|
BCE Fine Needle Aspiration ea additional
|
Professional
|
Both
|
$214.00
|
|
|
Service Code
|
CPT 10006 TC
|
| Hospital Charge Code |
5649626
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$94.16 |
| Max. Negotiated Rate |
$203.30 |
| Rate for Payer: Aetna Commercial |
$203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$203.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.40
|
| Rate for Payer: Health EOS Commercial |
$194.74
|
| Rate for Payer: HFN Commercial |
$203.30
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: Preferred Network Access Commercial |
$203.30
|
| Rate for Payer: Quartz Beloit One Network |
$94.16
|
| Rate for Payer: Quartz Commercial |
$121.98
|
| Rate for Payer: The Alliance Commercial |
$107.00
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
BCE Fine Needle Aspiration ea additional
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
CPT 10006 TC
|
| Hospital Charge Code |
5649626
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$59.92 |
| Max. Negotiated Rate |
$856.00 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Aetna Managed Medicare |
$59.92
|
| 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 |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.75
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$160.50
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$139.10
|
| Rate for Payer: Quartz Medicare Advantage |
$128.40
|
| Rate for Payer: The Alliance Commercial |
$856.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
BCE Image Guided Fluid Drainage Catheter
|
Professional
|
Both
|
$7,649.00
|
|
|
Service Code
|
CPT 49406 TC
|
| Hospital Charge Code |
5649633
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$3,365.56 |
| Max. Negotiated Rate |
$7,266.55 |
| Rate for Payer: Aetna Commercial |
$7,266.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,578.14
|
| Rate for Payer: Cash Price |
$2,294.70
|
| Rate for Payer: Cash Price |
$2,294.70
|
| Rate for Payer: Cigna Commercial |
$7,266.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,824.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,589.40
|
| Rate for Payer: Health EOS Commercial |
$6,960.59
|
| Rate for Payer: HFN Commercial |
$7,266.55
|
| Rate for Payer: Multiplan Commercial |
$6,119.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,266.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,365.56
|
| Rate for Payer: Quartz Commercial |
$4,359.93
|
| Rate for Payer: The Alliance Commercial |
$3,824.50
|
| Rate for Payer: WEA Trust Commercial |
$4,206.95
|
| Rate for Payer: WPS Commercial |
$5,665.61
|
|
|
BCE Image Guided Fluid Drainage Catheter
|
Facility
|
OP
|
$7,649.00
|
|
|
Service Code
|
CPT 49406 TC
|
| Hospital Charge Code |
5649633
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$574.00 |
| Max. Negotiated Rate |
$30,596.00 |
| Rate for Payer: Aetna Commercial |
$6,884.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,578.14
|
| Rate for Payer: Aetna Managed Medicare |
$2,141.72
|
| 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 |
$4,053.97
|
| Rate for Payer: Cash Price |
$2,294.70
|
| Rate for Payer: Cash Price |
$2,294.70
|
| Rate for Payer: Cash Price |
$2,294.70
|
| Rate for Payer: Cigna Commercial |
$7,037.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,280.38
|
| Rate for Payer: Health EOS Commercial |
$6,807.61
|
| Rate for Payer: HFN Commercial |
$7,037.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,736.75
|
| Rate for Payer: Multiplan Commercial |
$6,119.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,589.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,037.08
|
| Rate for Payer: Quartz Beloit One Network |
$3,748.01
|
| Rate for Payer: Quartz Commercial |
$4,971.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,589.40
|
| Rate for Payer: The Alliance Commercial |
$30,596.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$4,206.95
|
| Rate for Payer: WPS Commercial |
$5,665.61
|
|
|
BCE Image Guided Fluid Drainage Catheter
|
Facility
|
IP
|
$7,649.00
|
|
|
Service Code
|
CPT 49406 TC
|
| Hospital Charge Code |
5649633
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$3,748.01 |
| Max. Negotiated Rate |
$7,037.08 |
| Rate for Payer: Aetna Commercial |
$6,884.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,578.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,053.97
|
| Rate for Payer: Cash Price |
$2,294.70
|
| Rate for Payer: Cigna Commercial |
$7,037.08
|
| Rate for Payer: Health EOS Commercial |
$6,807.61
|
| Rate for Payer: HFN Commercial |
