|
US Left Lower Quadrant
|
Facility
|
OP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711775
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,379.08 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$974.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$749.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$719.52
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$794.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,379.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$838.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,334.11
|
| Rate for Payer: HFN Commercial |
$1,379.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,379.08
|
| Rate for Payer: Quartz Beloit One Network |
$734.51
|
| Rate for Payer: Quartz Commercial |
$974.35
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Left Lower Quadrant
|
Facility
|
OP
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544915
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$436.52 |
| Max. Negotiated Rate |
$6,236.00 |
| Rate for Payer: Aetna Commercial |
$1,403.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Aetna Managed Medicare |
$436.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$826.27
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cigna Commercial |
$1,434.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$872.42
|
| Rate for Payer: Health EOS Commercial |
$1,387.51
|
| Rate for Payer: HFN Commercial |
$1,434.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,169.25
|
| Rate for Payer: Multiplan Commercial |
$1,247.20
|
| Rate for Payer: NAPHCARE Commercial |
$935.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,434.28
|
| Rate for Payer: Quartz Beloit One Network |
$763.91
|
| Rate for Payer: Quartz Commercial |
$1,013.35
|
| Rate for Payer: Quartz Medicare Advantage |
$935.40
|
| Rate for Payer: The Alliance Commercial |
$6,236.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
|
US Left Lower Quadrant
|
Facility
|
IP
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544915
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$763.91 |
| Max. Negotiated Rate |
$1,434.28 |
| Rate for Payer: Aetna Commercial |
$1,403.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$826.27
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cigna Commercial |
$1,434.28
|
| Rate for Payer: Health EOS Commercial |
$1,387.51
|
| Rate for Payer: HFN Commercial |
$1,434.28
|
| Rate for Payer: Multiplan Commercial |
$1,247.20
|
| Rate for Payer: NAPHCARE Commercial |
$935.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,434.28
|
| Rate for Payer: Quartz Beloit One Network |
$763.91
|
| Rate for Payer: Quartz Commercial |
$935.40
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
|
US Left Lower Quadrant
|
Professional
|
Both
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711775
|
| Min. Negotiated Rate |
$310.04 |
| Max. Negotiated Rate |
$1,424.05 |
| Rate for Payer: Aetna Commercial |
$1,424.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,424.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$749.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$899.40
|
| Rate for Payer: Health EOS Commercial |
$1,364.09
|
| Rate for Payer: HFN Commercial |
$1,424.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$310.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$310.04
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,424.05
|
| Rate for Payer: Quartz Beloit One Network |
$659.56
|
| Rate for Payer: Quartz Commercial |
$854.43
|
| Rate for Payer: The Alliance Commercial |
$749.50
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Left Lower Quadrant
|
Professional
|
Both
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544915
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$211.55 |
| Max. Negotiated Rate |
$1,481.05 |
| Rate for Payer: Aetna Commercial |
$1,481.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cigna Commercial |
$1,481.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$779.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$935.40
|
| Rate for Payer: Health EOS Commercial |
$1,418.69
|
| Rate for Payer: HFN Commercial |
$1,481.05
|
| 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 |
$1,247.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,481.05
|
| Rate for Payer: Quartz Beloit One Network |
$685.96
|
| Rate for Payer: Quartz Commercial |
$888.63
|
| Rate for Payer: The Alliance Commercial |
$779.50
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
|
US Left Lower Quadrant
|
Facility
|
IP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711775
|
| Min. Negotiated Rate |
$734.51 |
| Max. Negotiated Rate |
$1,379.08 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$794.47
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,379.08
|
| Rate for Payer: Health EOS Commercial |
$1,334.11
|
| Rate for Payer: HFN Commercial |
$1,379.08
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: NAPHCARE Commercial |
$899.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,379.08
|
| Rate for Payer: Quartz Beloit One Network |
$734.51
|
| Rate for Payer: Quartz Commercial |
$899.40
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Left Upper Quadrant
|
Professional
|
Both
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544918
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$211.55 |
| Max. Negotiated Rate |
$1,481.05 |
| Rate for Payer: Aetna Commercial |
$1,481.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cigna Commercial |
