|
US Retroperitoneal Limited
|
Facility
|
OP
|
$1,634.00
|
|
|
Service Code
|
CPT 76775 TC
|
| Hospital Charge Code |
2544967
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$457.52 |
| Max. Negotiated Rate |
$6,536.00 |
| Rate for Payer: Aetna Commercial |
$1,470.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,405.24
|
| Rate for Payer: Aetna Managed Medicare |
$457.52
|
| 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 |
$866.02
|
| Rate for Payer: Cash Price |
$490.20
|
| Rate for Payer: Cash Price |
$490.20
|
| Rate for Payer: Cash Price |
$490.20
|
| Rate for Payer: Cigna Commercial |
$1,503.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$914.39
|
| Rate for Payer: Health EOS Commercial |
$1,454.26
|
| Rate for Payer: HFN Commercial |
$1,503.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,225.50
|
| Rate for Payer: Multiplan Commercial |
$1,307.20
|
| Rate for Payer: NAPHCARE Commercial |
$980.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,503.28
|
| Rate for Payer: Quartz Beloit One Network |
$800.66
|
| Rate for Payer: Quartz Commercial |
$1,062.10
|
| Rate for Payer: Quartz Medicare Advantage |
$980.40
|
| Rate for Payer: The Alliance Commercial |
$6,536.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$898.70
|
| Rate for Payer: WPS Commercial |
$1,210.30
|
|
|
US Retroperitoneal Limited
|
Professional
|
Both
|
$2,044.00
|
|
|
Service Code
|
CPT 76775 TC
|
| Hospital Charge Code |
3072700
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$102.48 |
| Max. Negotiated Rate |
$1,941.80 |
| Rate for Payer: Aetna Commercial |
$1,941.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,757.84
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cigna Commercial |
$1,941.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,022.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,226.40
|
| Rate for Payer: Health EOS Commercial |
$1,860.04
|
| Rate for Payer: HFN Commercial |
$1,941.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$102.48
|
| Rate for Payer: Multiplan Commercial |
$1,635.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,941.80
|
| Rate for Payer: Quartz Beloit One Network |
$899.36
|
| Rate for Payer: Quartz Commercial |
$1,165.08
|
| Rate for Payer: The Alliance Commercial |
$1,022.00
|
| Rate for Payer: WEA Trust Commercial |
$1,124.20
|
| Rate for Payer: WPS Commercial |
$1,513.99
|
|
|
US Retroperitoneal Limited
|
Professional
|
Both
|
$1,634.00
|
|
|
Service Code
|
CPT 76775 TC
|
| Hospital Charge Code |
2544967
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$102.48 |
| Max. Negotiated Rate |
$1,552.30 |
| Rate for Payer: Aetna Commercial |
$1,552.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,405.24
|
| Rate for Payer: Cash Price |
$490.20
|
| Rate for Payer: Cash Price |
$490.20
|
| Rate for Payer: Cigna Commercial |
$1,552.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$817.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$980.40
|
| Rate for Payer: Health EOS Commercial |
$1,486.94
|
| Rate for Payer: HFN Commercial |
$1,552.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$102.48
|
| Rate for Payer: Multiplan Commercial |
$1,307.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,552.30
|
| Rate for Payer: Quartz Beloit One Network |
$718.96
|
| Rate for Payer: Quartz Commercial |
$931.38
|
| Rate for Payer: The Alliance Commercial |
$817.00
|
| Rate for Payer: WEA Trust Commercial |
$898.70
|
| Rate for Payer: WPS Commercial |
$1,210.30
|
|
|
US Retroperitoneal Limited
|
Professional
|
Both
|
$1,571.00
|
|
|
Service Code
|
CPT 76775
|
| Hospital Charge Code |
630854
|
| Min. Negotiated Rate |
$199.73 |
| Max. Negotiated Rate |
$1,492.45 |
| Rate for Payer: Aetna Commercial |
$1,492.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,351.06
|
| Rate for Payer: Cash Price |
$471.30
|
| Rate for Payer: Cash Price |
$471.30
|
| Rate for Payer: Cigna Commercial |
$1,492.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$785.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$942.60
|
| Rate for Payer: Health EOS Commercial |
$1,429.61
|
| Rate for Payer: HFN Commercial |
$1,492.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$199.73
|
| Rate for Payer: Multiplan Commercial |
$1,256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.45
|
| Rate for Payer: Quartz Beloit One Network |
$691.24
|
| Rate for Payer: Quartz Commercial |
$895.47
