|
US Bladder
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
CPT 76857
|
| Hospital Charge Code |
2552805
|
| Min. Negotiated Rate |
$163.62 |
| Max. Negotiated Rate |
$950.00 |
| Rate for Payer: Aetna Commercial |
$950.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$860.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$950.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$500.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$600.00
|
| Rate for Payer: Health EOS Commercial |
$910.00
|
| Rate for Payer: HFN Commercial |
$950.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$163.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$163.62
|
| Rate for Payer: Multiplan Commercial |
$800.00
|
| Rate for Payer: Preferred Network Access Commercial |
$950.00
|
| Rate for Payer: Quartz Beloit One Network |
$440.00
|
| Rate for Payer: Quartz Commercial |
$570.00
|
| Rate for Payer: The Alliance Commercial |
$500.00
|
| Rate for Payer: WEA Trust Commercial |
$550.00
|
| Rate for Payer: WPS Commercial |
$740.70
|
|
|
US Bladder
|
Professional
|
Both
|
$1,067.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
3072736
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.58 |
| Max. Negotiated Rate |
$1,013.65 |
| Rate for Payer: Aetna Commercial |
$1,013.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$917.62
|
| Rate for Payer: Cash Price |
$320.10
|
| Rate for Payer: Cash Price |
$320.10
|
| Rate for Payer: Cigna Commercial |
$1,013.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$533.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$640.20
|
| Rate for Payer: Health EOS Commercial |
$970.97
|
| Rate for Payer: HFN Commercial |
$1,013.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$81.58
|
| Rate for Payer: Multiplan Commercial |
$853.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,013.65
|
| Rate for Payer: Quartz Beloit One Network |
$469.48
|
| Rate for Payer: Quartz Commercial |
$608.19
|
| Rate for Payer: The Alliance Commercial |
$533.50
|
| Rate for Payer: WEA Trust Commercial |
$586.85
|
| Rate for Payer: WPS Commercial |
$790.33
|
|
|
US Bladder
|
Professional
|
Both
|
$1,067.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
2587082
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.58 |
| Max. Negotiated Rate |
$1,013.65 |
| Rate for Payer: Aetna Commercial |
$1,013.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$917.62
|
| Rate for Payer: Cash Price |
$320.10
|
| Rate for Payer: Cash Price |
$320.10
|
| Rate for Payer: Cigna Commercial |
$1,013.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$533.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$640.20
|
| Rate for Payer: Health EOS Commercial |
$970.97
|
| Rate for Payer: HFN Commercial |
$1,013.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$81.58
|
| Rate for Payer: Multiplan Commercial |
$853.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,013.65
|
| Rate for Payer: Quartz Beloit One Network |
$469.48
|
| Rate for Payer: Quartz Commercial |
$608.19
|
| Rate for Payer: The Alliance Commercial |
$533.50
|
| Rate for Payer: WEA Trust Commercial |
$586.85
|
| Rate for Payer: WPS Commercial |
$790.33
|
|
|
US Bladder
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
CPT 76857
|
| Hospital Charge Code |
2552805
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$920.00 |
| Rate for Payer: Aetna Commercial |
$900.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$860.00
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$650.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$500.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$480.00
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$530.00
|
| 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 |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$920.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$559.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$890.00
|
| Rate for Payer: HFN Commercial |
$920.00
|
| 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 |
$800.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$920.00
|
| Rate for Payer: Quartz Beloit One Network |
$490.00
|
| Rate for Payer: Quartz Commercial |
$650.00
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$550.00
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$740.70
|
|
|
US Bladder
|
Facility
|
IP
|
$1,067.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
2587082
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$522.83 |
| Max. Negotiated Rate |
$981.64 |
| Rate for Payer: Aetna Commercial |
$960.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$917.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$565.51
|
| Rate for Payer: Cash Price |
$320.10
|
| Rate for Payer: Cigna Commercial |
$981.64
|
| Rate for Payer: Health EOS Commercial |
$949.63
|
| Rate for Payer: HFN Commercial |
$981.64
|
| Rate for Payer: Multiplan Commercial |
$853.60
|
| Rate for Payer: NAPHCARE Commercial |
$640.20
|
| Rate for Payer: Preferred Network Access Commercial |
$981.64
|
| Rate for Payer: Quartz Beloit One Network |
$522.83
|
| Rate for Payer: Quartz Commercial |
$640.20
|
| Rate for Payer: WEA Trust Commercial |
$586.85
|
| Rate for Payer: WPS Commercial |
$790.33
|
|
|
US Bone Stimulation 20979
|
Professional
|
Both
|
$1,535.00
|
|
|
Service Code
|
CPT 20979
|
| Hospital Charge Code |
3798690
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.58 |
| Max. Negotiated Rate |
$1,458.25 |
| Rate for Payer: Aetna Commercial |
$1,458.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,320.10
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,458.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$921.00
|
| Rate for Payer: Health EOS Commercial |
$1,396.85
|
| Rate for Payer: HFN Commercial |
$1,458.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$105.16
