rate for Payer: United Healthcare PPO |
$596.96
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Bilateral
|
Professional
|
Both
|
$807.00
|
|
|
Service Code
|
CPT 76642 LT,LT
|
| Hospital Charge Code |
6196521
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$311.02 |
| Max. Negotiated Rate |
$797.32 |
| Rate for Payer: Aetna Commercial |
$797.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$797.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$419.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$503.57
|
| Rate for Payer: Health EOS Commercial |
$763.74
|
| Rate for Payer: HFN Commercial |
$797.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$311.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$311.02
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: Preferred Network Access Commercial |
$797.32
|
| Rate for Payer: Quartz Beloit One Network |
$369.28
|
| Rate for Payer: Quartz Commercial |
$478.39
|
| Rate for Payer: The Alliance Commercial |
$419.64
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Left
|
Facility
|
OP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
6196524
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$848.64 |
| Rate for Payer: Aetna Commercial |
$755.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Aetna Managed Medicare |
$235.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$848.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$681.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.82
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$772.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$469.67
|
| Rate for Payer: Health EOS Commercial |
$746.96
|
| Rate for Payer: HFN Commercial |
$772.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$629.46
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: NAPHCARE Commercial |
$503.57
|
| Rate for Payer: Preferred Network Access Commercial |
$772.14
|
| Rate for Payer: Quartz Beloit One Network |
$411.25
|
| Rate for Payer: Quartz Commercial |
$545.53
|
| Rate for Payer: Quartz Medicare Advantage |
$503.57
|
| Rate for Payer: The Alliance Commercial |
$419.64
|
| Rate for Payer: United Healthcare PPO |
$596.96
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Left
|
Facility
|
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
6196524
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$411.25 |
| Max. Negotiated Rate |
$772.14 |
| Rate for Payer: Aetna Commercial |
$755.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.82
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$772.14
|
| Rate for Payer: Health EOS Commercial |
$746.96
|
| Rate for Payer: HFN Commercial |
$772.14
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: Preferred Network Access Commercial |
$772.14
|
| Rate for Payer: Quartz Beloit One Network |
$411.25
|
| Rate for Payer: Quartz Commercial |
$503.57
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Left
|
Professional
|
Both
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
6196524
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$311.02 |
| Max. Negotiated Rate |
$797.32 |
| Rate for Payer: Aetna Commercial |
$797.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$797.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$419.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$503.57
|
| Rate for Payer: Health EOS Commercial |
$763.74
|
| Rate for Payer: HFN Commercial |
$797.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$311.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$311.02
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: Preferred Network Access Commercial |
$797.32
|
| Rate for Payer: Quartz Beloit One Network |
$369.28
|
| Rate for Payer: Quartz Commercial |
$478.39
|
| Rate for Payer: The Alliance Commercial |
$419.64
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Right
|
Facility
|
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6196527
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$411.25 |
| Max. Negotiated Rate |
$772.14 |
| Rate for Payer: Aetna Commercial |
$755.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.82
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$772.14
|
| Rate for Payer: Health EOS Commercial |
$746.96
|
| Rate for Payer: HFN Commercial |
$772.14
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: Preferred Network Access Commercial |
$772.14
|
| Rate for Payer: Quartz Beloit One Network |
$411.25
|
| Rate for Payer: Quartz Commercial |
$503.57
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Right
|
Facility
|
OP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6196527
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$848.64 |
| Rate for Payer: Aetna Commercial |
$755.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Aetna Managed Medicare |
$235.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$848.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$681.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.82
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$772.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$469.67
|
| Rate for Payer: Health EOS Commercial |
$746.96
|
| Rate for Payer: HFN Commercial |
$772.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$629.46
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: NAPHCARE Commercial |
$503.57
|
| Rate for Payer: Preferred Network Access Commercial |
$772.14
|
| Rate for Payer: Quartz Beloit One Network |
$411.25
|
| Rate for Payer: Quartz Commercial |
$545.53
|
| Rate for Payer: Quartz Medicare Advantage |
$503.57
|
| Rate for Payer: The Alliance Commercial |
$419.64
|
| Rate for Payer: United Healthcare PPO |
$596.96
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Right
|
Facility
|
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6208968
