|
BCE Saliva Confirmation 1-7
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
5542875
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$87.22 |
| Max. Negotiated Rate |
$163.76 |
| Rate for Payer: Aetna Commercial |
$160.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.34
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$163.76
|
| Rate for Payer: Health EOS Commercial |
$158.42
|
| Rate for Payer: HFN Commercial |
$163.76
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: NAPHCARE Commercial |
$106.80
|
| Rate for Payer: Preferred Network Access Commercial |
$163.76
|
| Rate for Payer: Quartz Beloit One Network |
$87.22
|
| Rate for Payer: Quartz Commercial |
$106.80
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
BCE Saliva Confirmation 22+
|
Professional
|
Both
|
$851.00
|
|
|
Service Code
|
HCPCS G0483
|
| Hospital Charge Code |
5542878
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$374.44 |
| Max. Negotiated Rate |
$871.63 |
| Rate for Payer: Aetna Commercial |
$808.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$731.86
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cigna Commercial |
$808.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$425.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$510.60
|
| Rate for Payer: Health EOS Commercial |
$774.41
|
| Rate for Payer: HFN Commercial |
$808.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$871.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$871.63
|
| Rate for Payer: Multiplan Commercial |
$680.80
|
| Rate for Payer: Preferred Network Access Commercial |
$808.45
|
| Rate for Payer: Quartz Beloit One Network |
$374.44
|
| Rate for Payer: Quartz Commercial |
$485.07
|
| Rate for Payer: The Alliance Commercial |
$425.50
|
| Rate for Payer: WEA Trust Commercial |
$468.05
|
| Rate for Payer: WPS Commercial |
$630.34
|
|
|
BCE Saliva Confirmation 22+
|
Facility
|
IP
|
$851.00
|
|
|
Service Code
|
HCPCS G0483
|
| Hospital Charge Code |
5542878
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$416.99 |
| Max. Negotiated Rate |
$782.92 |
| Rate for Payer: Aetna Commercial |
$765.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$731.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$451.03
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cigna Commercial |
$782.92
|
| Rate for Payer: Health EOS Commercial |
$757.39
|
| Rate for Payer: HFN Commercial |
$782.92
|
| Rate for Payer: Multiplan Commercial |
$680.80
|
| Rate for Payer: NAPHCARE Commercial |
$510.60
|
| Rate for Payer: Preferred Network Access Commercial |
$782.92
|
| Rate for Payer: Quartz Beloit One Network |
$416.99
|
| Rate for Payer: Quartz Commercial |
$510.60
|
| Rate for Payer: WEA Trust Commercial |
$468.05
|
| Rate for Payer: WPS Commercial |
$630.34
|
|
|
BCE Saliva Confirmation 22+
|
Facility
|
OP
|
$851.00
|
|
|
Service Code
|
HCPCS G0483
|
| Hospital Charge Code |
5542878
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$172.18 |
| Max. Negotiated Rate |
$987.68 |
| Rate for Payer: Aetna Commercial |
$765.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$731.86
|
| Rate for Payer: Aetna Managed Medicare |
$246.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$553.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$425.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$408.48
|
| Rate for Payer: Anthem Medicaid |
$172.18
|
| Rate for Payer: Anthem Medicare Advantage |
$246.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$451.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$246.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$246.92
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cigna Commercial |
$782.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$246.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$172.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$476.22
|
| Rate for Payer: Dean Health Medicaid |
$172.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$246.92
|
| Rate for Payer: Health EOS Commercial |
$757.39
|
| Rate for Payer: HFN Commercial |
$782.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$918.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$246.92
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$172.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$246.92
