|
US Pregnancy Follow Up
|
Facility
|
OP
|
$909.00
|
|
|
Service Code
|
CPT 76816
|
| Hospital Charge Code |
630910
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$836.28 |
| Rate for Payer: Aetna Commercial |
$818.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$781.74
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$590.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$454.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$436.32
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$481.77
|
| 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 |
$272.70
|
| Rate for Payer: Cash Price |
$272.70
|
| Rate for Payer: Cigna Commercial |
$836.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$508.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$809.01
|
| Rate for Payer: HFN Commercial |
$836.28
|
| 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 |
$727.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$836.28
|
| Rate for Payer: Quartz Beloit One Network |
$445.41
|
| Rate for Payer: Quartz Commercial |
$590.85
|
| 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 |
$499.95
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$673.30
|
|
|
US Pregnancy Follow Up
|
Facility
|
IP
|
$1,322.00
|
|
|
Service Code
|
CPT 76816 TC
|
| Hospital Charge Code |
2544952
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$647.78 |
| Max. Negotiated Rate |
$1,216.24 |
| Rate for Payer: Aetna Commercial |
$1,189.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.66
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cigna Commercial |
$1,216.24
|
| Rate for Payer: Health EOS Commercial |
$1,176.58
|
| Rate for Payer: HFN Commercial |
$1,216.24
|
| Rate for Payer: Multiplan Commercial |
$1,057.60
|
| Rate for Payer: NAPHCARE Commercial |
$793.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,216.24
|
| Rate for Payer: Quartz Beloit One Network |
$647.78
|
| Rate for Payer: Quartz Commercial |
$793.20
|
| Rate for Payer: WEA Trust Commercial |
$727.10
|
| Rate for Payer: WPS Commercial |
$979.21
|
|
|
US Pregnancy Follow Up
|
Facility
|
OP
|
$1,322.00
|
|
|
Service Code
|
CPT 76816 TC
|
| Hospital Charge Code |
2544952
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$370.16 |
| Max. Negotiated Rate |
$5,288.00 |
| Rate for Payer: Aetna Commercial |
$1,189.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.92
|
| Rate for Payer: Aetna Managed Medicare |
$370.16
|
| 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 |
$700.66
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cigna Commercial |
$1,216.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$739.79
|
| Rate for Payer: Health EOS Commercial |
$1,176.58
|
| Rate for Payer: HFN Commercial |
$1,216.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$991.50
|
| Rate for Payer: Multiplan Commercial |
$1,057.60
|
| Rate for Payer: NAPHCARE Commercial |
$793.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,216.24
|
| Rate for Payer: Quartz Beloit One Network |
$647.78
|
| Rate for Payer: Quartz Commercial |
$859.30
|
| Rate for Payer: Quartz Medicare Advantage |
$793.20
|
| Rate for Payer: The Alliance Commercial |
$5,288.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$727.10
|
| Rate for Payer: WPS Commercial |
$979.21
|
|
|
US Pregnancy Follow Up
|
Facility
|
IP
|
$909.00
|
|
|
Service Code
|
CPT 76816
|
| Hospital Charge Code |
630910
|
| Min. Negotiated Rate |
$445.41 |
| Max. Negotiated Rate |
$836.28 |
| Rate for Payer: Aetna Commercial |
$818.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$781.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$481.77
|
| Rate for Payer: Cash Price |
$272.70
|
| Rate for Payer: Cigna Commercial |
$836.28
|
| Rate for Payer: Health EOS Commercial |
$809.01
|
| Rate for Payer: HFN Commercial |
$836.28
|
| Rate for Payer: Multiplan Commercial |
$727.20
|
| Rate for Payer: NAPHCARE Commercial |
$545.40
|
| Rate for Payer: Preferred Network Access Commercial |
$836.28
|
| Rate for Payer: Quartz Beloit One Network |
$445.41
|
| Rate for Payer: Quartz Commercial |
$545.40
|
| Rate for Payer: WEA Trust Commercial |
$499.95
|
| Rate for Payer: WPS Commercial |
$673.30
|
|
|
US Pregnancy Follow Up
|
Professional
|
Both
|
$1,322.00
|
|
|
Service Code
|
CPT 76816 TC
|
| Hospital Charge Code |
2544952
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$245.19 |