|
| Rate for Payer: The Alliance Commercial |
$785.50
|
| Rate for Payer: WEA Trust Commercial |
$864.05
|
| Rate for Payer: WPS Commercial |
$1,163.64
|
|
|
US Retroperitoneal Limited
|
Facility
|
IP
|
$2,044.00
|
|
|
Service Code
|
CPT 76775 TC
|
| Hospital Charge Code |
3072700
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1,001.56 |
| Max. Negotiated Rate |
$1,880.48 |
| Rate for Payer: Aetna Commercial |
$1,839.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,757.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,083.32
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cigna Commercial |
$1,880.48
|
| Rate for Payer: Health EOS Commercial |
$1,819.16
|
| Rate for Payer: HFN Commercial |
$1,880.48
|
| Rate for Payer: Multiplan Commercial |
$1,635.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,226.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,880.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,001.56
|
| Rate for Payer: Quartz Commercial |
$1,226.40
|
| Rate for Payer: WEA Trust Commercial |
$1,124.20
|
| Rate for Payer: WPS Commercial |
$1,513.99
|
|
|
US Right Lower Quadrant
|
Professional
|
Both
|
$1,472.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711781
|
| Min. Negotiated Rate |
$310.04 |
| Max. Negotiated Rate |
$1,398.40 |
| Rate for Payer: Aetna Commercial |
$1,398.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,265.92
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Cigna Commercial |
$1,398.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$736.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$883.20
|
| Rate for Payer: Health EOS Commercial |
$1,339.52
|
| Rate for Payer: HFN Commercial |
$1,398.40
|
| 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 |
$1,177.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,398.40
|
| Rate for Payer: Quartz Beloit One Network |
$647.68
|
| Rate for Payer: Quartz Commercial |
$839.04
|
| Rate for Payer: The Alliance Commercial |
$736.00
|
| Rate for Payer: WEA Trust Commercial |
$809.60
|
| Rate for Payer: WPS Commercial |
$1,090.31
|
|
|
US Right Lower Quadrant
|
Professional
|
Both
|
$1,531.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544969
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$211.55 |
| Max. Negotiated Rate |
$1,454.45 |
| Rate for Payer: Aetna Commercial |
$1,454.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,316.66
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cigna Commercial |
$1,454.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$765.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$918.60
|
| Rate for Payer: Health EOS Commercial |
$1,393.21
|
| Rate for Payer: HFN Commercial |
$1,454.45
|
| 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 |
$1,224.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,454.45
|
| Rate for Payer: Quartz Beloit One Network |
$673.64
|
| Rate for Payer: Quartz Commercial |
$872.67
|
| Rate for Payer: The Alliance Commercial |
$765.50
|
| Rate for Payer: WEA Trust Commercial |
$842.05
|
| Rate for Payer: WPS Commercial |
$1,134.01
|
|
|
US Right Lower Quadrant
|
Facility
|
OP
|
$1,472.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711781
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,354.24 |
| Rate for Payer: Aetna Commercial |
$1,324.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,265.92
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$956.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$736.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$706.56
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$780.16
|
| 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 |
$441.60
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Cigna Commercial |
$1,354.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$823.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,310.08
|
| Rate for Payer: HFN Commercial |
$1,354.24
|
| 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 |
$1,177.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,354.24
|
| Rate for Payer: Quartz Beloit One Network |
$721.28
|
| Rate for Payer: Quartz Commercial |
$956.80
|
| 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 |
$809.60
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,090.31
|
|
|
US Right Lower Quadrant
|
Facility
|
IP
|
$1,531.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544969
