|
US Drainage Abscess or Cyst
|
Facility
|
IP
|
$1,444.00
|
|
|
Service Code
|
CPT 76942
|
| Hospital Charge Code |
2544829
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$707.56 |
| Max. Negotiated Rate |
$1,328.48 |
| Rate for Payer: Aetna Commercial |
$1,299.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,241.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$765.32
|
| Rate for Payer: Cash Price |
$433.20
|
| Rate for Payer: Cigna Commercial |
$1,328.48
|
| Rate for Payer: Health EOS Commercial |
$1,285.16
|
| Rate for Payer: HFN Commercial |
$1,328.48
|
| Rate for Payer: Multiplan Commercial |
$1,155.20
|
| Rate for Payer: NAPHCARE Commercial |
$866.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,328.48
|
| Rate for Payer: Quartz Beloit One Network |
$707.56
|
| Rate for Payer: Quartz Commercial |
$866.40
|
| Rate for Payer: WEA Trust Commercial |
$794.20
|
| Rate for Payer: WPS Commercial |
$1,069.57
|
|
|
US Drainage Gallbladder
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
CPT 75989 TC
|
| Hospital Charge Code |
5963643
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1,102.50 |
| Max. Negotiated Rate |
$2,070.00 |
| Rate for Payer: Aetna Commercial |
$2,025.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,935.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,192.50
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$2,070.00
|
| Rate for Payer: Health EOS Commercial |
$2,002.50
|
| Rate for Payer: HFN Commercial |
$2,070.00
|
| Rate for Payer: Multiplan Commercial |
$1,800.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,350.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,070.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,102.50
|
| Rate for Payer: Quartz Commercial |
$1,350.00
|
| Rate for Payer: WEA Trust Commercial |
$1,237.50
|
| Rate for Payer: WPS Commercial |
$1,666.58
|
|
|
US Drainage Gallbladder
|
Facility
|
OP
|
$2,250.00
|
|
|
Service Code
|
CPT 75989 TC
|
| Hospital Charge Code |
5963643
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$574.00 |
| Max. Negotiated Rate |
$9,000.00 |
| Rate for Payer: Aetna Commercial |
$2,025.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,935.00
|
| Rate for Payer: Aetna Managed Medicare |
$630.00
|
| 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 |
$1,192.50
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$2,070.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,259.10
|
| Rate for Payer: Health EOS Commercial |
$2,002.50
|
| Rate for Payer: HFN Commercial |
$2,070.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,800.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,350.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,070.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,102.50
|
| Rate for Payer: Quartz Commercial |
$1,462.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,350.00
|
| Rate for Payer: The Alliance Commercial |
$9,000.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$1,237.50
|
| Rate for Payer: WPS Commercial |
$1,666.58
|
|
|
US Drainage Gallbladder
|
Professional
|
Both
|
$2,250.00
|
|
|
Service Code
|
CPT 75989 TC
|
| Hospital Charge Code |
5963643
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$213.88 |
| Max. Negotiated Rate |
$2,137.50 |
| Rate for Payer: Aetna Commercial |
$2,137.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,935.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$2,137.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,125.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,350.00
|
| Rate for Payer: Health EOS Commercial |
$2,047.50
|
| Rate for Payer: HFN Commercial |
$2,137.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$213.88
|
| Rate for Payer: Multiplan Commercial |
$1,800.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,137.50
|
| Rate for Payer: Quartz Beloit One Network |
$990.00
|
| Rate for Payer: Quartz Commercial |
$1,282.50
|
| Rate for Payer: The Alliance Commercial |
$1,125.00
|
| Rate for Payer: WEA Trust Commercial |
$1,237.50
|
| Rate for Payer: WPS Commercial |
$1,666.58
|
|
|
US Drainage Liver
|
Facility
|
OP
|
$2,250.00
|
|
|
Service Code
|
CPT 75989 TC
|
| Hospital Charge Code |
2544831
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$574.00 |
| Max. Negotiated Rate |
$9,000.00 |
| Rate for Payer: Aetna Commercial |
$2,025.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,935.00
|
| Rate for Payer: Aetna Managed Medicare |
$630.00
|
| 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 |
$1,192.50
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$2,070.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,259.10
|
| Rate for Payer: Health EOS Commercial |
$2,002.50
|
| Rate for Payer: HFN Commercial |
$2,070.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,800.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,350.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,070.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,102.50