$7,037.08
|
| Rate for Payer: Multiplan Commercial |
$6,119.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,589.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,037.08
|
| Rate for Payer: Quartz Beloit One Network |
$3,748.01
|
| Rate for Payer: Quartz Commercial |
$4,589.40
|
| Rate for Payer: WEA Trust Commercial |
$4,206.95
|
| Rate for Payer: WPS Commercial |
$5,665.61
|
|
|
BCE Image Guided Fluid Drainage Cath Perc
|
Facility
|
IP
|
$4,612.00
|
|
|
Service Code
|
CPT 10030 TC
|
| Hospital Charge Code |
5649640
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$2,259.88 |
| Max. Negotiated Rate |
$4,243.04 |
| Rate for Payer: Aetna Commercial |
$4,150.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,966.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,444.36
|
| Rate for Payer: Cash Price |
$1,383.60
|
| Rate for Payer: Cigna Commercial |
$4,243.04
|
| Rate for Payer: Health EOS Commercial |
$4,104.68
|
| Rate for Payer: HFN Commercial |
$4,243.04
|
| Rate for Payer: Multiplan Commercial |
$3,689.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,767.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,243.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,259.88
|
| Rate for Payer: Quartz Commercial |
$2,767.20
|
| Rate for Payer: WEA Trust Commercial |
$2,536.60
|
| Rate for Payer: WPS Commercial |
$3,416.11
|
|
|
BCE Image Guided Fluid Drainage Cath Perc
|
Professional
|
Both
|
$4,612.00
|
|
|
Service Code
|
CPT 10030 TC
|
| Hospital Charge Code |
5649640
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$2,029.28 |
| Max. Negotiated Rate |
$4,381.40 |
| Rate for Payer: Aetna Commercial |
$4,381.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,966.32
|
| Rate for Payer: Cash Price |
$1,383.60
|
| Rate for Payer: Cash Price |
$1,383.60
|
| Rate for Payer: Cigna Commercial |
$4,381.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,306.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,767.20
|
| Rate for Payer: Health EOS Commercial |
$4,196.92
|
| Rate for Payer: HFN Commercial |
$4,381.40
|
| Rate for Payer: Multiplan Commercial |
$3,689.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,381.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,029.28
|
| Rate for Payer: Quartz Commercial |
$2,628.84
|
| Rate for Payer: The Alliance Commercial |
$2,306.00
|
| Rate for Payer: WEA Trust Commercial |
$2,536.60
|
| Rate for Payer: WPS Commercial |
$3,416.11
|
|
|
BCE Image Guided Fluid Drainage Cath Perc
|
Facility
|
OP
|
$4,612.00
|
|
|
Service Code
|
CPT 10030 TC
|
| Hospital Charge Code |
5649640
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$574.00 |
| Max. Negotiated Rate |
$18,448.00 |
| Rate for Payer: Aetna Commercial |
$4,150.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,966.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,291.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,444.36
|
| Rate for Payer: Cash Price |
$1,383.60
|
| Rate for Payer: Cash Price |
$1,383.60
|
| Rate for Payer: Cash Price |
$1,383.60
|
| Rate for Payer: Cigna Commercial |
$4,243.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,580.88
|
| Rate for Payer: Health EOS Commercial |
$4,104.68
|
| Rate for Payer: HFN Commercial |
$4,243.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,459.00
|
| Rate for Payer: Multiplan Commercial |
$3,689.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,767.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,243.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,259.88
|
| Rate for Payer: Quartz Commercial |
$2,997.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,767.20
|
| Rate for Payer: The Alliance Commercial |
$18,448.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$2,536.60
|
| Rate for Payer: WPS Commercial |
$3,416.11
|
|
|
BCE Inj Knee Arthrogram
|
Facility
|
OP
|
$972.00
|
|
|
Service Code
|
CPT 27369
|
| Hospital Charge Code |
5577379
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$272.16 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$874.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$835.92
|
| Rate for Payer: Aetna Managed Medicare |
$272.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$515.16
|
| Rate for Payer: Cash Price |
$291.60
|
| Rate for Payer: Cash Price |
$291.60
|
| Rate for Payer: Cash Price |
$291.60
|
| Rate for Payer: Cash Price |
$291.60
|
| Rate for Payer: Cigna Commercial |
$894.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Health EOS Commercial |
$865.08
|
| Rate for Payer: HFN Commercial |