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$750.19 |
| Max. Negotiated Rate |
$1,408.52 |
| Rate for Payer: Aetna Commercial |
$1,377.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,316.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$811.43
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cigna Commercial |
$1,408.52
|
| Rate for Payer: Health EOS Commercial |
$1,362.59
|
| Rate for Payer: HFN Commercial |
$1,408.52
|
| Rate for Payer: Multiplan Commercial |
$1,224.80
|
| Rate for Payer: NAPHCARE Commercial |
$918.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,408.52
|
| Rate for Payer: Quartz Beloit One Network |
$750.19
|
| Rate for Payer: Quartz Commercial |
$918.60
|
| Rate for Payer: WEA Trust Commercial |
$842.05
|
| Rate for Payer: WPS Commercial |
$1,134.01
|
|
|
US Right Lower Quadrant
|
Facility
|
IP
|
$1,472.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711781
|
| Min. Negotiated Rate |
$721.28 |
| Max. Negotiated Rate |
$1,354.24 |
| Rate for Payer: Aetna Commercial |
$1,324.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,265.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$780.16
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Cigna Commercial |
$1,354.24
|
| Rate for Payer: Health EOS Commercial |
$1,310.08
|
| Rate for Payer: HFN Commercial |
$1,354.24
|
| Rate for Payer: Multiplan Commercial |
$1,177.60
|
| Rate for Payer: NAPHCARE Commercial |
$883.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,354.24
|
| Rate for Payer: Quartz Beloit One Network |
$721.28
|
| Rate for Payer: Quartz Commercial |
$883.20
|
| Rate for Payer: WEA Trust Commercial |
$809.60
|
| Rate for Payer: WPS Commercial |
$1,090.31
|
|
|
US Right Lower Quadrant
|
Facility
|
OP
|
$1,531.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544969
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$428.68 |
| Max. Negotiated Rate |
$6,124.00 |
| Rate for Payer: Aetna Commercial |
$1,377.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,316.66
|
| Rate for Payer: Aetna Managed Medicare |
$428.68
|
| 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 |
$811.43
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cigna Commercial |
$1,408.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$856.75
|
| Rate for Payer: Health EOS Commercial |
$1,362.59
|
| Rate for Payer: HFN Commercial |
$1,408.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,148.25
|
| Rate for Payer: Multiplan Commercial |
$1,224.80
|
| Rate for Payer: NAPHCARE Commercial |
$918.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,408.52
|
| Rate for Payer: Quartz Beloit One Network |
$750.19
|
| Rate for Payer: Quartz Commercial |
$995.15
|
| Rate for Payer: Quartz Medicare Advantage |
$918.60
|
| Rate for Payer: The Alliance Commercial |
$6,124.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$842.05
|
| Rate for Payer: WPS Commercial |
$1,134.01
|
|
|
US Right Upper Quadrant
|
Facility
|
IP
|
$1,472.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711782
|
| Min. Negotiated Rate |
$721.28 |
| Max. Negotiated Rate |
$1,354.24 |
| Rate for Payer: Aetna Commercial |
$1,324.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,265.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$780.16
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Cigna Commercial |
$1,354.24
|
| Rate for Payer: Health EOS Commercial |
$1,310.08
|
| Rate for Payer: HFN Commercial |
$1,354.24
|
| Rate for Payer: Multiplan Commercial |
$1,177.60
|
| Rate for Payer: NAPHCARE Commercial |
$883.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,354.24
|
| Rate for Payer: Quartz Beloit One Network |
$721.28
|
| Rate for Payer: Quartz Commercial |
$883.20
|
| Rate for Payer: WEA Trust Commercial |
$809.60
|
| Rate for Payer: WPS Commercial |
$1,090.31
|
|
|
US Right Upper Quadrant
|
Facility
|
OP
|
$1,472.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711782
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,354.24 |
| Rate for Payer: Aetna Commercial |
$1,324.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,265.92
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$956.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$736.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$706.56
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$780.16
|
| 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 |
$441.60
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Cigna Commercial |