|
| Rate for Payer: Quartz Commercial |
$1,462.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,350.00
|
| Rate for Payer: The Alliance Commercial |
$9,000.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$1,237.50
|
| Rate for Payer: WPS Commercial |
$1,666.58
|
|
|
US Drainage Liver
|
Professional
|
Both
|
$2,250.00
|
|
|
Service Code
|
CPT 75989 TC
|
| Hospital Charge Code |
2544831
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$213.88 |
| Max. Negotiated Rate |
$2,137.50 |
| Rate for Payer: Aetna Commercial |
$2,137.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,935.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$2,137.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,125.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,350.00
|
| Rate for Payer: Health EOS Commercial |
$2,047.50
|
| Rate for Payer: HFN Commercial |
$2,137.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$213.88
|
| Rate for Payer: Multiplan Commercial |
$1,800.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,137.50
|
| Rate for Payer: Quartz Beloit One Network |
$990.00
|
| Rate for Payer: Quartz Commercial |
$1,282.50
|
| Rate for Payer: The Alliance Commercial |
$1,125.00
|
| Rate for Payer: WEA Trust Commercial |
$1,237.50
|
| Rate for Payer: WPS Commercial |
$1,666.58
|
|
|
US Drainage Liver
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
CPT 75989 TC
|
| Hospital Charge Code |
2544831
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1,102.50 |
| Max. Negotiated Rate |
$2,070.00 |
| Rate for Payer: Aetna Commercial |
$2,025.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,935.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,192.50
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$2,070.00
|
| Rate for Payer: Health EOS Commercial |
$2,002.50
|
| Rate for Payer: HFN Commercial |
$2,070.00
|
| Rate for Payer: Multiplan Commercial |
$1,800.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,350.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,070.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,102.50
|
| Rate for Payer: Quartz Commercial |
$1,350.00
|
| Rate for Payer: WEA Trust Commercial |
$1,237.50
|
| Rate for Payer: WPS Commercial |
$1,666.58
|
|
|
US Drainage Peritoneal
|
Professional
|
Both
|
$1,839.00
|
|
|
Service Code
|
CPT 76999
|
| Hospital Charge Code |
2544841
|
|
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: HFN Commercial |
$1,747.05
|
| 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 Drainage Peritoneal
|
Facility
|
IP
|
$1,839.00
|
|
|
Service Code
|
CPT 76999
|
| Hospital Charge Code |
2544841
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$1,581.54
|
| 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 Drainage Peritoneal
|
Facility
|
OP
|
$1,839.00
|
|
|
Service Code
|
CPT 76999
|
| Hospital Charge Code |
2544841
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$1,691.88 |
| Rate for Payer: Aetna Commercial |
$1,655.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,581.54
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| 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: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,029.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| 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 |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$1,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| 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 |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$1,011.45
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$1,362.15
|
|
|
US Drainage Renal Right
|
Facility
|
IP
|
$1,927.00
|
|
|
Service Code
|
CPT 76942
|
| Hospital Charge Code |
2544847
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$944.23 |
| Max. Negotiated Rate |
$1,772.84 |
| Rate for Payer: Aetna Commercial |
$1,734.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,657.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,021.31
|
| Rate for Payer: Cash Price |
$578.10
|
| Rate for Payer: Cigna Commercial |
$1,772.84
|
| Rate for Payer: Health EOS Commercial |
$1,715.03
|
| Rate for Payer: HFN Commercial |
$1,772.84
|
| Rate for Payer: Multiplan Commercial |
$1,541.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,156.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,772.84
|
| Rate for Payer: Quartz Beloit One Network |
$944.23
|
| Rate for Payer: Quartz Commercial |
$1,156.20
|
| Rate for Payer: WEA Trust Commercial |
$1,059.85
|
| Rate for Payer: WPS Commercial |
$1,427.33
|
|
|
US Drainage Renal Right
|
Facility
|
OP
|
$1,927.00
|
|
|
Service Code
|
CPT 76942
|
| Hospital Charge Code |
2544847
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$539.56 |
| Max. Negotiated Rate |
$7,708.00 |
| Rate for Payer: Aetna Commercial |
$1,734.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,657.22