$894.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$729.00
|
| Rate for Payer: Multiplan Commercial |
$777.60
|
| Rate for Payer: NAPHCARE Commercial |
$583.20
|
| Rate for Payer: Preferred Network Access Commercial |
$894.24
|
| Rate for Payer: Quartz Beloit One Network |
$476.28
|
| Rate for Payer: Quartz Commercial |
$631.80
|
| Rate for Payer: Quartz Medicare Advantage |
$583.20
|
| Rate for Payer: The Alliance Commercial |
$3,888.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$534.60
|
| Rate for Payer: WPS Commercial |
$719.96
|
|
|
BCE Inj Knee Arthrogram
|
Professional
|
Both
|
$972.00
|
|
|
Service Code
|
CPT 27369
|
| Hospital Charge Code |
5577379
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$111.43 |
| Max. Negotiated Rate |
$923.40 |
| Rate for Payer: Aetna Commercial |
$923.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$835.92
|
| Rate for Payer: Cash Price |
$291.60
|
| Rate for Payer: Cash Price |
$291.60
|
| Rate for Payer: Cigna Commercial |
$923.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$111.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$583.20
|
| Rate for Payer: Health EOS Commercial |
$884.52
|
| Rate for Payer: HFN Commercial |
$923.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$133.29
|
| Rate for Payer: Multiplan Commercial |
$777.60
|
| Rate for Payer: Preferred Network Access Commercial |
$923.40
|
| Rate for Payer: Quartz Beloit One Network |
$427.68
|
| Rate for Payer: Quartz Commercial |
$554.04
|
| Rate for Payer: The Alliance Commercial |
$486.00
|
| Rate for Payer: United Healthcare Medicaid |
$111.43
|
| Rate for Payer: WEA Trust Commercial |
$534.60
|
| Rate for Payer: WPS Commercial |
$719.96
|
|
|
BCE Inj Knee Arthrogram
|
Facility
|
IP
|
$972.00
|
|
|
Service Code
|
CPT 27369
|
| Hospital Charge Code |
5577379
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$476.28 |
| Max. Negotiated Rate |
$894.24 |
| Rate for Payer: Aetna Commercial |
$874.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$835.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$515.16
|
| Rate for Payer: Cash Price |
$291.60
|
| Rate for Payer: Cigna Commercial |
$894.24
|
| Rate for Payer: Health EOS Commercial |
$865.08
|
| Rate for Payer: HFN Commercial |
$894.24
|
| Rate for Payer: Multiplan Commercial |
$777.60
|
| Rate for Payer: NAPHCARE Commercial |
$583.20
|
| Rate for Payer: Preferred Network Access Commercial |
$894.24
|
| Rate for Payer: Quartz Beloit One Network |
$476.28
|
| Rate for Payer: Quartz Commercial |
$583.20
|
| Rate for Payer: WEA Trust Commercial |
$534.60
|
| Rate for Payer: WPS Commercial |
$719.96
|
|
|
BCE Inj Procedure Retrograde Urethrocystography
|
Facility
|
IP
|
$889.00
|
|
|
Service Code
|
CPT 51610
|
| Hospital Charge Code |
5506847
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$435.61 |
| Max. Negotiated Rate |
$817.88 |
| Rate for Payer: Aetna Commercial |
$800.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$764.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$471.17
|
| Rate for Payer: Cash Price |
$266.70
|
| Rate for Payer: Cigna Commercial |
$817.88
|
| Rate for Payer: Health EOS Commercial |
$791.21
|
| Rate for Payer: HFN Commercial |
$817.88
|
| Rate for Payer: Multiplan Commercial |
$711.20
|
| Rate for Payer: NAPHCARE Commercial |
$533.40
|
| Rate for Payer: Preferred Network Access Commercial |
$817.88
|
| Rate for Payer: Quartz Beloit One Network |
$435.61
|
| Rate for Payer: Quartz Commercial |
$533.40
|
| Rate for Payer: WEA Trust Commercial |
$488.95
|
| Rate for Payer: WPS Commercial |
$658.48
|
|
|
BCE Inj Procedure Retrograde Urethrocystography
|
Facility
|
OP
|
$889.00
|
|
|
Service Code
|
CPT 51610
|
| Hospital Charge Code |
5506847
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$248.92 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$800.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$764.54
|
| Rate for Payer: Aetna Managed Medicare |
$248.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$577.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$444.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$426.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$471.17
|
| Rate for Payer: Cash Price |
$266.70
|
| Rate for Payer: Cash Price |
$266.70
|
| Rate for Payer: Cash Price |
$266.70
|
| Rate for Payer: Cigna Commercial |
$817.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Health EOS Commercial |
$791.21
|
| Rate for Payer: HFN Commercial |
$817.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.75
|
| Rate for Payer: Multiplan Commercial |