$1,481.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$779.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$935.40
|
| Rate for Payer: Health EOS Commercial |
$1,418.69
|
| Rate for Payer: HFN Commercial |
$1,481.05
|
| 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 |
$1,247.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,481.05
|
| Rate for Payer: Quartz Beloit One Network |
$685.96
|
| Rate for Payer: Quartz Commercial |
$888.63
|
| Rate for Payer: The Alliance Commercial |
$779.50
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
|
US Left Upper Quadrant
|
Professional
|
Both
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711776
|
| Min. Negotiated Rate |
$310.04 |
| Max. Negotiated Rate |
$1,424.05 |
| Rate for Payer: Aetna Commercial |
$1,424.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,424.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$749.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$899.40
|
| Rate for Payer: Health EOS Commercial |
$1,364.09
|
| Rate for Payer: HFN Commercial |
$1,424.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$310.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$310.04
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,424.05
|
| Rate for Payer: Quartz Beloit One Network |
$659.56
|
| Rate for Payer: Quartz Commercial |
$854.43
|
| Rate for Payer: The Alliance Commercial |
$749.50
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Left Upper Quadrant
|
Facility
|
IP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711776
|
| Min. Negotiated Rate |
$734.51 |
| Max. Negotiated Rate |
$1,379.08 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$794.47
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,379.08
|
| Rate for Payer: Health EOS Commercial |
$1,334.11
|
| Rate for Payer: HFN Commercial |
$1,379.08
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: NAPHCARE Commercial |
$899.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,379.08
|
| Rate for Payer: Quartz Beloit One Network |
$734.51
|
| Rate for Payer: Quartz Commercial |
$899.40
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Left Upper Quadrant
|
Facility
|
OP
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544918
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$436.52 |
| Max. Negotiated Rate |
$6,236.00 |
| Rate for Payer: Aetna Commercial |
$1,403.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Aetna Managed Medicare |
$436.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$826.27
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cigna Commercial |
$1,434.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$872.42
|
| Rate for Payer: Health EOS Commercial |
$1,387.51
|
| Rate for Payer: HFN Commercial |
$1,434.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,169.25
|
| Rate for Payer: Multiplan Commercial |
$1,247.20
|
| Rate for Payer: NAPHCARE Commercial |
$935.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,434.28
|
| Rate for Payer: Quartz Beloit One Network |
$763.91
|
| Rate for Payer: Quartz Commercial |
$1,013.35
|
| Rate for Payer: Quartz Medicare Advantage |
$935.40
|
| Rate for Payer: The Alliance Commercial |
$6,236.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
|
US Left Upper Quadrant
|
Facility
|
IP
|
$1,559.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544918
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$763.91 |
| Max. Negotiated Rate |
$1,434.28 |
| Rate for Payer: Aetna Commercial |
$1,403.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$826.27
|
| Rate for Payer: Cash Price |
$467.70
|
| Rate for Payer: Cigna Commercial |
$1,434.28
|
| Rate for Payer: Health EOS Commercial |
$1,387.51
|
| Rate for Payer: HFN Commercial |
$1,434.28
|
| Rate for Payer: Multiplan Commercial |
$1,247.20
|
| Rate for Payer: NAPHCARE Commercial |
$935.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,434.28
|
| Rate for Payer: Quartz Beloit One Network |
$763.91
|
| Rate for Payer: Quartz Commercial |
$935.40
|
| Rate for Payer: WEA Trust Commercial |
$857.45
|
| Rate for Payer: WPS Commercial |
$1,154.75
|
|
|
US Left Upper Quadrant
|
Facility
|
OP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711776
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,379.08 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$974.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$749.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$719.52
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$794.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,379.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$838.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,334.11
|
| Rate for Payer: HFN Commercial |
$1,379.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,379.08
|
| Rate for Payer: Quartz Beloit One Network |
$734.51
|
| Rate for Payer: Quartz Commercial |
$974.35
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Liver
|
Professional
|
Both
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
2552807
|
| Min. Negotiated Rate |
$310.04 |
| Max. Negotiated Rate |
$1,424.05 |
| Rate for Payer: Aetna Commercial |
$1,424.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,424.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$749.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$899.40
|
| Rate for Payer: Health EOS Commercial |
$1,364.09
|
| Rate for Payer: HFN Commercial |
$1,424.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$310.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$310.04