| Max. Negotiated Rate |
$1,255.90 |
| Rate for Payer: Aetna Commercial |
$1,255.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.92
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cigna Commercial |
$1,255.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$661.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$793.20
|
| Rate for Payer: Health EOS Commercial |
$1,203.02
|
| Rate for Payer: HFN Commercial |
$1,255.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$245.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$245.19
|
| Rate for Payer: Multiplan Commercial |
$1,057.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,255.90
|
| Rate for Payer: Quartz Beloit One Network |
$581.68
|
| Rate for Payer: Quartz Commercial |
$753.54
|
| Rate for Payer: The Alliance Commercial |
$661.00
|
| Rate for Payer: WEA Trust Commercial |
$727.10
|
| Rate for Payer: WPS Commercial |
$979.21
|
|
|
US Pregnancy Follow Up & BPP
|
Professional
|
Both
|
$1,322.00
|
|
|
Service Code
|
CPT 76816 TC
|
| Hospital Charge Code |
6196384
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$245.19 |
| Max. Negotiated Rate |
$1,255.90 |
| Rate for Payer: Aetna Commercial |
$1,255.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.92
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cigna Commercial |
$1,255.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$661.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$793.20
|
| Rate for Payer: Health EOS Commercial |
$1,203.02
|
| Rate for Payer: HFN Commercial |
$1,255.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$245.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$245.19
|
| Rate for Payer: Multiplan Commercial |
$1,057.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,255.90
|
| Rate for Payer: Quartz Beloit One Network |
$581.68
|
| Rate for Payer: Quartz Commercial |
$753.54
|
| Rate for Payer: The Alliance Commercial |
$661.00
|
| Rate for Payer: WEA Trust Commercial |
$727.10
|
| Rate for Payer: WPS Commercial |
$979.21
|
|
|
US Pregnancy Follow Up & BPP
|
Facility
|
OP
|
$1,322.00
|
|
|
Service Code
|
CPT 76816 TC
|
| Hospital Charge Code |
6196384
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$370.16 |
| Max. Negotiated Rate |
$5,288.00 |
| Rate for Payer: Aetna Commercial |
$1,189.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.92
|
| Rate for Payer: Aetna Managed Medicare |
$370.16
|
| 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 |
$700.66
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cigna Commercial |
$1,216.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$739.79
|
| Rate for Payer: Health EOS Commercial |
$1,176.58
|
| Rate for Payer: HFN Commercial |
$1,216.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$991.50
|
| Rate for Payer: Multiplan Commercial |
$1,057.60
|
| Rate for Payer: NAPHCARE Commercial |
$793.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,216.24
|
| Rate for Payer: Quartz Beloit One Network |
$647.78
|
| Rate for Payer: Quartz Commercial |
$859.30
|
| Rate for Payer: Quartz Medicare Advantage |
$793.20
|
| Rate for Payer: The Alliance Commercial |
$5,288.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$727.10
|
| Rate for Payer: WPS Commercial |
$979.21
|
|
|
US Pregnancy Follow Up & BPP
|
Facility
|
IP
|
$1,322.00
|
|
|
Service Code
|
CPT 76816 TC
|
| Hospital Charge Code |
6196384
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$647.78 |
| Max. Negotiated Rate |
$1,216.24 |
| Rate for Payer: Aetna Commercial |
$1,189.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.66
|
| Rate for Payer: Cash Price |
$396.60
|
| Rate for Payer: Cigna Commercial |
$1,216.24
|
| Rate for Payer: Health EOS Commercial |
$1,176.58
|
| Rate for Payer: HFN Commercial |
$1,216.24
|
| Rate for Payer: Multiplan Commercial |
$1,057.60
|
| Rate for Payer: NAPHCARE Commercial |
$793.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,216.24
|
| Rate for Payer: Quartz Beloit One Network |
$647.78
|
| Rate for Payer: Quartz Commercial |
$793.20
|
| Rate for Payer: WEA Trust Commercial |
$727.10
|
| Rate for Payer: WPS Commercial |
$979.21
|
|
|
US Pregnancy Limited
|
Facility
|
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
630906
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,031.32 |
| Rate for Payer: Aetna Commercial |
$1,008.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$964.06