$1,354.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$823.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,310.08
|
| Rate for Payer: HFN Commercial |
$1,354.24
|
| 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 |
$1,177.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,354.24
|
| Rate for Payer: Quartz Beloit One Network |
$721.28
|
| Rate for Payer: Quartz Commercial |
$956.80
|
| 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 |
$809.60
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,090.31
|
|
|
US Right Upper Quadrant
|
Facility
|
IP
|
$1,531.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544972
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$750.19 |
| Max. Negotiated Rate |
$1,408.52 |
| Rate for Payer: Aetna Commercial |
$1,377.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,316.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$811.43
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cigna Commercial |
$1,408.52
|
| Rate for Payer: Health EOS Commercial |
$1,362.59
|
| Rate for Payer: HFN Commercial |
$1,408.52
|
| Rate for Payer: Multiplan Commercial |
$1,224.80
|
| Rate for Payer: NAPHCARE Commercial |
$918.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,408.52
|
| Rate for Payer: Quartz Beloit One Network |
$750.19
|
| Rate for Payer: Quartz Commercial |
$918.60
|
| Rate for Payer: WEA Trust Commercial |
$842.05
|
| Rate for Payer: WPS Commercial |
$1,134.01
|
|
|
US Right Upper Quadrant
|
Facility
|
OP
|
$1,531.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544972
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$428.68 |
| Max. Negotiated Rate |
$6,124.00 |
| Rate for Payer: Aetna Commercial |
$1,377.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,316.66
|
| Rate for Payer: Aetna Managed Medicare |
$428.68
|
| 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 |
$811.43
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cigna Commercial |
$1,408.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$856.75
|
| Rate for Payer: Health EOS Commercial |
$1,362.59
|
| Rate for Payer: HFN Commercial |
$1,408.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,148.25
|
| Rate for Payer: Multiplan Commercial |
$1,224.80
|
| Rate for Payer: NAPHCARE Commercial |
$918.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,408.52
|
| Rate for Payer: Quartz Beloit One Network |
$750.19
|
| Rate for Payer: Quartz Commercial |
$995.15
|
| Rate for Payer: Quartz Medicare Advantage |
$918.60
|
| Rate for Payer: The Alliance Commercial |
$6,124.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$842.05
|
| Rate for Payer: WPS Commercial |
$1,134.01
|
|
|
US Right Upper Quadrant
|
Professional
|
Both
|
$1,472.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
711782
|
| Min. Negotiated Rate |
$310.04 |
| Max. Negotiated Rate |
$1,398.40 |
| Rate for Payer: Aetna Commercial |
$1,398.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,265.92
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Cigna Commercial |
$1,398.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$736.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$883.20
|
| Rate for Payer: Health EOS Commercial |
$1,339.52
|
| Rate for Payer: HFN Commercial |
$1,398.40
|
| 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 |
$1,177.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,398.40
|
| Rate for Payer: Quartz Beloit One Network |
$647.68
|
| Rate for Payer: Quartz Commercial |
$839.04
|
| Rate for Payer: The Alliance Commercial |
$736.00
|
| Rate for Payer: WEA Trust Commercial |
$809.60
|
| Rate for Payer: WPS Commercial |
$1,090.31
|
|
|
US Right Upper Quadrant
|
Professional
|
Both
|
$1,531.00
|
|
|
Service Code
|
CPT 76705 TC
|
| Hospital Charge Code |
2544972
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$211.55 |
| Max. Negotiated Rate |
$1,454.45 |
| Rate for Payer: Aetna Commercial |
$1,454.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,316.66
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cash Price |
$459.30
|
| Rate for Payer: Cigna Commercial |
$1,454.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$765.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$918.60
|
| Rate for Payer: Health EOS Commercial |
$1,393.21
|
| Rate for Payer: HFN Commercial |
$1,454.45
|
| 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 |