|
| Rate for Payer: Aetna Managed Medicare |
$539.56
|
| 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 |
$1,021.31
|
| Rate for Payer: Cash Price |
$578.10
|
| Rate for Payer: Cash Price |
$578.10
|
| Rate for Payer: Cash Price |
$578.10
|
| Rate for Payer: Cigna Commercial |
$1,772.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,078.35
|
| Rate for Payer: Health EOS Commercial |
$1,715.03
|
| Rate for Payer: HFN Commercial |
$1,772.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,445.25
|
| Rate for Payer: Multiplan Commercial |
$1,541.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,156.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,772.84
|
| Rate for Payer: Quartz Beloit One Network |
$944.23
|
| Rate for Payer: Quartz Commercial |
$1,252.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,156.20
|
| Rate for Payer: The Alliance Commercial |
$7,708.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$1,059.85
|
| Rate for Payer: WPS Commercial |
$1,427.33
|
|
|
US Drainage Renal Right
|
Professional
|
Both
|
$1,927.00
|
|
|
Service Code
|
CPT 76942
|
| Hospital Charge Code |
2544847
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$196.90 |
| Max. Negotiated Rate |
$1,830.65 |
| Rate for Payer: Aetna Commercial |
$1,830.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,657.22
|
| Rate for Payer: Cash Price |
$578.10
|
| Rate for Payer: Cash Price |
$578.10
|
| Rate for Payer: Cigna Commercial |
$1,830.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$963.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,156.20
|
| Rate for Payer: Health EOS Commercial |
$1,753.57
|
| Rate for Payer: HFN Commercial |
$1,830.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$196.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$196.90
|
| Rate for Payer: Multiplan Commercial |
$1,541.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,830.65
|
| Rate for Payer: Quartz Beloit One Network |
$847.88
|
| Rate for Payer: Quartz Commercial |
$1,098.39
|
| Rate for Payer: The Alliance Commercial |
$963.50
|
| Rate for Payer: WEA Trust Commercial |
$1,059.85
|
| Rate for Payer: WPS Commercial |
$1,427.33
|
|
|
US ED Abdomen Limited
|
Professional
|
Both
|
$590.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587091
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$211.55 |
| Max. Negotiated Rate |
$560.50 |
| Rate for Payer: Aetna Commercial |
$560.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$507.40
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$560.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$295.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$354.00
|
| Rate for Payer: Health EOS Commercial |
$536.90
|
| Rate for Payer: HFN Commercial |
$560.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$211.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.55
|
| Rate for Payer: Multiplan Commercial |
$472.00
|
| Rate for Payer: Preferred Network Access Commercial |
$560.50
|
| Rate for Payer: Quartz Beloit One Network |
$259.60
|
| Rate for Payer: Quartz Commercial |
$336.30
|
| Rate for Payer: The Alliance Commercial |
$295.00
|
| Rate for Payer: WEA Trust Commercial |
$324.50
|
| Rate for Payer: WPS Commercial |
$437.01
|
|
|
US ED Abdomen Limited
|
Facility
|
OP
|
$615.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
3100311
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$172.20 |
| Max. Negotiated Rate |
$2,460.00 |
| Rate for Payer: Aetna Commercial |
$553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.90
|
| Rate for Payer: Aetna Managed Medicare |
$172.20
|
| 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 |
$325.95
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$565.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$344.15
|
| Rate for Payer: Health EOS Commercial |
$547.35
|
| Rate for Payer: HFN Commercial |
$565.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$461.25
|
| Rate for Payer: Multiplan Commercial |
$492.00
|
| Rate for Payer: NAPHCARE Commercial |
$369.00
|
| Rate for Payer: Preferred Network Access Commercial |
$565.80
|
| Rate for Payer: Quartz Beloit One Network |
$301.35
|
| Rate for Payer: Quartz Commercial |
$399.75
|
| Rate for Payer: Quartz Medicare Advantage |
$369.00
|
| Rate for Payer: The Alliance Commercial |
$2,460.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: WPS Commercial |
$455.53
|
|
|
US ED Abdomen Limited
|
Facility
|
IP
|
$615.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
3100311
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$301.35 |
| Max. Negotiated Rate |
$565.80 |
| Rate for Payer: Aetna Commercial |
$553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.95
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$565.80
|
| Rate for Payer: Health EOS Commercial |
$547.35
|
| Rate for Payer: HFN Commercial |
$565.80
|
| Rate for Payer: Multiplan Commercial |