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$411.25 |
| Max. Negotiated Rate |
$772.14 |
| Rate for Payer: Aetna Commercial |
$755.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.82
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$772.14
|
| Rate for Payer: Health EOS Commercial |
$746.96
|
| Rate for Payer: HFN Commercial |
$772.14
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: Preferred Network Access Commercial |
$772.14
|
| Rate for Payer: Quartz Beloit One Network |
$411.25
|
| Rate for Payer: Quartz Commercial |
$503.57
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Right
|
Facility
|
OP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6208968
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$848.64 |
| Rate for Payer: Aetna Commercial |
$755.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Aetna Managed Medicare |
$235.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$848.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$681.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.82
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$772.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$469.67
|
| Rate for Payer: Health EOS Commercial |
$746.96
|
| Rate for Payer: HFN Commercial |
$772.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$629.46
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: NAPHCARE Commercial |
$503.57
|
| Rate for Payer: Preferred Network Access Commercial |
$772.14
|
| Rate for Payer: Quartz Beloit One Network |
$411.25
|
| Rate for Payer: Quartz Commercial |
$545.53
|
| Rate for Payer: Quartz Medicare Advantage |
$503.57
|
| Rate for Payer: The Alliance Commercial |
$419.64
|
| Rate for Payer: United Healthcare PPO |
$596.96
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Right
|
Professional
|
Both
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6208968
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$311.02 |
| Max. Negotiated Rate |
$797.32 |
| Rate for Payer: Aetna Commercial |
$797.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$797.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$419.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$503.57
|
| Rate for Payer: Health EOS Commercial |
$763.74
|
| Rate for Payer: HFN Commercial |
$797.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$311.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$311.02
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: Preferred Network Access Commercial |
$797.32
|
| Rate for Payer: Quartz Beloit One Network |
$369.28
|
| Rate for Payer: Quartz Commercial |
$478.39
|
| Rate for Payer: The Alliance Commercial |
$419.64
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited & Axillary Right
|
Professional
|
Both
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,RT
|
| Hospital Charge Code |
6196527
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$311.02 |
| Max. Negotiated Rate |
$797.32 |
| Rate for Payer: Aetna Commercial |
$797.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$797.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$419.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$503.57
|
| Rate for Payer: Health EOS Commercial |
$763.74
|
| Rate for Payer: HFN Commercial |
$797.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$311.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$311.02
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: Preferred Network Access Commercial |
$797.32
|
| Rate for Payer: Quartz Beloit One Network |
$369.28
|
| Rate for Payer: Quartz Commercial |
$478.39
|
| Rate for Payer: The Alliance Commercial |
$419.64
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited Left
|
Facility
|
OP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
5102620
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$848.64 |
| Rate for Payer: Aetna Commercial |
$755.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Aetna Managed Medicare |
$235.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$848.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$681.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.82
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$772.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$469.67
|
| Rate for Payer: Health EOS Commercial |
$746.96
|
| Rate for Payer: HFN Commercial |
$772.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$629.46
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: NAPHCARE Commercial |
$503.57
|
| Rate for Payer: Preferred Network Access Commercial |
$772.14
|
| Rate for Payer: Quartz Beloit One Network |
$411.25
|
| Rate for Payer: Quartz Commercial |
$545.53
|
| Rate for Payer: Quartz Medicare Advantage |
$503.57
|
| Rate for Payer: The Alliance Commercial |
$419.64
|
| Rate for Payer: United Healthcare PPO |
$596.96
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited Left
|
Professional
|
Both
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
5102620
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$311.02 |
| Max. Negotiated Rate |
$797.32 |
| Rate for Payer: Aetna Commercial |
$797.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$797.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$419.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$503.57
|
| Rate for Payer: Health EOS Commercial |
$763.74
|
| Rate for Payer: HFN Commercial |
$797.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$311.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$311.02
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: Preferred Network Access Commercial |
$797.32
|
| Rate for Payer: Quartz Beloit One Network |
$369.28
|
| Rate for Payer: Quartz Commercial |
$478.39
|
| Rate for Payer: The Alliance Commercial |
$419.64