|
| Rate for Payer: Managed Health Services Medicaid |
$179.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$246.92
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$246.92
|
| Rate for Payer: Multiplan Commercial |
$680.80
|
| Rate for Payer: NAPHCARE Commercial |
$370.38
|
| Rate for Payer: Preferred Network Access Commercial |
$782.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$172.18
|
| Rate for Payer: Quartz Beloit One Network |
$416.99
|
| Rate for Payer: Quartz Commercial |
$553.15
|
| Rate for Payer: Quartz Medicare Advantage |
$246.92
|
| Rate for Payer: The Alliance Commercial |
$987.68
|
| Rate for Payer: United Healthcare Medicaid |
$172.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$246.92
|
| Rate for Payer: United Healthcare PPO |
$638.25
|
| Rate for Payer: WEA Trust Commercial |
$468.05
|
| Rate for Payer: Wellcare Medicare |
$246.92
|
| Rate for Payer: WMAP Medicaid |
$172.18
|
| Rate for Payer: WPS Commercial |
$630.34
|
|
|
BCE Saliva Confirmation 5
|
Professional
|
Both
|
$287.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
5260624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$126.28 |
| Max. Negotiated Rate |
$272.65 |
| Rate for Payer: Aetna Commercial |
$272.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.82
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$272.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$143.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$172.20
|
| Rate for Payer: Health EOS Commercial |
$261.17
|
| Rate for Payer: HFN Commercial |
$272.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$219.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$219.35
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: Preferred Network Access Commercial |
$272.65
|
| Rate for Payer: Quartz Beloit One Network |
$126.28
|
| Rate for Payer: Quartz Commercial |
$163.59
|
| Rate for Payer: The Alliance Commercial |
$143.50
|
| Rate for Payer: WEA Trust Commercial |
$157.85
|
| Rate for Payer: WPS Commercial |
$212.58
|
|
|
BCE Saliva Confirmation 5
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
5260624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$140.63 |
| Max. Negotiated Rate |
$264.04 |
| Rate for Payer: Aetna Commercial |
$258.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.11
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$264.04
|
| Rate for Payer: Health EOS Commercial |
$255.43
|
| Rate for Payer: HFN Commercial |
$264.04
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: NAPHCARE Commercial |
$172.20
|
| Rate for Payer: Preferred Network Access Commercial |
$264.04
|
| Rate for Payer: Quartz Beloit One Network |
$140.63
|
| Rate for Payer: Quartz Commercial |
$172.20
|
| Rate for Payer: WEA Trust Commercial |
$157.85
|
| Rate for Payer: WPS Commercial |
$212.58
|
|
|
BCE Saliva Confirmation 5
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
5260624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.14 |
| Max. Negotiated Rate |
$264.04 |
| Rate for Payer: Aetna Commercial |
$258.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.82
|
| Rate for Payer: Aetna Managed Medicare |
$62.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$233.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$108.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$103.15
|
| Rate for Payer: Anthem Medicaid |
$63.40
|
| Rate for Payer: Anthem Medicare Advantage |
$62.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.14
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$264.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$62.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$63.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.61
|
| Rate for Payer: Dean Health Medicaid |
$63.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$62.14
|
| Rate for Payer: Health EOS Commercial |
$255.43
|
| Rate for Payer: HFN Commercial |
$264.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$231.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.14
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.14
|
| Rate for Payer: Managed Health Services Medicaid |
$65.94
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$62.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$62.14