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$728.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$560.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.08
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$594.13
|
| 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 |
$336.30
|
| Rate for Payer: Cash Price |
$336.30
|
| Rate for Payer: Cigna Commercial |
$1,031.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$627.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$997.69
|
| Rate for Payer: HFN Commercial |
$1,031.32
|
| 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 |
$896.80
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,031.32
|
| Rate for Payer: Quartz Beloit One Network |
$549.29
|
| Rate for Payer: Quartz Commercial |
$728.65
|
| 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 |
$616.55
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$830.32
|
|
|
US Pregnancy Limited
|
Facility
|
OP
|
$1,024.00
|
|
|
Service Code
|
CPT 76815 TC
|
| Hospital Charge Code |
2544954
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$286.72 |
| Max. Negotiated Rate |
$4,096.00 |
| Rate for Payer: Aetna Commercial |
$921.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$880.64
|
| Rate for Payer: Aetna Managed Medicare |
$286.72
|
| 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 |
$542.72
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cigna Commercial |
$942.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$573.03
|
| Rate for Payer: Health EOS Commercial |
$911.36
|
| Rate for Payer: HFN Commercial |
$942.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$768.00
|
| Rate for Payer: Multiplan Commercial |
$819.20
|
| Rate for Payer: NAPHCARE Commercial |
$614.40
|
| Rate for Payer: Preferred Network Access Commercial |
$942.08
|
| Rate for Payer: Quartz Beloit One Network |
$501.76
|
| Rate for Payer: Quartz Commercial |
$665.60
|
| Rate for Payer: Quartz Medicare Advantage |
$614.40
|
| Rate for Payer: The Alliance Commercial |
$4,096.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$563.20
|
| Rate for Payer: WPS Commercial |
$758.48
|
|
|
US Pregnancy Limited
|
Facility
|
IP
|
$1,024.00
|
|
|
Service Code
|
CPT 76815 TC
|
| Hospital Charge Code |
2544954
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$501.76 |
| Max. Negotiated Rate |
$942.08 |
| Rate for Payer: Aetna Commercial |
$921.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$880.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$542.72
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cigna Commercial |
$942.08
|
| Rate for Payer: Health EOS Commercial |
$911.36
|
| Rate for Payer: HFN Commercial |
$942.08
|
| Rate for Payer: Multiplan Commercial |
$819.20
|
| Rate for Payer: NAPHCARE Commercial |
$614.40
|
| Rate for Payer: Preferred Network Access Commercial |
$942.08
|
| Rate for Payer: Quartz Beloit One Network |
$501.76
|
| Rate for Payer: Quartz Commercial |
$614.40
|
| Rate for Payer: WEA Trust Commercial |
$563.20
|
| Rate for Payer: WPS Commercial |
$758.48
|
|
|
US Pregnancy Limited
|
Professional
|
Both
|
$1,024.00
|
|
|
Service Code
|
CPT 76815 TC
|
| Hospital Charge Code |
2544954
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$177.91 |
| Max. Negotiated Rate |
$972.80 |
| Rate for Payer: Aetna Commercial |
$972.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$880.64
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cigna Commercial |
$972.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$512.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$614.40
|
| Rate for Payer: Health EOS Commercial |
$931.84
|
| Rate for Payer: HFN Commercial |
$972.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$177.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$177.91
|
| Rate for Payer: Multiplan Commercial |
$819.20
|
| Rate for Payer: Preferred Network Access Commercial |
$972.80
|
| Rate for Payer: Quartz Beloit One Network |
$450.56
|
| Rate for Payer: Quartz Commercial |
$583.68
|
| Rate for Payer: The Alliance Commercial |
$512.00
|
| Rate for Payer: WEA Trust Commercial |
$563.20
|
| Rate for Payer: WPS Commercial |
$758.48
|
|
|
US Pregnancy Limited
|
Facility
|
IP
|
$1,121.00
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
630906
|
| Min. Negotiated Rate |
$549.29 |
| Max. Negotiated Rate |
$1,031.32 |
| Rate for Payer: Aetna Commercial |