|
| Rate for Payer: Multiplan Commercial |
$1,228.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,458.25
|
| Rate for Payer: Quartz Beloit One Network |
$675.40
|
| Rate for Payer: Quartz Commercial |
$874.95
|
| Rate for Payer: The Alliance Commercial |
$767.50
|
| Rate for Payer: United Healthcare Medicaid |
$15.58
|
| Rate for Payer: WEA Trust Commercial |
$844.25
|
| Rate for Payer: WPS Commercial |
$1,136.97
|
|
|
US Breast & Axillary Bilateral
|
Facility
|
IP
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC
|
| Hospital Charge Code |
6196375
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$471.87 |
| Max. Negotiated Rate |
$885.96 |
| Rate for Payer: Aetna Commercial |
$866.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| 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 Breast & Axillary Bilateral
|
Facility
|
OP
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC
|
| Hospital Charge Code |
6196375
|
|
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: Dean Health DHI/DHP/ASO |
$538.89
|
| 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 Breast & Axillary Bilateral
|
Professional
|
Both
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC
|
| Hospital Charge Code |
6196375
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$241.70 |
| 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: HFN Commercial |
$914.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$241.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$241.70
|
| Rate for Payer: 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 Breast & Axillary Left
|
Facility
|
OP
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC,LT
|
| Hospital Charge Code |
6196378
|
|
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: Dean Health DHI/DHP/ASO |
$538.89
|
| 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 Breast & Axillary Left
|
Professional
|
Both
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC,LT
|
| Hospital Charge Code |
6196378
|
|
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: HFN Commercial |
$914.85
|
| 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 Breast & Axillary Left
|
Facility
|
IP
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC,LT
|
| Hospital Charge Code |
6196378
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$471.87 |
| Max. Negotiated Rate |
$885.96 |
| Rate for Payer: Aetna Commercial |
$866.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| 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 Breast & Axillary Right
|
Facility
|
OP
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC,RT
|
| Hospital Charge Code |
6196381
|
|
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: Dean Health DHI/DHP/ASO |
$538.89
|
| 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 Breast & Axillary Right
|
Professional
|
Both
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC,RT
|
| Hospital Charge Code |
6196381
|
|
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: HFN Commercial |
$914.85
|
| 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 Breast & Axillary Right
|
Facility
|
IP
|
$963.00
|
|
|
Service Code
|
CPT 76641 TC,RT
|
| Hospital Charge Code |
6196381
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$471.87 |
| Max. Negotiated Rate |
$885.96 |
| Rate for Payer: Aetna Commercial |
$866.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| 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 Breast Bilateral
|
Facility
|
OP
|
$3,260.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627716
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$2,999.20 |
| Rate for Payer: Aetna Commercial |
$2,934.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,803.60
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,119.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,630.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,564.80
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,727.80
|
| 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 |
$978.00
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cigna Commercial |
$2,999.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,824.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$2,901.40
|
| Rate for Payer: HFN Commercial |
$2,999.20
|
| 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 |
$2,608.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,999.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,597.40
|
| Rate for Payer: Quartz Commercial |
$2,119.00
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$1,793.00
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$2,414.68
|
|
|
US Breast Bilateral
|
Professional
|
Both
|
$3,260.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627716
|
| Min. Negotiated Rate |
$363.24 |
| Max. Negotiated Rate |
$3,097.00 |
| Rate for Payer: Aetna Commercial |
$3,097.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,803.60
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cigna Commercial |
$3,097.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,630.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,956.00
|
| Rate for Payer: Health EOS Commercial |
$2,966.60
|
| Rate for Payer: HFN Commercial |
$3,097.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$363.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$363.24
|
| Rate for Payer: Multiplan Commercial |
$2,608.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,097.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,434.40
|
| Rate for Payer: Quartz Commercial |
$1,858.20
|
| Rate for Payer: The Alliance Commercial |
$1,630.00
|
| Rate for Payer: WEA Trust Commercial |
$1,793.00
|
| Rate for Payer: WPS Commercial |
$2,414.68
|
|
|
US Breast Bilateral
|
Facility
|
IP
|
$3,260.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627716