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: NAPHCARE Commercial |
$93.21
|
| Rate for Payer: Preferred Network Access Commercial |
$264.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$63.40
|
| Rate for Payer: Quartz Beloit One Network |
$140.63
|
| Rate for Payer: Quartz Commercial |
$186.55
|
| Rate for Payer: Quartz Medicare Advantage |
$62.14
|
| Rate for Payer: The Alliance Commercial |
$248.56
|
| Rate for Payer: United Healthcare Medicaid |
$63.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.14
|
| Rate for Payer: United Healthcare PPO |
$215.25
|
| Rate for Payer: WEA Trust Commercial |
$157.85
|
| Rate for Payer: Wellcare Medicare |
$62.14
|
| Rate for Payer: WMAP Medicaid |
$63.40
|
| Rate for Payer: WPS Commercial |
$212.58
|
|
|
BCE Saliva Confirmation 8-14
|
Facility
|
OP
|
$426.00
|
|
|
Service Code
|
HCPCS G0481
|
| Hospital Charge Code |
5542876
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.39 |
| Max. Negotiated Rate |
$626.36 |
| Rate for Payer: Aetna Commercial |
$383.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$366.36
|
| Rate for Payer: Aetna Managed Medicare |
$156.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$276.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$213.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$204.48
|
| Rate for Payer: Anthem Medicaid |
$98.39
|
| Rate for Payer: Anthem Medicare Advantage |
$156.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$225.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$156.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$156.59
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cigna Commercial |
$391.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$156.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$98.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$238.39
|
| Rate for Payer: Dean Health Medicaid |
$98.39
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$156.59
|
| Rate for Payer: Health EOS Commercial |
$379.14
|
| Rate for Payer: HFN Commercial |
$391.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$582.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$156.59
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$98.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$156.59
|
| Rate for Payer: Managed Health Services Medicaid |
$102.33
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$156.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$156.59
|
| Rate for Payer: Multiplan Commercial |
$340.80
|
| Rate for Payer: NAPHCARE Commercial |
$234.88
|
| Rate for Payer: Preferred Network Access Commercial |
$391.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$98.39
|
| Rate for Payer: Quartz Beloit One Network |
$208.74
|
| Rate for Payer: Quartz Commercial |
$276.90
|
| Rate for Payer: Quartz Medicare Advantage |
$156.59
|
| Rate for Payer: The Alliance Commercial |
$626.36
|
| Rate for Payer: United Healthcare Medicaid |
$98.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$156.59
|
| Rate for Payer: United Healthcare PPO |
$319.50
|
| Rate for Payer: WEA Trust Commercial |
$234.30
|
| Rate for Payer: Wellcare Medicare |
$156.59
|
| Rate for Payer: WMAP Medicaid |
$98.39
|
| Rate for Payer: WPS Commercial |
$315.54
|
|
|
BCE Saliva Confirmation 8-14
|
Facility
|
IP
|
$426.00
|
|
|
Service Code
|
HCPCS G0481
|
| Hospital Charge Code |
5542876
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$208.74 |
| Max. Negotiated Rate |
$391.92 |
| Rate for Payer: Aetna Commercial |
$383.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$366.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$225.78
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cigna Commercial |
$391.92
|
| Rate for Payer: Health EOS Commercial |
$379.14
|
| Rate for Payer: HFN Commercial |
$391.92
|
| Rate for Payer: Multiplan Commercial |
$340.80
|
| Rate for Payer: NAPHCARE Commercial |
$255.60
|
| Rate for Payer: Preferred Network Access Commercial |
$391.92
|
| Rate for Payer: Quartz Beloit One Network |
$208.74
|
| Rate for Payer: Quartz Commercial |
$255.60
|
| Rate for Payer: WEA Trust Commercial |
$234.30
|
| Rate for Payer: WPS Commercial |
$315.54
|
|
|
BCE Saliva Confirmation 8-14