$1,224.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,454.45
|
| Rate for Payer: Quartz Beloit One Network |
$673.64
|
| Rate for Payer: Quartz Commercial |
$872.67
|
| Rate for Payer: The Alliance Commercial |
$765.50
|
| Rate for Payer: WEA Trust Commercial |
$842.05
|
| Rate for Payer: WPS Commercial |
$1,134.01
|
|
|
US Screening AAA
|
Facility
|
IP
|
$471.00
|
|
|
Service Code
|
CPT 76706 TC
|
| Hospital Charge Code |
5238867
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$230.79 |
| Max. Negotiated Rate |
$433.32 |
| Rate for Payer: Aetna Commercial |
$423.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.63
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cigna Commercial |
$433.32
|
| Rate for Payer: Health EOS Commercial |
$419.19
|
| Rate for Payer: HFN Commercial |
$433.32
|
| Rate for Payer: Multiplan Commercial |
$376.80
|
| Rate for Payer: NAPHCARE Commercial |
$282.60
|
| Rate for Payer: Preferred Network Access Commercial |
$433.32
|
| Rate for Payer: Quartz Beloit One Network |
$230.79
|
| Rate for Payer: Quartz Commercial |
$282.60
|
| Rate for Payer: WEA Trust Commercial |
$259.05
|
| Rate for Payer: WPS Commercial |
$348.87
|
|
|
US Screening AAA
|
Facility
|
OP
|
$471.00
|
|
|
Service Code
|
CPT 76706 TC
|
| Hospital Charge Code |
5238867
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$131.88 |
| Max. Negotiated Rate |
$1,884.00 |
| Rate for Payer: Aetna Commercial |
$423.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.06
|
| Rate for Payer: Aetna Managed Medicare |
$131.88
|
| 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 |
$249.63
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cigna Commercial |
$433.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$263.57
|
| Rate for Payer: Health EOS Commercial |
$419.19
|
| Rate for Payer: HFN Commercial |
$433.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$353.25
|
| Rate for Payer: Multiplan Commercial |
$376.80
|
| Rate for Payer: NAPHCARE Commercial |
$282.60
|
| Rate for Payer: Preferred Network Access Commercial |
$433.32
|
| Rate for Payer: Quartz Beloit One Network |
$230.79
|
| Rate for Payer: Quartz Commercial |
$306.15
|
| Rate for Payer: Quartz Medicare Advantage |
$282.60
|
| Rate for Payer: The Alliance Commercial |
$1,884.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$259.05
|
| Rate for Payer: WPS Commercial |
$348.87
|
|
|
US Screening AAA
|
Professional
|
Both
|
$471.00
|
|
|
Service Code
|
CPT 76706 TC
|
| Hospital Charge Code |
5238867
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$207.24 |
| Max. Negotiated Rate |
$447.45 |
| Rate for Payer: Aetna Commercial |
$447.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.06
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cigna Commercial |
$447.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$235.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$282.60
|
| Rate for Payer: Health EOS Commercial |
$428.61
|
| Rate for Payer: HFN Commercial |
$447.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$281.16
|
| Rate for Payer: Multiplan Commercial |
$376.80
|
| Rate for Payer: Preferred Network Access Commercial |
$447.45
|
| Rate for Payer: Quartz Beloit One Network |
$207.24
|
| Rate for Payer: Quartz Commercial |
$268.47
|
| Rate for Payer: The Alliance Commercial |
$235.50
|
| Rate for Payer: WEA Trust Commercial |
$259.05
|
| Rate for Payer: WPS Commercial |
$348.87
|
|
|
US Scrotum (Contents)
|
Professional
|
Both
|
$1,442.00
|
|
|
Service Code
|
CPT 76870 TC
|
| Hospital Charge Code |
2544975
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$251.02 |
| Max. Negotiated Rate |
$1,369.90 |
| Rate for Payer: Aetna Commercial |
$1,369.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,240.12
|
| Rate for Payer: Cash Price |
$432.60
|
| Rate for Payer: Cash Price |
$432.60
|
| Rate for Payer: Cigna Commercial |
$1,369.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$721.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$865.20
|
| Rate for Payer: Health EOS Commercial |
$1,312.22
|
| Rate for Payer: HFN Commercial |
$1,369.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$251.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$251.02
|
| Rate for Payer: Multiplan Commercial |
$1,153.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,369.90
|
| Rate for Payer: Quartz Beloit One Network |
$634.48
|
| Rate for Payer: Quartz Commercial |