$711.20
|
| Rate for Payer: NAPHCARE Commercial |
$533.40
|
| Rate for Payer: Preferred Network Access Commercial |
$817.88
|
| Rate for Payer: Quartz Beloit One Network |
$435.61
|
| Rate for Payer: Quartz Commercial |
$577.85
|
| Rate for Payer: Quartz Medicare Advantage |
$533.40
|
| Rate for Payer: The Alliance Commercial |
$3,556.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$488.95
|
| Rate for Payer: WPS Commercial |
$658.48
|
|
|
BCE Inj Procedure Retrograde Urethrocystography
|
Professional
|
Both
|
$889.00
|
|
|
Service Code
|
CPT 51610
|
| Hospital Charge Code |
5506847
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$24.91 |
| Max. Negotiated Rate |
$844.55 |
| Rate for Payer: Aetna Commercial |
$844.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$764.54
|
| Rate for Payer: Cash Price |
$266.70
|
| Rate for Payer: Cash Price |
$266.70
|
| Rate for Payer: Cigna Commercial |
$844.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$533.40
|
| Rate for Payer: Health EOS Commercial |
$808.99
|
| Rate for Payer: HFN Commercial |
$844.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$213.39
|
| Rate for Payer: Multiplan Commercial |
$711.20
|
| Rate for Payer: Preferred Network Access Commercial |
$844.55
|
| Rate for Payer: Quartz Beloit One Network |
$391.16
|
| Rate for Payer: Quartz Commercial |
$506.73
|
| Rate for Payer: The Alliance Commercial |
$444.50
|
| Rate for Payer: United Healthcare Medicaid |
$24.91
|
| Rate for Payer: WEA Trust Commercial |
$488.95
|
| Rate for Payer: WPS Commercial |
$658.48
|
|
|
B Cell
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT 86359
|
| Hospital Charge Code |
4524628
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
B Cell
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
CPT 86359
|
| Hospital Charge Code |
4524628
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.73 |
| Max. Negotiated Rate |
$150.92 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$37.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$141.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$66.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$62.63
|
| Rate for Payer: Anthem Medicaid |
$38.99
|
| Rate for Payer: Anthem Medicare Advantage |
$37.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$37.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$37.73
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$37.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Dean Health Medicaid |
$38.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$37.73
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$140.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$37.73
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$38.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$37.73
|
| Rate for Payer: Managed Health Services Medicaid |
$40.55
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$37.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$37.73
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$56.60
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$38.99
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$37.73
|
| Rate for Payer: The Alliance Commercial |
$150.92
|
| Rate for Payer: United Healthcare Medicaid |
$38.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.73
|
| Rate for Payer: United Healthcare PPO |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: Wellcare Medicare |
$37.73
|
| Rate for Payer: WMAP Medicaid |
$38.99
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
B Cell
|
Professional
|
Both
|
$104.00
|
|
|
Service Code
|
CPT 86359
|
| Hospital Charge Code |
4524628
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.76 |
| Max. Negotiated Rate |
$133.19 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.40
|
| Rate for Payer: Health EOS Commercial |
$94.64
|
| Rate for Payer: HFN Commercial |
$98.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$133.19
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Preferred Network Access Commercial |
$98.80
|
| Rate for Payer: Quartz Beloit One Network |
$45.76
|
| Rate for Payer: Quartz Commercial |
$59.28
|
| Rate for Payer: The Alliance Commercial |
$52.00
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
BCE MA Breast Ndl Loc Placement Left ea add
|
Facility
|
IP
|
$1,255.00
|
|
|
Service Code
|
CPT 19282 TC,LT
|
| Hospital Charge Code |
4521246
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$614.95 |
| Max. Negotiated Rate |
$1,154.60 |
| Rate for Payer: Aetna Commercial |