|
Professional
|
Both
|
$426.00
|
|
|
Service Code
|
HCPCS G0481
|
| Hospital Charge Code |
5542876
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$187.44 |
| Max. Negotiated Rate |
$552.76 |
| Rate for Payer: Aetna Commercial |
$404.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$366.36
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cigna Commercial |
$404.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$213.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$255.60
|
| Rate for Payer: Health EOS Commercial |
$387.66
|
| Rate for Payer: HFN Commercial |
$404.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$552.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$552.76
|
| Rate for Payer: Multiplan Commercial |
$340.80
|
| Rate for Payer: Preferred Network Access Commercial |
$404.70
|
| Rate for Payer: Quartz Beloit One Network |
$187.44
|
| Rate for Payer: Quartz Commercial |
$242.82
|
| Rate for Payer: The Alliance Commercial |
$213.00
|
| Rate for Payer: WEA Trust Commercial |
$234.30
|
| Rate for Payer: WPS Commercial |
$315.54
|
|
|
BCE Tc-99m Ceretec(HMPAO)
|
Professional
|
Both
|
$1,946.00
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
5709754
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$856.24 |
| Max. Negotiated Rate |
$2,550.85 |
| Rate for Payer: Aetna Commercial |
$1,848.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,673.56
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cigna Commercial |
$1,848.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$973.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,167.60
|
| Rate for Payer: Health EOS Commercial |
$1,770.86
|
| Rate for Payer: HFN Commercial |
$1,848.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,550.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,550.85
|
| Rate for Payer: Multiplan Commercial |
$1,556.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,848.70
|
| Rate for Payer: Quartz Beloit One Network |
$856.24
|
| Rate for Payer: Quartz Commercial |
$1,109.22
|
| Rate for Payer: The Alliance Commercial |
$973.00
|
| Rate for Payer: WEA Trust Commercial |
$1,070.30
|
| Rate for Payer: WPS Commercial |
$1,441.40
|
|
|
BCE Tc-99m Ceretec(HMPAO)
|
Facility
|
OP
|
$1,946.00
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
5709754
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$544.88 |
| Max. Negotiated Rate |
$7,784.00 |
| Rate for Payer: Aetna Commercial |
$1,751.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,673.56
|
| Rate for Payer: Aetna Managed Medicare |
$544.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,264.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$973.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$934.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,031.38
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cigna Commercial |
$1,790.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,088.98
|
| Rate for Payer: Health EOS Commercial |
$1,731.94
|
| Rate for Payer: HFN Commercial |
$1,790.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,459.50
|
| Rate for Payer: Multiplan Commercial |
$1,556.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,167.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,790.32
|
| Rate for Payer: Quartz Beloit One Network |
$953.54
|
| Rate for Payer: Quartz Commercial |
$1,264.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,167.60
|
| Rate for Payer: The Alliance Commercial |
$7,784.00
|
| Rate for Payer: WEA Trust Commercial |
$1,070.30
|
| Rate for Payer: WPS Commercial |
$1,441.40
|
|
|
BCE Tc-99m Ceretec(HMPAO)
|
Facility
|
IP
|
$1,946.00
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
5709754
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$953.54 |
| Max. Negotiated Rate |
$1,790.32 |
| Rate for Payer: Aetna Commercial |
$1,751.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,673.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,031.38
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cigna Commercial |
$1,790.32
|
| Rate for Payer: Health EOS Commercial |
$1,731.94
|
| Rate for Payer: HFN Commercial |
$1,790.32
|
| Rate for Payer: Multiplan Commercial |