$1,008.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$964.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$594.13
|
| Rate for Payer: Cash Price |
$336.30
|
| Rate for Payer: Cigna Commercial |
$1,031.32
|
| Rate for Payer: Health EOS Commercial |
$997.69
|
| Rate for Payer: HFN Commercial |
$1,031.32
|
| Rate for Payer: Multiplan Commercial |
$896.80
|
| Rate for Payer: NAPHCARE Commercial |
$672.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,031.32
|
| Rate for Payer: Quartz Beloit One Network |
$549.29
|
| Rate for Payer: Quartz Commercial |
$672.60
|
| Rate for Payer: WEA Trust Commercial |
$616.55
|
| Rate for Payer: WPS Commercial |
$830.32
|
|
|
US Pregnancy Limited
|
Professional
|
Both
|
$1,121.00
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
630906
|
| Min. Negotiated Rate |
$287.27 |
| Max. Negotiated Rate |
$1,064.95 |
| Rate for Payer: Aetna Commercial |
$1,064.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$964.06
|
| Rate for Payer: Cash Price |
$336.30
|
| Rate for Payer: Cash Price |
$336.30
|
| Rate for Payer: Cigna Commercial |
$1,064.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$560.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$672.60
|
| Rate for Payer: Health EOS Commercial |
$1,020.11
|
| Rate for Payer: HFN Commercial |
$1,064.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$287.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$287.27
|
| Rate for Payer: Multiplan Commercial |
$896.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,064.95
|
| Rate for Payer: Quartz Beloit One Network |
$493.24
|
| Rate for Payer: Quartz Commercial |
$638.97
|
| Rate for Payer: The Alliance Commercial |
$560.50
|
| Rate for Payer: WEA Trust Commercial |
$616.55
|
| Rate for Payer: WPS Commercial |
$830.32
|
|
|
US Pregnancy Limited & BPP
|
Facility
|
IP
|
$1,024.00
|
|
|
Service Code
|
CPT 76815 TC
|
| Hospital Charge Code |
6196387
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$501.76 |
| Max. Negotiated Rate |
$942.08 |
| Rate for Payer: Aetna Commercial |
$921.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$880.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$542.72
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cigna Commercial |
$942.08
|
| Rate for Payer: Health EOS Commercial |
$911.36
|
| Rate for Payer: HFN Commercial |
$942.08
|
| Rate for Payer: Multiplan Commercial |
$819.20
|
| Rate for Payer: NAPHCARE Commercial |
$614.40
|
| Rate for Payer: Preferred Network Access Commercial |
$942.08
|
| Rate for Payer: Quartz Beloit One Network |
$501.76
|
| Rate for Payer: Quartz Commercial |
$614.40
|
| Rate for Payer: WEA Trust Commercial |
$563.20
|
| Rate for Payer: WPS Commercial |
$758.48
|
|
|
US Pregnancy Limited & BPP
|
Facility
|
OP
|
$1,024.00
|
|
|
Service Code
|
CPT 76815 TC
|
| Hospital Charge Code |
6196387
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$286.72 |
| Max. Negotiated Rate |
$4,096.00 |
| Rate for Payer: Aetna Commercial |
$921.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$880.64
|
| Rate for Payer: Aetna Managed Medicare |
$286.72
|
| 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 |
$542.72
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cigna Commercial |
$942.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$573.03
|
| Rate for Payer: Health EOS Commercial |
$911.36
|
| Rate for Payer: HFN Commercial |
$942.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$768.00
|
| Rate for Payer: Multiplan Commercial |
$819.20
|
| Rate for Payer: NAPHCARE Commercial |
$614.40
|
| Rate for Payer: Preferred Network Access Commercial |
$942.08
|
| Rate for Payer: Quartz Beloit One Network |
$501.76
|
| Rate for Payer: Quartz Commercial |
$665.60
|
| Rate for Payer: Quartz Medicare Advantage |
$614.40
|
| Rate for Payer: The Alliance Commercial |
$4,096.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$563.20
|
| Rate for Payer: WPS Commercial |
$758.48
|
|
|
US Pregnancy Limited & BPP
|
Professional
|
Both
|
$1,024.00
|
|
|
Service Code
|
CPT 76815 TC
|
| Hospital Charge Code |
6196387
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$177.91 |
| Max. Negotiated Rate |
$972.80 |
| Rate for Payer: Aetna Commercial |
$972.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$880.64
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cash Price |
$307.20
|