|
| Min. Negotiated Rate |
$1,597.40 |
| Max. Negotiated Rate |
$2,999.20 |
| Rate for Payer: Aetna Commercial |
$2,934.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,803.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,727.80
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cigna Commercial |
$2,999.20
|
| Rate for Payer: Health EOS Commercial |
$2,901.40
|
| Rate for Payer: HFN Commercial |
$2,999.20
|
| Rate for Payer: Multiplan Commercial |
$2,608.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,956.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,999.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,597.40
|
| Rate for Payer: Quartz Commercial |
$1,956.00
|
| Rate for Payer: WEA Trust Commercial |
$1,793.00
|
| Rate for Payer: WPS Commercial |
$2,414.68
|
|
|
US BREAST BIL REAL TIME WITH IMAGE 7664150
|
Professional
|
Both
|
$1,016.00
|
|
|
Service Code
|
CPT 76641 50
|
| Hospital Charge Code |
5577481
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$447.04 |
| Max. Negotiated Rate |
$965.20 |
| Rate for Payer: Aetna Commercial |
$965.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$873.76
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$965.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$508.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$609.60
|
| Rate for Payer: Health EOS Commercial |
$924.56
|
| Rate for Payer: HFN Commercial |
$965.20
|
| Rate for Payer: Multiplan Commercial |
$812.80
|
| Rate for Payer: Preferred Network Access Commercial |
$965.20
|
| Rate for Payer: Quartz Beloit One Network |
$447.04
|
| Rate for Payer: Quartz Commercial |
$579.12
|
| Rate for Payer: The Alliance Commercial |
$508.00
|
| Rate for Payer: WEA Trust Commercial |
$558.80
|
| Rate for Payer: WPS Commercial |
$752.55
|
|
|
US Breast Left
|
Professional
|
Both
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627718
|
| Min. Negotiated Rate |
$363.24 |
| Max. Negotiated Rate |
$1,548.50 |
| Rate for Payer: Aetna Commercial |
$1,548.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,401.80
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cigna Commercial |
$1,548.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$815.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$978.00
|
| Rate for Payer: Health EOS Commercial |
$1,483.30
|
| Rate for Payer: HFN Commercial |
$1,548.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$363.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$363.24
|
| Rate for Payer: Multiplan Commercial |
$1,304.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,548.50
|
| Rate for Payer: Quartz Beloit One Network |
$717.20
|
| Rate for Payer: Quartz Commercial |
$929.10
|
| Rate for Payer: The Alliance Commercial |
$815.00
|
| Rate for Payer: WEA Trust Commercial |
$896.50
|
| Rate for Payer: WPS Commercial |
$1,207.34
|
|
|
US Breast Left
|
Facility
|
IP
|
$963.00
|
|
|
Service Code
|
CPT 76641 LT,TC
|
| Hospital Charge Code |
2544821
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$471.87 |
| Max. Negotiated Rate |
$885.96 |
| Rate for Payer: Aetna Commercial |
$866.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.18
|
| 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 Breast Left
|
Professional
|
Both
|
$963.00
|
|
|
Service Code
|
CPT 76641 LT,TC
|
| Hospital Charge Code |
2544821
|
|
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: HFN Commercial |
$914.85
|
| 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 Breast Left
|
Facility
|
OP
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627718
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,499.60 |
| Rate for Payer: Aetna Commercial |
$1,467.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,401.80
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,059.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$815.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$782.40
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$863.90
|
| 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 |
$489.00
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cigna Commercial |
$1,499.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$912.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,450.70
|
| Rate for Payer: HFN Commercial |
$1,499.60
|
| 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 |
$1,304.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,499.60
|
| Rate for Payer: Quartz Beloit One Network |
$798.70
|
| Rate for Payer: Quartz Commercial |
$1,059.50
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$896.50
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,207.34
|
|
|
US Breast Left
|
Facility
|
IP
|
$1,630.00
|
|
|
Service Code
|
CPT 76641
|
| Hospital Charge Code |
627718
|
| Min. Negotiated Rate |
$798.70 |
| Max. Negotiated Rate |
$1,499.60 |
| Rate for Payer: Aetna Commercial |
$1,467.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,401.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$863.90
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cigna Commercial |
$1,499.60
|
| Rate for Payer: Health EOS Commercial |
$1,450.70
|
| Rate for Payer: HFN Commercial |
$1,499.60
|
| Rate for Payer: Multiplan Commercial |
$1,304.00
|
| Rate for Payer: NAPHCARE Commercial |
$978.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,499.60
|
| Rate for Payer: Quartz Beloit One Network |
$798.70
|
| Rate for Payer: Quartz Commercial |
$978.00
|
| Rate for Payer: WEA Trust Commercial |
$896.50
|
| Rate for Payer: WPS Commercial |
$1,207.34
|
|
|
US Breast Left
|
Facility
|
OP
|
$963.00
|
|
|
Service Code
|
CPT 76641 LT,TC
|
| Hospital Charge Code |
2544821
|
|
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: Dean Health DHI/DHP/ASO |
$538.89
|
| 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
|
|