$1,556.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,167.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,790.32
|
| Rate for Payer: Quartz Beloit One Network |
$953.54
|
| Rate for Payer: Quartz Commercial |
$1,167.60
|
| Rate for Payer: WEA Trust Commercial |
$1,070.30
|
| Rate for Payer: WPS Commercial |
$1,441.40
|
|
|
BCE US Biopsy of Thyroid
|
Facility
|
IP
|
$447.00
|
|
|
Service Code
|
CPT 60100 TC
|
| Hospital Charge Code |
4464946
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$219.03 |
| Max. Negotiated Rate |
$411.24 |
| Rate for Payer: Aetna Commercial |
$402.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$236.91
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$411.24
|
| Rate for Payer: Health EOS Commercial |
$397.83
|
| Rate for Payer: HFN Commercial |
$411.24
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: NAPHCARE Commercial |
$268.20
|
| Rate for Payer: Preferred Network Access Commercial |
$411.24
|
| Rate for Payer: Quartz Beloit One Network |
$219.03
|
| Rate for Payer: Quartz Commercial |
$268.20
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
|
BCE US Biopsy of Thyroid
|
Facility
|
OP
|
$447.00
|
|
|
Service Code
|
CPT 60100 TC
|
| Hospital Charge Code |
4464946
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$125.16 |
| Max. Negotiated Rate |
$1,788.00 |
| Rate for Payer: Aetna Commercial |
$402.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Aetna Managed Medicare |
$125.16
|
| 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 |
$236.91
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$411.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.14
|
| Rate for Payer: Health EOS Commercial |
$397.83
|
| Rate for Payer: HFN Commercial |
$411.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$335.25
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: NAPHCARE Commercial |
$268.20
|
| Rate for Payer: Preferred Network Access Commercial |
$411.24
|
| Rate for Payer: Quartz Beloit One Network |
$219.03
|
| Rate for Payer: Quartz Commercial |
$290.55
|
| Rate for Payer: Quartz Medicare Advantage |
$268.20
|
| Rate for Payer: The Alliance Commercial |
$1,788.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
|
BCE US Biopsy of Thyroid
|
Professional
|
Both
|
$447.00
|
|
|
Service Code
|
CPT 60100 TC
|
| Hospital Charge Code |
4464946
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$196.68 |
| Max. Negotiated Rate |
$424.65 |
| Rate for Payer: Aetna Commercial |
$424.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$424.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$223.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.20
|
| Rate for Payer: Health EOS Commercial |
$406.77
|
| Rate for Payer: HFN Commercial |
$424.65
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: Preferred Network Access Commercial |
$424.65
|
| Rate for Payer: Quartz Beloit One Network |
$196.68
|
| Rate for Payer: Quartz Commercial |
$254.79
|
| Rate for Payer: The Alliance Commercial |
$223.50
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
|
BCE US Breast Biopsy each additional LT
|
Professional
|
Both
|
$1,481.00
|
|
|
Service Code
|
CPT 19084 TC,LT
|
| Hospital Charge Code |
4076047
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$651.64 |
| Max. Negotiated Rate |
$1,406.95 |
| Rate for Payer: Aetna Commercial |
$1,406.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,273.66
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cigna Commercial |
$1,406.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$740.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$888.60
|
| Rate for Payer: Health EOS Commercial |
$1,347.71
|
| Rate for Payer: HFN Commercial |
$1,406.95
|
| Rate for Payer: Multiplan Commercial |
$1,184.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,406.95
|
| Rate for Payer: Quartz Beloit One Network |
$651.64
|
| Rate for Payer: Quartz Commercial |
$844.17
|
| Rate for Payer: The Alliance Commercial |
$740.50
|
| Rate for Payer: WEA Trust Commercial |
$814.55
|
| Rate for Payer: WPS Commercial |
$1,096.98
|
|
|
BCE US Breast Biopsy each additional LT
|
Facility
|
OP
|
$1,481.00
|
|
|
Service Code
|
CPT 19084 TC,LT
|
| Hospital Charge Code |
4076047
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$414.68 |
| Max. Negotiated Rate |