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Limited Left
|
Facility
|
IP
|
$807.00
|
|
|
Service Code
|
CPT 76642 TC,LT
|
| Hospital Charge Code |
5102620
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$411.25 |
| Max. Negotiated Rate |
$772.14 |
| Rate for Payer: Aetna Commercial |
$755.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$721.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.82
|
| Rate for Payer: Cash Price |
$242.10
|
| Rate for Payer: Cigna Commercial |
$772.14
|
| Rate for Payer: Health EOS Commercial |
$746.96
|
| Rate for Payer: HFN Commercial |
$772.14
|
| Rate for Payer: Multiplan Commercial |
$671.42
|
| Rate for Payer: Preferred Network Access Commercial |
$772.14
|
| Rate for Payer: Quartz Beloit One Network |
$411.25
|
| Rate for Payer: Quartz Commercial |
$503.57
|
| Rate for Payer: WEA Trust Commercial |
$461.60
|
| Rate for Payer: WPS Commercial |
$621.63
|
|
|
US Breast Right
|
Facility
|
IP
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2980118
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$490.74 |
| Max. Negotiated Rate |
$921.40 |
| Rate for Payer: Aetna Commercial |
$901.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$861.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$530.81
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$921.40
|
| Rate for Payer: Health EOS Commercial |
$891.35
|
| Rate for Payer: HFN Commercial |
$921.40
|
| Rate for Payer: Multiplan Commercial |
$801.22
|
| Rate for Payer: Preferred Network Access Commercial |
$921.40
|
| Rate for Payer: Quartz Beloit One Network |
$490.74
|
| Rate for Payer: Quartz Commercial |
$600.91
|
| Rate for Payer: WEA Trust Commercial |
$550.84
|
| Rate for Payer: WPS Commercial |
$741.80
|
|
|
US Breast Right
|
Professional
|
Both
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2544823
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$377.77 |
| Max. Negotiated Rate |
$951.44 |
| Rate for Payer: Aetna Commercial |
$951.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$861.31
|
| 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 |
$951.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$500.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$600.91
|
| Rate for Payer: Health EOS Commercial |
$911.38
|
| Rate for Payer: HFN Commercial |
$951.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$377.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$377.77
|
| Rate for Payer: Multiplan Commercial |
$801.22
|
| Rate for Payer: Preferred Network Access Commercial |
$951.44
|
| Rate for Payer: Quartz Beloit One Network |
$440.67
|
| Rate for Payer: Quartz Commercial |
$570.87
|
| Rate for Payer: The Alliance Commercial |
$500.76
|
| Rate for Payer: WEA Trust Commercial |
$550.84
|
| Rate for Payer: WPS Commercial |
$741.80
|
|
|
US Breast Right
|
Facility
|
OP
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2980118
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$280.43 |
| Max. Negotiated Rate |
$921.40 |
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$921.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$560.47
|
| Rate for Payer: Health EOS Commercial |
$891.35
|
| Rate for Payer: HFN Commercial |
$921.40
|
| Rate for Payer: Aetna Commercial |
$901.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$861.31
|
| Rate for Payer: Aetna Managed Medicare |
$280.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$848.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$681.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$530.81
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$751.14
|
| Rate for Payer: Multiplan Commercial |
$801.22
|
| Rate for Payer: NAPHCARE Commercial |
$600.91
|
| Rate for Payer: Preferred Network Access Commercial |
$921.40
|
| Rate for Payer: Quartz Beloit One Network |
$490.74
|
| Rate for Payer: Quartz Commercial |
$650.99
|
| Rate for Payer: Quartz Medicare Advantage |
$600.91
|
| Rate for Payer: The Alliance Commercial |
$500.76
|
| Rate for Payer: United Healthcare PPO |
$596.96
|
| Rate for Payer: WEA Trust Commercial |
$550.84
|
| Rate for Payer: WPS Commercial |
$741.80
|
|
|
US Breast Right
|
Facility
|
IP
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2544823
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$490.74 |
| Max. Negotiated Rate |
$921.40 |
| Rate for Payer: Aetna Commercial |
$901.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$861.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$530.81
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$921.40
|
| Rate for Payer: Health EOS Commercial |
$891.35
|
| Rate for Payer: HFN Commercial |
$921.40
|
| Rate for Payer: Multiplan Commercial |
$801.22
|
| Rate for Payer: Preferred Network Access Commercial |
$921.40
|
| Rate for Payer: Quartz Beloit One Network |
$490.74
|
| Rate for Payer: Quartz Commercial |
$600.91
|
| Rate for Payer: WEA Trust Commercial |
$550.84
|
| Rate for Payer: WPS Commercial |
$741.80
|
|
|
US Breast Right
|
Professional
|
Both
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627720
|
| Min. Negotiated Rate |
$99.74 |
| Max. Negotiated Rate |
$1,610.44 |
| Rate for Payer: Aetna Commercial |
$1,610.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,457.87
|
| Rate for Payer: Aetna Managed Medicare |
$99.74
|
| Rate for Payer: Anthem Medicare Advantage |
$99.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$99.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$99.74
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cigna Commercial |
$1,610.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$847.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$99.74
|
| Rate for Payer: Health EOS Commercial |
$1,542.63
|
| Rate for Payer: HFN Commercial |