$821.94
|
| Rate for Payer: The Alliance Commercial |
$721.00
|
| Rate for Payer: WEA Trust Commercial |
$793.10
|
| Rate for Payer: WPS Commercial |
$1,068.09
|
|
|
US Scrotum (Contents)
|
Facility
|
IP
|
$1,285.00
|
|
|
Service Code
|
CPT 76870
|
| Hospital Charge Code |
630851
|
| Min. Negotiated Rate |
$629.65 |
| Max. Negotiated Rate |
$1,182.20 |
| Rate for Payer: Aetna Commercial |
$1,156.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,105.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$681.05
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cigna Commercial |
$1,182.20
|
| Rate for Payer: Health EOS Commercial |
$1,143.65
|
| Rate for Payer: HFN Commercial |
$1,182.20
|
| Rate for Payer: Multiplan Commercial |
$1,028.00
|
| Rate for Payer: NAPHCARE Commercial |
$771.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,182.20
|
| Rate for Payer: Quartz Beloit One Network |
$629.65
|
| Rate for Payer: Quartz Commercial |
$771.00
|
| Rate for Payer: WEA Trust Commercial |
$706.75
|
| Rate for Payer: WPS Commercial |
$951.80
|
|
|
US Scrotum (Contents)
|
Professional
|
Both
|
$1,285.00
|
|
|
Service Code
|
CPT 76870
|
| Hospital Charge Code |
630851
|
| Min. Negotiated Rate |
$357.98 |
| Max. Negotiated Rate |
$1,220.75 |
| Rate for Payer: Aetna Commercial |
$1,220.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,105.10
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cigna Commercial |
$1,220.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$642.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$771.00
|
| Rate for Payer: Health EOS Commercial |
$1,169.35
|
| Rate for Payer: HFN Commercial |
$1,220.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$357.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$357.98
|
| Rate for Payer: Multiplan Commercial |
$1,028.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,220.75
|
| Rate for Payer: Quartz Beloit One Network |
$565.40
|
| Rate for Payer: Quartz Commercial |
$732.45
|
| Rate for Payer: The Alliance Commercial |
$642.50
|
| Rate for Payer: WEA Trust Commercial |
$706.75
|
| Rate for Payer: WPS Commercial |
$951.80
|
|
|
US Scrotum (Contents)
|
Facility
|
OP
|
$1,442.00
|
|
|
Service Code
|
CPT 76870 TC
|
| Hospital Charge Code |
2544975
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$403.76 |
| Max. Negotiated Rate |
$5,768.00 |
| Rate for Payer: Aetna Commercial |
$1,297.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,240.12
|
| Rate for Payer: Aetna Managed Medicare |
$403.76
|
| 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 |
$764.26
|
| Rate for Payer: Cash Price |
$432.60
|
| Rate for Payer: Cash Price |
$432.60
|
| Rate for Payer: Cash Price |
$432.60
|
| Rate for Payer: Cigna Commercial |
$1,326.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$806.94
|
| Rate for Payer: Health EOS Commercial |
$1,283.38
|
| Rate for Payer: HFN Commercial |
$1,326.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,081.50
|
| Rate for Payer: Multiplan Commercial |
$1,153.60
|
| Rate for Payer: NAPHCARE Commercial |
$865.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,326.64
|
| Rate for Payer: Quartz Beloit One Network |
$706.58
|
| Rate for Payer: Quartz Commercial |
$937.30
|
| Rate for Payer: Quartz Medicare Advantage |
$865.20
|
| Rate for Payer: The Alliance Commercial |
$5,768.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$793.10
|
| Rate for Payer: WPS Commercial |
$1,068.09
|
|
|
US Scrotum (Contents)
|
Facility
|
IP
|
$1,442.00
|
|
|
Service Code
|
CPT 76870 TC
|
| Hospital Charge Code |
2544975
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$706.58 |
| Max. Negotiated Rate |
$1,326.64 |
| Rate for Payer: Aetna Commercial |
$1,297.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,240.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$764.26
|
| Rate for Payer: Cash Price |
$432.60
|
| Rate for Payer: Cigna Commercial |
$1,326.64
|
| Rate for Payer: Health EOS Commercial |
$1,283.38
|
| Rate for Payer: HFN Commercial |
$1,326.64
|
| Rate for Payer: Multiplan Commercial |
$1,153.60
|
| Rate for Payer: NAPHCARE Commercial |
$865.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,326.64
|
| Rate for Payer: Quartz Beloit One Network |
$706.58
|
| Rate for Payer: Quartz Commercial |
$865.20
|
| Rate for Payer: WEA Trust Commercial |
$793.10
|
| Rate for Payer: WPS Commercial |
$1,068.09
|
|