$5,924.00 |
| Rate for Payer: Aetna Commercial |
$1,332.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,273.66
|
| Rate for Payer: Aetna Managed Medicare |
$414.68
|
| 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 |
$784.93
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cigna Commercial |
$1,362.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$828.77
|
| Rate for Payer: Health EOS Commercial |
$1,318.09
|
| Rate for Payer: HFN Commercial |
$1,362.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,110.75
|
| Rate for Payer: Multiplan Commercial |
$1,184.80
|
| Rate for Payer: NAPHCARE Commercial |
$888.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,362.52
|
| Rate for Payer: Quartz Beloit One Network |
$725.69
|
| Rate for Payer: Quartz Commercial |
$962.65
|
| Rate for Payer: Quartz Medicare Advantage |
$888.60
|
| Rate for Payer: The Alliance Commercial |
$5,924.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$814.55
|
| Rate for Payer: WPS Commercial |
$1,096.98
|
|
|
BCE US Breast Biopsy each additional LT
|
Facility
|
IP
|
$1,481.00
|
|
|
Service Code
|
CPT 19084 TC,LT
|
| Hospital Charge Code |
4076047
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$725.69 |
| Max. Negotiated Rate |
$1,362.52 |
| Rate for Payer: Aetna Commercial |
$1,332.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,273.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$784.93
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cigna Commercial |
$1,362.52
|
| Rate for Payer: Health EOS Commercial |
$1,318.09
|
| Rate for Payer: HFN Commercial |
$1,362.52
|
| Rate for Payer: Multiplan Commercial |
$1,184.80
|
| Rate for Payer: NAPHCARE Commercial |
$888.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,362.52
|
| Rate for Payer: Quartz Beloit One Network |
$725.69
|
| Rate for Payer: Quartz Commercial |
$888.60
|
| Rate for Payer: WEA Trust Commercial |
$814.55
|
| Rate for Payer: WPS Commercial |
$1,096.98
|
|
|
BCE US Breast Biopsy each additional RT
|
Professional
|
Both
|
$1,481.00
|
|
|
Service Code
|
CPT 19084 TC,RT
|
| Hospital Charge Code |
4076046
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$651.64 |
| Max. Negotiated Rate |
$1,406.95 |
| Rate for Payer: Aetna Commercial |
$1,406.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,273.66
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cigna Commercial |
$1,406.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$740.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$888.60
|
| Rate for Payer: Health EOS Commercial |
$1,347.71
|
| Rate for Payer: HFN Commercial |
$1,406.95
|
| Rate for Payer: Multiplan Commercial |
$1,184.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,406.95
|
| Rate for Payer: Quartz Beloit One Network |
$651.64
|
| Rate for Payer: Quartz Commercial |
$844.17
|
| Rate for Payer: The Alliance Commercial |
$740.50
|
| Rate for Payer: WEA Trust Commercial |
$814.55
|
| Rate for Payer: WPS Commercial |
$1,096.98
|
|
|
BCE US Breast Biopsy each additional RT
|
Facility
|
IP
|
$1,481.00
|
|
|
Service Code
|
CPT 19084 TC,RT
|
| Hospital Charge Code |
4076046
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$725.69 |
| Max. Negotiated Rate |
$1,362.52 |
| Rate for Payer: Aetna Commercial |
$1,332.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,273.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$784.93
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cigna Commercial |
$1,362.52
|
| Rate for Payer: Health EOS Commercial |
$1,318.09
|
| Rate for Payer: HFN Commercial |
$1,362.52
|
| Rate for Payer: Multiplan Commercial |
$1,184.80
|
| Rate for Payer: NAPHCARE Commercial |
$888.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,362.52
|
| Rate for Payer: Quartz Beloit One Network |
$725.69
|
| Rate for Payer: Quartz Commercial |
$888.60
|
| Rate for Payer: WEA Trust Commercial |
$814.55
|
| Rate for Payer: WPS Commercial |
$1,096.98
|
|
|
BCE US Breast Biopsy each additional RT
|
Facility
|
OP
|
$1,481.00
|
|
|
Service Code
|
CPT 19084 TC,RT
|
| Hospital Charge Code |
4076046
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$414.68 |
| Max. Negotiated Rate |
$5,924.00 |
| Rate for Payer: Aetna Commercial |
$1,332.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,273.66