$492.00
|
| Rate for Payer: NAPHCARE Commercial |
$369.00
|
| Rate for Payer: Preferred Network Access Commercial |
$565.80
|
| Rate for Payer: Quartz Beloit One Network |
$301.35
|
| Rate for Payer: Quartz Commercial |
$369.00
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: WPS Commercial |
$455.53
|
|
|
US ED Abdomen Limited
|
Facility
|
OP
|
$590.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587091
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$165.20 |
| Max. Negotiated Rate |
$2,360.00 |
| Rate for Payer: Aetna Commercial |
$531.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$507.40
|
| Rate for Payer: Aetna Managed Medicare |
$165.20
|
| 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 |
$312.70
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$542.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$330.16
|
| Rate for Payer: Health EOS Commercial |
$525.10
|
| Rate for Payer: HFN Commercial |
$542.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$442.50
|
| Rate for Payer: Multiplan Commercial |
$472.00
|
| Rate for Payer: NAPHCARE Commercial |
$354.00
|
| Rate for Payer: Preferred Network Access Commercial |
$542.80
|
| Rate for Payer: Quartz Beloit One Network |
$289.10
|
| Rate for Payer: Quartz Commercial |
$383.50
|
| Rate for Payer: Quartz Medicare Advantage |
$354.00
|
| Rate for Payer: The Alliance Commercial |
$2,360.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$324.50
|
| Rate for Payer: WPS Commercial |
$437.01
|
|
|
US ED Abdomen Limited
|
Professional
|
Both
|
$615.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
3100311
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$211.55 |
| Max. Negotiated Rate |
$584.25 |
| Rate for Payer: Aetna Commercial |
$584.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.90
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$584.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$307.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$369.00
|
| Rate for Payer: Health EOS Commercial |
$559.65
|
| Rate for Payer: HFN Commercial |
$584.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$211.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.55
|
| Rate for Payer: Multiplan Commercial |
$492.00
|
| Rate for Payer: Preferred Network Access Commercial |
$584.25
|
| Rate for Payer: Quartz Beloit One Network |
$270.60
|
| Rate for Payer: Quartz Commercial |
$350.55
|
| Rate for Payer: The Alliance Commercial |
$307.50
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: WPS Commercial |
$455.53
|
|
|
US ED Abdomen Limited
|
Facility
|
IP
|
$590.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587091
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$289.10 |
| Max. Negotiated Rate |
$542.80 |
| Rate for Payer: Aetna Commercial |
$531.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$507.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$312.70
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$542.80
|
| Rate for Payer: Health EOS Commercial |
$525.10
|
| Rate for Payer: HFN Commercial |
$542.80
|
| Rate for Payer: Multiplan Commercial |
$472.00
|
| Rate for Payer: NAPHCARE Commercial |
$354.00
|
| Rate for Payer: Preferred Network Access Commercial |
$542.80
|
| Rate for Payer: Quartz Beloit One Network |
$289.10
|
| Rate for Payer: Quartz Commercial |
$354.00
|
| Rate for Payer: WEA Trust Commercial |
$324.50
|
| Rate for Payer: WPS Commercial |
$437.01
|
|
|
US ED Abd, Pel, Non OB eval
|
Professional
|
Both
|
$387.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
2587085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.58 |
| Max. Negotiated Rate |
$367.65 |
| Rate for Payer: Aetna Commercial |
$367.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$332.82
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$367.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$193.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$232.20
|
| Rate for Payer: Health EOS Commercial |
$352.17
|
| Rate for Payer: HFN Commercial |
$367.65
|
| 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 |
$309.60
|
| Rate for Payer: Preferred Network Access Commercial |
$367.65
|
| Rate for Payer: Quartz Beloit One Network |
$170.28
|
| Rate for Payer: Quartz Commercial |
$220.59
|
| Rate for Payer: The Alliance Commercial |
$193.50
|
| Rate for Payer: WEA Trust Commercial |
$212.85
|
| Rate for Payer: WPS Commercial |
$286.65
|
|
|
US ED Abd, Pel, Non OB eval
|
Facility
|
OP
|
$387.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
2587085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.36 |
| Max. Negotiated Rate |
$1,548.00 |
| Rate for Payer: Aetna Commercial |
$348.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$332.82
|
| Rate for Payer: Aetna Managed Medicare |
$108.36
|
| 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 |
$205.11
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$356.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$216.57