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,424.05
|
| Rate for Payer: Quartz Beloit One Network |
$659.56
|
| Rate for Payer: Quartz Commercial |
$854.43
|
| Rate for Payer: The Alliance Commercial |
$749.50
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Liver
|
Facility
|
IP
|
$1,763.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587172
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$863.87 |
| Max. Negotiated Rate |
$1,621.96 |
| Rate for Payer: Aetna Commercial |
$1,586.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.39
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,621.96
|
| Rate for Payer: Health EOS Commercial |
$1,569.07
|
| Rate for Payer: HFN Commercial |
$1,621.96
|
| Rate for Payer: Multiplan Commercial |
$1,410.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,057.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,621.96
|
| Rate for Payer: Quartz Beloit One Network |
$863.87
|
| Rate for Payer: Quartz Commercial |
$1,057.80
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
US Liver
|
Facility
|
OP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
2552807
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,379.08 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$974.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$749.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$719.52
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$794.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,379.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$838.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,334.11
|
| Rate for Payer: HFN Commercial |
$1,379.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,379.08
|
| Rate for Payer: Quartz Beloit One Network |
$734.51
|
| Rate for Payer: Quartz Commercial |
$974.35
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Liver
|
Facility
|
OP
|
$1,763.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587172
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$493.64 |
| Max. Negotiated Rate |
$7,052.00 |
| Rate for Payer: Aetna Commercial |
$1,586.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Aetna Managed Medicare |
$493.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.39
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,621.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$986.57
|
| Rate for Payer: Health EOS Commercial |
$1,569.07
|
| Rate for Payer: HFN Commercial |
$1,621.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,322.25
|
| Rate for Payer: Multiplan Commercial |
$1,410.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,057.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,621.96
|
| Rate for Payer: Quartz Beloit One Network |
$863.87
|
| Rate for Payer: Quartz Commercial |
$1,145.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,057.80
|
| Rate for Payer: The Alliance Commercial |
$7,052.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
US Liver
|
Professional
|
Both
|
$1,763.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2587172
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$211.55 |
| Max. Negotiated Rate |
$1,674.85 |
| Rate for Payer: Aetna Commercial |
$1,674.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,674.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$881.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,057.80
|
| Rate for Payer: Health EOS Commercial |
$1,604.33
|
| Rate for Payer: HFN Commercial |
$1,674.85
|
| 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 |
$1,410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,674.85
|
| Rate for Payer: Quartz Beloit One Network |
$775.72
|
| Rate for Payer: Quartz Commercial |
$1,004.91
|
| Rate for Payer: The Alliance Commercial |
$881.50
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
US Liver
|
Facility
|
IP
|
$1,499.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
2552807
|
| Min. Negotiated Rate |
$734.51 |
| Max. Negotiated Rate |
$1,379.08 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$794.47
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,379.08
|
| Rate for Payer: Health EOS Commercial |
$1,334.11
|
| Rate for Payer: HFN Commercial |
$1,379.08
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: NAPHCARE Commercial |
$899.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,379.08
|
| Rate for Payer: Quartz Beloit One Network |
$734.51
|
| Rate for Payer: Quartz Commercial |
$899.40
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
US Lower Extremity Non-Vascular Bilat
|
Facility
|
OP
|
$1,128.00
|
|
|
Service Code
|
CPT 76882 LT,TC
|
| Hospital Charge Code |
2544921
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$315.84 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$1,015.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.08
|
| Rate for Payer: Aetna Managed Medicare |
$315.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.84
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cigna Commercial |
$1,037.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$631.23
|
| Rate for Payer: Health EOS Commercial |
$1,003.92
|
| Rate for Payer: HFN Commercial |
$1,037.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$846.00
|
| Rate for Payer: Multiplan Commercial |
$902.40
|
| Rate for Payer: NAPHCARE Commercial |
$676.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.76
|
| Rate for Payer: Quartz Beloit One Network |
$552.72
|