|
| Rate for Payer: Aetna Managed Medicare |
$414.68
|
| 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 |
$784.93
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cigna Commercial |
$1,362.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$828.77
|
| Rate for Payer: Health EOS Commercial |
$1,318.09
|
| Rate for Payer: HFN Commercial |
$1,362.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,110.75
|
| Rate for Payer: Multiplan Commercial |
$1,184.80
|
| Rate for Payer: NAPHCARE Commercial |
$888.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,362.52
|
| Rate for Payer: Quartz Beloit One Network |
$725.69
|
| Rate for Payer: Quartz Commercial |
$962.65
|
| Rate for Payer: Quartz Medicare Advantage |
$888.60
|
| Rate for Payer: The Alliance Commercial |
$5,924.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$814.55
|
| Rate for Payer: WPS Commercial |
$1,096.98
|
|
|
BCE US Pregnancy Transvaginal
|
Professional
|
Both
|
$1,085.00
|
|
|
Service Code
|
CPT 76817 TC
|
| Hospital Charge Code |
3091485
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$202.23 |
| Max. Negotiated Rate |
$1,030.75 |
| Rate for Payer: Aetna Commercial |
$1,030.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$933.10
|
| Rate for Payer: Cash Price |
$325.50
|
| Rate for Payer: Cash Price |
$325.50
|
| Rate for Payer: Cigna Commercial |
$1,030.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$542.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$651.00
|
| Rate for Payer: Health EOS Commercial |
$987.35
|
| Rate for Payer: HFN Commercial |
$1,030.75
|
| 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 |
$868.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,030.75
|
| Rate for Payer: Quartz Beloit One Network |
$477.40
|
| Rate for Payer: Quartz Commercial |
$618.45
|
| Rate for Payer: The Alliance Commercial |
$542.50
|
| Rate for Payer: WEA Trust Commercial |
$596.75
|
| Rate for Payer: WPS Commercial |
$803.66
|
|
|
BCE US Pregnancy Transvaginal
|
Facility
|
IP
|
$1,085.00
|
|
|
Service Code
|
CPT 76817 TC
|
| Hospital Charge Code |
3091485
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$531.65 |
| Max. Negotiated Rate |
$998.20 |
| Rate for Payer: Aetna Commercial |
$976.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$933.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$575.05
|
| Rate for Payer: Cash Price |
$325.50
|
| Rate for Payer: Cigna Commercial |
$998.20
|
| Rate for Payer: Health EOS Commercial |
$965.65
|
| Rate for Payer: HFN Commercial |
$998.20
|
| Rate for Payer: Multiplan Commercial |
$868.00
|
| Rate for Payer: NAPHCARE Commercial |
$651.00
|
| Rate for Payer: Preferred Network Access Commercial |
$998.20
|
| Rate for Payer: Quartz Beloit One Network |
$531.65
|
| Rate for Payer: Quartz Commercial |
$651.00
|
| Rate for Payer: WEA Trust Commercial |
$596.75
|
| Rate for Payer: WPS Commercial |
$803.66
|
|
|
BCE US Pregnancy Transvaginal
|
Facility
|
OP
|
$1,085.00
|
|
|
Service Code
|
CPT 76817 TC
|
| Hospital Charge Code |
3091485
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$303.80 |
| Max. Negotiated Rate |
$4,340.00 |
| Rate for Payer: Aetna Commercial |
$976.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$933.10
|
| Rate for Payer: Aetna Managed Medicare |
$303.80
|
| 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 |
$575.05
|
| Rate for Payer: Cash Price |
$325.50
|
| Rate for Payer: Cash Price |
$325.50
|
| Rate for Payer: Cash Price |
$325.50
|
| Rate for Payer: Cigna Commercial |
$998.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$607.17
|
| Rate for Payer: Health EOS Commercial |
$965.65
|
| Rate for Payer: HFN Commercial |
$998.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.75
|
| Rate for Payer: Multiplan Commercial |
$868.00
|
| Rate for Payer: NAPHCARE Commercial |
$651.00
|
| Rate for Payer: Preferred Network Access Commercial |
$998.20
|
| Rate for Payer: Quartz Beloit One Network |
$531.65
|
| Rate for Payer: Quartz Commercial |
$705.25
|
| Rate for Payer: Quartz Medicare Advantage |
$651.00
|
| Rate for Payer: The Alliance Commercial |
$4,340.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$596.75
|
| Rate for Payer: WPS Commercial |
$803.66
|
|