$1,610.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$377.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$377.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$99.74
|
| Rate for Payer: Multiplan Commercial |
$1,356.16
|
| Rate for Payer: NAPHCARE Commercial |
$149.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.44
|
| Rate for Payer: Quartz Beloit One Network |
$745.89
|
| Rate for Payer: Quartz Commercial |
$966.26
|
| Rate for Payer: Quartz Medicare Advantage |
$99.74
|
| Rate for Payer: The Alliance Commercial |
$379.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$99.74
|
| Rate for Payer: WEA Trust Commercial |
$932.36
|
| Rate for Payer: WPS Commercial |
$498.68
|
|
|
US Breast Right
|
Professional
|
Both
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2980118
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$377.77 |
| Max. Negotiated Rate |
$951.44 |
| Rate for Payer: Aetna Commercial |
$951.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$861.31
|
| 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 |
$951.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$500.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$600.91
|
| Rate for Payer: Health EOS Commercial |
$911.38
|
| Rate for Payer: HFN Commercial |
$951.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$377.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$377.77
|
| Rate for Payer: Multiplan Commercial |
$801.22
|
| Rate for Payer: Preferred Network Access Commercial |
$951.44
|
| Rate for Payer: Quartz Beloit One Network |
$440.67
|
| Rate for Payer: Quartz Commercial |
$570.87
|
| Rate for Payer: The Alliance Commercial |
$500.76
|
| Rate for Payer: WEA Trust Commercial |
$550.84
|
| Rate for Payer: WPS Commercial |
$741.80
|
|
|
US Breast Right
|
Facility
|
OP
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627720
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$1,559.58 |
| Rate for Payer: Aetna Commercial |
$1,525.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,457.87
|
| Rate for Payer: Aetna Managed Medicare |
$110.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,101.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$847.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$813.70
|
| Rate for Payer: Anthem Medicare Advantage |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$898.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$110.02
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cigna Commercial |
$1,559.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$110.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$948.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$110.02
|
| Rate for Payer: Health EOS Commercial |
$1,508.73
|
| Rate for Payer: HFN Commercial |
$1,559.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$409.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$110.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$110.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$110.02
|
| Rate for Payer: Multiplan Commercial |
$1,356.16
|
| Rate for Payer: NAPHCARE Commercial |
$165.03
|
| Rate for Payer: Preferred Network Access Commercial |
$1,559.58
|
| Rate for Payer: Quartz Beloit One Network |
$830.65
|
| Rate for Payer: Quartz Commercial |
$1,101.88
|
| Rate for Payer: Quartz Medicare Advantage |
$110.02
|
| Rate for Payer: The Alliance Commercial |
$440.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.02
|
| Rate for Payer: WEA Trust Commercial |
$932.36
|
| Rate for Payer: Wellcare Medicare |
$110.02
|
| Rate for Payer: WPS Commercial |
$1,255.59
|
|
|
US Breast Right
|
Facility
|
OP
|
$963.00
|
|
|
Service Code
|
CPT 76641 RT,TC
|
| Hospital Charge Code |
2544823
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$280.43 |
| Max. Negotiated Rate |
$921.40 |
| Rate for Payer: Aetna Commercial |
$901.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$861.31
|
| Rate for Payer: Aetna Managed Medicare |
$280.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$848.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$681.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$530.81
|
| 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 |
$921.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$560.47
|
| Rate for Payer: Health EOS Commercial |
$891.35
|
| Rate for Payer: HFN Commercial |
$921.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$751.14
|
| Rate for Payer: Multiplan Commercial |
$801.22
|
| Rate for Payer: NAPHCARE Commercial |
$600.91
|
| Rate for Payer: Preferred Network Access Commercial |
$921.40
|
| Rate for Payer: Quartz Beloit One Network |
$490.74
|
| Rate for Payer: Quartz Commercial |
$650.99
|
| Rate for Payer: Quartz Medicare Advantage |
$600.91
|
| Rate for Payer: The Alliance Commercial |
$500.76
|
| Rate for Payer: United Healthcare PPO |
$596.96
|
| Rate for Payer: WEA Trust Commercial |
$550.84
|
| Rate for Payer: WPS Commercial |
$741.80
|
|
|
US Breast Right
|
Facility
|
IP
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627720
|
| Min. Negotiated Rate |
$830.65 |
| Max. Negotiated Rate |
$1,559.58 |
| Rate for Payer: Aetna Commercial |
$1,525.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,457.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$898.46
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cigna Commercial |
$1,559.58
|
| Rate for Payer: Health EOS Commercial |
$1,508.73
|
| Rate for Payer: HFN Commercial |
$1,559.58
|
| Rate for Payer: Multiplan Commercial |
$1,356.16
|
| Rate for Payer: Preferred Network Access Commercial |
$1,559.58
|
| Rate for Payer: Quartz Beloit One Network |
$830.65
|
| Rate for Payer: Quartz Commercial |
$1,017.12
|
| Rate for Payer: WEA Trust Commercial |
$932.36
|
| Rate for Payer: WPS Commercial |
$1,255.59
|
|