| Rate for Payer: Quartz Commercial |
$733.20
|
| Rate for Payer: Quartz Medicare Advantage |
$676.80
|
| Rate for Payer: The Alliance Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$620.40
|
| Rate for Payer: WPS Commercial |
$835.51
|
|
|
US Lower Extremity Non-Vascular Bilat
|
Professional
|
Both
|
$1,128.00
|
|
|
Service Code
|
CPT 76882 LT,TC
|
| Hospital Charge Code |
2544921
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$496.32 |
| Max. Negotiated Rate |
$1,071.60 |
| Rate for Payer: Aetna Commercial |
$1,071.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.08
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cigna Commercial |
$1,071.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$564.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$676.80
|
| Rate for Payer: Health EOS Commercial |
$1,026.48
|
| Rate for Payer: HFN Commercial |
$1,071.60
|
| Rate for Payer: Multiplan Commercial |
$902.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,071.60
|
| Rate for Payer: Quartz Beloit One Network |
$496.32
|
| Rate for Payer: Quartz Commercial |
$642.96
|
| Rate for Payer: The Alliance Commercial |
$564.00
|
| Rate for Payer: WEA Trust Commercial |
$620.40
|
| Rate for Payer: WPS Commercial |
$835.51
|
|
|
US Lower Extremity Non-Vascular Bilat
|
Facility
|
IP
|
$1,128.00
|
|
|
Service Code
|
CPT 76882 LT,TC
|
| Hospital Charge Code |
2544921
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$552.72 |
| Max. Negotiated Rate |
$1,037.76 |
| Rate for Payer: Aetna Commercial |
$1,015.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.84
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cigna Commercial |
$1,037.76
|
| Rate for Payer: Health EOS Commercial |
$1,003.92
|
| Rate for Payer: HFN Commercial |
$1,037.76
|
| Rate for Payer: Multiplan Commercial |
$902.40
|
| Rate for Payer: NAPHCARE Commercial |
$676.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.76
|
| Rate for Payer: Quartz Beloit One Network |
$552.72
|
| Rate for Payer: Quartz Commercial |
$676.80
|
| Rate for Payer: WEA Trust Commercial |
$620.40
|
| Rate for Payer: WPS Commercial |
$835.51
|
|
|
US Lower Extremity Non-Vascular Left
|
Facility
|
IP
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 LT,TC
|
| Hospital Charge Code |
2544924
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$540.47 |
| Max. Negotiated Rate |
$1,014.76 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$661.80
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Lower Extremity Non-Vascular Left
|
Professional
|
Both
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 LT,TC
|
| Hospital Charge Code |
2544924
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$485.32 |
| Max. Negotiated Rate |
$1,047.85 |
| Rate for Payer: Aetna Commercial |
$1,047.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,047.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$551.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$661.80
|
| Rate for Payer: Health EOS Commercial |
$1,003.73
|
| Rate for Payer: HFN Commercial |
$1,047.85
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,047.85
|
| Rate for Payer: Quartz Beloit One Network |
$485.32
|
| Rate for Payer: Quartz Commercial |
$628.71
|
| Rate for Payer: The Alliance Commercial |
$551.50
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Lower Extremity Non-Vascular Left
|
Facility
|
OP
|
$1,103.00
|
|
|
Service Code
|
CPT 76882 LT,TC
|
| Hospital Charge Code |
2544924
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$308.84 |
| Max. Negotiated Rate |
$4,412.00 |
| Rate for Payer: Aetna Commercial |
$992.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.58
|
| Rate for Payer: Aetna Managed Medicare |
$308.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$584.59
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cash Price |
$330.90
|
| Rate for Payer: Cigna Commercial |
$1,014.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$617.24
|
| Rate for Payer: Health EOS Commercial |
$981.67
|
| Rate for Payer: HFN Commercial |
$1,014.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$827.25
|
| Rate for Payer: Multiplan Commercial |
$882.40
|
| Rate for Payer: NAPHCARE Commercial |
$661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,014.76
|
| Rate for Payer: Quartz Beloit One Network |
$540.47
|
| Rate for Payer: Quartz Commercial |
$716.95
|
| Rate for Payer: Quartz Medicare Advantage |
$661.80
|
| Rate for Payer: The Alliance Commercial |
$4,412.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$606.65
|
| Rate for Payer: WPS Commercial |
$816.99
|
|
|
US Lower Extremity Non-Vascular Right
|
Facility
|
IP
|
$1,020.00
|
|
|
Service Code
|
CPT 76882 RT,TC
|
| Hospital Charge Code |
2544928
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$499.80 |
| Max. Negotiated Rate |
$938.40 |
| Rate for Payer: Aetna Commercial |
$918.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$877.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$540.60
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$938.40
|
| Rate for Payer: Health EOS Commercial |
$907.80
|
| Rate for Payer: HFN Commercial |
$938.40
|
| Rate for Payer: Multiplan Commercial |
$816.00
|
| Rate for Payer: NAPHCARE Commercial |
$612.00
|
| Rate for Payer: Preferred Network Access Commercial |
$938.40
|
| Rate for Payer: Quartz Beloit One Network |
$499.80
|
| Rate for Payer: Quartz Commercial |
$612.00
|
| Rate for Payer: WEA Trust Commercial |
$561.00
|
| Rate for Payer: WPS Commercial |
$755.51
|
|