| Rate for Payer: Cigna Commercial |
$972.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$512.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$614.40
|
| Rate for Payer: Health EOS Commercial |
$931.84
|
| Rate for Payer: HFN Commercial |
$972.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$177.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$177.91
|
| Rate for Payer: Multiplan Commercial |
$819.20
|
| Rate for Payer: Preferred Network Access Commercial |
$972.80
|
| Rate for Payer: Quartz Beloit One Network |
$450.56
|
| Rate for Payer: Quartz Commercial |
$583.68
|
| Rate for Payer: The Alliance Commercial |
$512.00
|
| Rate for Payer: WEA Trust Commercial |
$563.20
|
| Rate for Payer: WPS Commercial |
$758.48
|
|
|
US Pregnancy Transvaginal
|
Facility
|
IP
|
$1,136.00
|
|
|
Service Code
|
CPT 76817 TC
|
| Hospital Charge Code |
4500656
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$556.64 |
| Max. Negotiated Rate |
$1,045.12 |
| Rate for Payer: Aetna Commercial |
$1,022.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.08
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,045.12
|
| Rate for Payer: Health EOS Commercial |
$1,011.04
|
| Rate for Payer: HFN Commercial |
$1,045.12
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: NAPHCARE Commercial |
$681.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,045.12
|
| Rate for Payer: Quartz Beloit One Network |
$556.64
|
| Rate for Payer: Quartz Commercial |
$681.60
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: WPS Commercial |
$841.44
|
|
|
US Pregnancy Transvaginal
|
Facility
|
OP
|
$1,136.00
|
|
|
Service Code
|
CPT 76817 TC
|
| Hospital Charge Code |
4500656
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$318.08 |
| Max. Negotiated Rate |
$4,544.00 |
| Rate for Payer: Aetna Commercial |
$1,022.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Aetna Managed Medicare |
$318.08
|
| 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 |
$602.08
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,045.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$635.71
|
| Rate for Payer: Health EOS Commercial |
$1,011.04
|
| Rate for Payer: HFN Commercial |
$1,045.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$852.00
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: NAPHCARE Commercial |
$681.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,045.12
|
| Rate for Payer: Quartz Beloit One Network |
$556.64
|
| Rate for Payer: Quartz Commercial |
$738.40
|
| Rate for Payer: Quartz Medicare Advantage |
$681.60
|
| Rate for Payer: The Alliance Commercial |
$4,544.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: WPS Commercial |
$841.44
|
|
|
US Pregnancy Transvaginal
|
Professional
|
Both
|
$1,136.00
|
|
|
Service Code
|
CPT 76817 TC
|
| Hospital Charge Code |
3072734
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$202.23 |
| Max. Negotiated Rate |
$1,079.20 |
| Rate for Payer: Aetna Commercial |
$1,079.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,079.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$568.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$681.60
|
| Rate for Payer: Health EOS Commercial |
$1,033.76
|
| Rate for Payer: HFN Commercial |
$1,079.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$202.23
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,079.20
|
| Rate for Payer: Quartz Beloit One Network |
$499.84
|
| Rate for Payer: Quartz Commercial |
$647.52
|
| Rate for Payer: The Alliance Commercial |
$568.00
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: WPS Commercial |
$841.44
|
|
|
US Pregnancy Transvaginal
|
Facility
|
IP
|
$1,136.00
|
|
|
Service Code
|
CPT 76817 TC
|
| Hospital Charge Code |
3072734
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$556.64 |
| Max. Negotiated Rate |
$1,045.12 |
| Rate for Payer: Aetna Commercial |
$1,022.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.08
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,045.12
|
| Rate for Payer: Health EOS Commercial |
$1,011.04
|
| Rate for Payer: HFN Commercial |
$1,045.12
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: NAPHCARE Commercial |
$681.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,045.12
|
| Rate for Payer: Quartz Beloit One Network |
$556.64
|
| Rate for Payer: Quartz Commercial |
$681.60
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: WPS Commercial |