|
| Rate for Payer: Health EOS Commercial |
$344.43
|
| Rate for Payer: HFN Commercial |
$356.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$290.25
|
| Rate for Payer: Multiplan Commercial |
$309.60
|
| Rate for Payer: NAPHCARE Commercial |
$232.20
|
| Rate for Payer: Preferred Network Access Commercial |
$356.04
|
| Rate for Payer: Quartz Beloit One Network |
$189.63
|
| Rate for Payer: Quartz Commercial |
$251.55
|
| Rate for Payer: Quartz Medicare Advantage |
$232.20
|
| Rate for Payer: The Alliance Commercial |
$1,548.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$212.85
|
| Rate for Payer: WPS Commercial |
$286.65
|
|
|
US ED Abd, Pel, Non OB eval
|
Facility
|
IP
|
$387.00
|
|
|
Service Code
|
CPT 76857 TC
|
| Hospital Charge Code |
2587085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$189.63 |
| Max. Negotiated Rate |
$356.04 |
| Rate for Payer: Aetna Commercial |
$348.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$332.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.11
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$356.04
|
| Rate for Payer: Health EOS Commercial |
$344.43
|
| Rate for Payer: HFN Commercial |
$356.04
|
| Rate for Payer: Multiplan Commercial |
$309.60
|
| Rate for Payer: NAPHCARE Commercial |
$232.20
|
| Rate for Payer: Preferred Network Access Commercial |
$356.04
|
| Rate for Payer: Quartz Beloit One Network |
$189.63
|
| Rate for Payer: Quartz Commercial |
$232.20
|
| Rate for Payer: WEA Trust Commercial |
$212.85
|
| Rate for Payer: WPS Commercial |
$286.65
|
|
|
US ED Abd, Pel, Pregnancy
|
Facility
|
IP
|
$438.00
|
|
|
Service Code
|
CPT 76815 TC
|
| Hospital Charge Code |
2587088
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$214.62 |
| Max. Negotiated Rate |
$402.96 |
| Rate for Payer: Aetna Commercial |
$394.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$376.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$232.14
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$402.96
|
| Rate for Payer: Health EOS Commercial |
$389.82
|
| Rate for Payer: HFN Commercial |
$402.96
|
| Rate for Payer: Multiplan Commercial |
$350.40
|
| Rate for Payer: NAPHCARE Commercial |
$262.80
|
| Rate for Payer: Preferred Network Access Commercial |
$402.96
|
| Rate for Payer: Quartz Beloit One Network |
$214.62
|
| Rate for Payer: Quartz Commercial |
$262.80
|
| Rate for Payer: WEA Trust Commercial |
$240.90
|
| Rate for Payer: WPS Commercial |
$324.43
|
|
|
US ED Abd, Pel, Pregnancy
|
Facility
|
OP
|
$438.00
|
|
|
Service Code
|
CPT 76815 TC
|
| Hospital Charge Code |
2587088
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$122.64 |
| Max. Negotiated Rate |
$1,752.00 |
| Rate for Payer: Aetna Commercial |
$394.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$376.68
|
| Rate for Payer: Aetna Managed Medicare |
$122.64
|
| 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 |
$232.14
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$402.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$245.10
|
| Rate for Payer: Health EOS Commercial |
$389.82
|
| Rate for Payer: HFN Commercial |
$402.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$328.50
|
| Rate for Payer: Multiplan Commercial |
$350.40
|
| Rate for Payer: NAPHCARE Commercial |
$262.80
|
| Rate for Payer: Preferred Network Access Commercial |
$402.96
|
| Rate for Payer: Quartz Beloit One Network |
$214.62
|
| Rate for Payer: Quartz Commercial |
$284.70
|
| Rate for Payer: Quartz Medicare Advantage |
$262.80
|
| Rate for Payer: The Alliance Commercial |
$1,752.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$240.90
|
| Rate for Payer: WPS Commercial |
$324.43
|
|
|
US ED Aorta/Renal
|
Facility
|
OP
|
$543.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587095
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$152.04 |
| Max. Negotiated Rate |
$2,172.00 |
| Rate for Payer: Aetna Commercial |
$488.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$466.98
|
| Rate for Payer: Aetna Managed Medicare |
$152.04
|
| 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 |
$287.79
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cigna Commercial |
$499.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$303.86
|
| Rate for Payer: Health EOS Commercial |
$483.27
|
| Rate for Payer: HFN Commercial |
$499.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$407.25
|
| Rate for Payer: Multiplan Commercial |
$434.40
|
| Rate for Payer: NAPHCARE Commercial |
$325.80
|
| Rate for Payer: Preferred Network Access Commercial |
$499.56
|
| Rate for Payer: Quartz Beloit One Network |
$266.07
|
| Rate for Payer: Quartz Commercial |
$352.95
|
| Rate for Payer: Quartz Medicare Advantage |
$325.80
|
| Rate for Payer: The Alliance Commercial |
$2,172.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$298.65
|
| Rate for Payer: WPS Commercial |
$402.20
|
|