$1,129.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,079.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$665.15
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cigna Commercial |
$1,154.60
|
| Rate for Payer: Health EOS Commercial |
$1,116.95
|
| Rate for Payer: HFN Commercial |
$1,154.60
|
| Rate for Payer: Multiplan Commercial |
$1,004.00
|
| Rate for Payer: NAPHCARE Commercial |
$753.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,154.60
|
| Rate for Payer: Quartz Beloit One Network |
$614.95
|
| Rate for Payer: Quartz Commercial |
$753.00
|
| Rate for Payer: WEA Trust Commercial |
$690.25
|
| Rate for Payer: WPS Commercial |
$929.58
|
|
|
BCE MA Breast Ndl Loc Placement Left ea add
|
Professional
|
Both
|
$1,255.00
|
|
|
Service Code
|
CPT 19282 TC,LT
|
| Hospital Charge Code |
4521246
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$552.20 |
| Max. Negotiated Rate |
$1,192.25 |
| Rate for Payer: Aetna Commercial |
$1,192.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,079.30
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cigna Commercial |
$1,192.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$627.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$753.00
|
| Rate for Payer: Health EOS Commercial |
$1,142.05
|
| Rate for Payer: HFN Commercial |
$1,192.25
|
| Rate for Payer: Multiplan Commercial |
$1,004.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,192.25
|
| Rate for Payer: Quartz Beloit One Network |
$552.20
|
| Rate for Payer: Quartz Commercial |
$715.35
|
| Rate for Payer: The Alliance Commercial |
$627.50
|
| Rate for Payer: WEA Trust Commercial |
$690.25
|
| Rate for Payer: WPS Commercial |
$929.58
|
|
|
BCE MA Breast Ndl Loc Placement Left ea add
|
Facility
|
OP
|
$1,255.00
|
|
|
Service Code
|
CPT 19282 TC,LT
|
| Hospital Charge Code |
4521246
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$5,020.00 |
| Rate for Payer: Aetna Commercial |
$1,129.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,079.30
|
| Rate for Payer: Aetna Managed Medicare |
$351.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$815.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$627.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$602.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$665.15
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cigna Commercial |
$1,154.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$702.30
|
| Rate for Payer: Health EOS Commercial |
$1,116.95
|
| Rate for Payer: HFN Commercial |
$1,154.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$941.25
|
| Rate for Payer: Multiplan Commercial |
$1,004.00
|
| Rate for Payer: NAPHCARE Commercial |
$753.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,154.60
|
| Rate for Payer: Quartz Beloit One Network |
$614.95
|
| Rate for Payer: Quartz Commercial |
$815.75
|
| Rate for Payer: Quartz Medicare Advantage |
$753.00
|
| Rate for Payer: The Alliance Commercial |
$5,020.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$690.25
|
| Rate for Payer: WPS Commercial |
$929.58
|
|
|
BCE MA Breast Ndl Loc Placement Right ea add
|
Professional
|
Both
|
$1,303.00
|
|
|
Service Code
|
CPT 19282 TC,RT
|
| Hospital Charge Code |
4521247
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$573.32 |
| Max. Negotiated Rate |
$1,237.85 |
| Rate for Payer: Aetna Commercial |
$1,237.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,120.58
|
| Rate for Payer: Cash Price |
$390.90
|
| Rate for Payer: Cash Price |
$390.90
|
| Rate for Payer: Cigna Commercial |
$1,237.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$651.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$781.80
|
| Rate for Payer: Health EOS Commercial |
$1,185.73
|
| Rate for Payer: HFN Commercial |
$1,237.85
|
| Rate for Payer: Multiplan Commercial |
$1,042.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,237.85
|
| Rate for Payer: Quartz Beloit One Network |
$573.32
|
| Rate for Payer: Quartz Commercial |
$742.71
|
| Rate for Payer: The Alliance Commercial |
$651.50
|
| Rate for Payer: WEA Trust Commercial |
$716.65
|
| Rate for Payer: WPS Commercial |
$965.13
|
|
|
BCE MA Breast Ndl Loc Placement Right ea add
|
Facility
|
OP
|
$1,303.00
|
|
|
Service Code
|
CPT 19282 TC,RT
|
| Hospital Charge Code |
4521247
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$5,212.00 |
| Rate for Payer: Aetna Commercial |
$1,172.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,120.58
|
| Rate for Payer: Aetna Managed Medicare |