$841.44
|
|
|
US Pregnancy Transvaginal
|
Facility
|
OP
|
$1,136.00
|
|
|
Service Code
|
CPT 76817 TC
|
| Hospital Charge Code |
3072734
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$318.08 |
| Max. Negotiated Rate |
$4,544.00 |
| Rate for Payer: Aetna Commercial |
$1,022.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Aetna Managed Medicare |
$318.08
|
| 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 |
$602.08
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,045.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$635.71
|
| Rate for Payer: Health EOS Commercial |
$1,011.04
|
| Rate for Payer: HFN Commercial |
$1,045.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$852.00
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: NAPHCARE Commercial |
$681.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,045.12
|
| Rate for Payer: Quartz Beloit One Network |
$556.64
|
| Rate for Payer: Quartz Commercial |
$738.40
|
| Rate for Payer: Quartz Medicare Advantage |
$681.60
|
| Rate for Payer: The Alliance Commercial |
$4,544.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: WPS Commercial |
$841.44
|
|
|
US Pregnancy Transvaginal
|
Professional
|
Both
|
$1,136.00
|
|
|
Service Code
|
CPT 76817 TC
|
| Hospital Charge Code |
4500656
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$202.23 |
| Max. Negotiated Rate |
$1,079.20 |
| Rate for Payer: Aetna Commercial |
$1,079.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,079.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$568.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$681.60
|
| Rate for Payer: Health EOS Commercial |
$1,033.76
|
| Rate for Payer: HFN Commercial |
$1,079.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$202.23
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,079.20
|
| Rate for Payer: Quartz Beloit One Network |
$499.84
|
| Rate for Payer: Quartz Commercial |
$647.52
|
| Rate for Payer: The Alliance Commercial |
$568.00
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: WPS Commercial |
$841.44
|
|
|
US Pregnancy, Transvaginal
|
Facility
|
OP
|
$1,846.00
|
|
|
Service Code
|
CPT 76801 TC
|
| Hospital Charge Code |
2587190
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$516.88 |
| Max. Negotiated Rate |
$7,384.00 |
| Rate for Payer: Aetna Commercial |
$1,661.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,587.56
|
| Rate for Payer: Aetna Managed Medicare |
$516.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$978.38
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,698.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,033.02
|
| Rate for Payer: Health EOS Commercial |
$1,642.94
|
| Rate for Payer: HFN Commercial |
$1,698.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,384.50
|
| Rate for Payer: Multiplan Commercial |
$1,476.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,107.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,698.32
|
| Rate for Payer: Quartz Beloit One Network |
$904.54
|
| Rate for Payer: Quartz Commercial |
$1,199.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,107.60
|
| Rate for Payer: The Alliance Commercial |
$7,384.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$1,015.30
|
| Rate for Payer: WPS Commercial |
$1,367.33
|
|
|
US Pregnancy, Transvaginal
|
Professional
|
Both
|
$1,846.00
|
|
|
Service Code
|
CPT 76801 TC
|
| Hospital Charge Code |
2587190
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$249.82 |
| Max. Negotiated Rate |
$1,753.70 |
| Rate for Payer: Aetna Commercial |
$1,753.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,587.56
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,753.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$923.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,107.60
|
| Rate for Payer: Health EOS Commercial |
$1,679.86
|
| Rate for Payer: HFN Commercial |
$1,753.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$249.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$249.82
|
| Rate for Payer: Multiplan Commercial |
$1,476.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,753.70
|
| Rate for Payer: Quartz Beloit One Network |
$812.24
|
| Rate for Payer: Quartz Commercial |
$1,052.22
|
| Rate for Payer: The Alliance Commercial |
$923.00
|
| Rate for Payer: WEA Trust Commercial |
$1,015.30
|
| Rate for Payer: WPS Commercial |
$1,367.33
|
|