$364.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$846.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$651.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$625.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.59
|
| Rate for Payer: Cash Price |
$390.90
|
| Rate for Payer: Cash Price |
$390.90
|
| Rate for Payer: Cigna Commercial |
$1,198.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$729.16
|
| Rate for Payer: Health EOS Commercial |
$1,159.67
|
| Rate for Payer: HFN Commercial |
$1,198.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$977.25
|
| Rate for Payer: Multiplan Commercial |
$1,042.40
|
| Rate for Payer: NAPHCARE Commercial |
$781.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,198.76
|
| Rate for Payer: Quartz Beloit One Network |
$638.47
|
| Rate for Payer: Quartz Commercial |
$846.95
|
| Rate for Payer: Quartz Medicare Advantage |
$781.80
|
| Rate for Payer: The Alliance Commercial |
$5,212.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$716.65
|
| Rate for Payer: WPS Commercial |
$965.13
|
|
|
BCE MA Breast Ndl Loc Placement Right ea add
|
Facility
|
IP
|
$1,303.00
|
|
|
Service Code
|
CPT 19282 TC,RT
|
| Hospital Charge Code |
4521247
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$638.47 |
| Max. Negotiated Rate |
$1,198.76 |
| Rate for Payer: Aetna Commercial |
$1,172.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,120.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$690.59
|
| Rate for Payer: Cash Price |
$390.90
|
| Rate for Payer: Cigna Commercial |
$1,198.76
|
| Rate for Payer: Health EOS Commercial |
$1,159.67
|
| Rate for Payer: HFN Commercial |
$1,198.76
|
| Rate for Payer: Multiplan Commercial |
$1,042.40
|
| Rate for Payer: NAPHCARE Commercial |
$781.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,198.76
|
| Rate for Payer: Quartz Beloit One Network |
$638.47
|
| Rate for Payer: Quartz Commercial |
$781.80
|
| Rate for Payer: WEA Trust Commercial |
$716.65
|
| Rate for Payer: WPS Commercial |
$965.13
|
|
|
BCE MA Stereotactic Localization ea additional lesion LT
|
Facility
|
OP
|
$2,262.00
|
|
|
Service Code
|
CPT 19082 TC,LT
|
| Hospital Charge Code |
4076048
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$633.36 |
| Max. Negotiated Rate |
$9,048.00 |
| Rate for Payer: Aetna Commercial |
$2,035.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,945.32
|
| Rate for Payer: Aetna Managed Medicare |
$633.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,470.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,131.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,085.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,198.86
|
| Rate for Payer: Cash Price |
$678.60
|
| Rate for Payer: Cigna Commercial |
$2,081.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,265.82
|
| Rate for Payer: Health EOS Commercial |
$2,013.18
|
| Rate for Payer: HFN Commercial |
$2,081.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,696.50
|
| Rate for Payer: Multiplan Commercial |
$1,809.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,357.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,081.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,108.38
|
| Rate for Payer: Quartz Commercial |
$1,470.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,357.20
|
| Rate for Payer: The Alliance Commercial |
$9,048.00
|
| Rate for Payer: United Healthcare PPO |
$1,696.50
|
| Rate for Payer: WEA Trust Commercial |
$1,244.10
|
| Rate for Payer: WPS Commercial |
$1,675.46
|
|
|
BCE MA Stereotactic Localization ea additional lesion LT
|
Professional
|
Both
|
$2,262.00
|
|
|
Service Code
|
CPT 19082 TC,LT
|
| Hospital Charge Code |
4076048
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$995.28 |
| Max. Negotiated Rate |
$2,148.90 |
| Rate for Payer: Aetna Commercial |
$2,148.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,945.32
|
| Rate for Payer: Cash Price |
$678.60
|
| Rate for Payer: Cash Price |
$678.60
|
| Rate for Payer: Cigna Commercial |
$2,148.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,131.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,357.20
|
| Rate for Payer: Health EOS Commercial |
$2,058.42
|
| Rate for Payer: HFN Commercial |
$2,148.90
|
| Rate for Payer: Multiplan Commercial |
$1,809.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,148.90
|
| Rate for Payer: Quartz Beloit One Network |
$995.28
|
| Rate for Payer: Quartz Commercial |
$1,289.34
|
| Rate for Payer: The Alliance Commercial |
$1,131.00
|
| Rate for Payer: WEA Trust Commercial |
$1,244.10
|
| Rate for Payer: WPS Commercial |
$1,675.46
|
|
