|
BRA MASTECTOMY KIT MEDEBRA MED 34-36 IN B-D MEDEKIT-002W
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611555
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.59 |
| Max. Negotiated Rate |
$2,148.00 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Aetna Managed Medicare |
$150.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.51
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$402.75
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$349.05
|
| Rate for Payer: Quartz Medicare Advantage |
$322.20
|
| Rate for Payer: The Alliance Commercial |
$2,148.00
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
|
BRA MASTECTOMY KIT MEDEBRA SMALL 32-34 IN A-C MEDEKIT-001W
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611554
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.59 |
| Max. Negotiated Rate |
$2,148.00 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Aetna Managed Medicare |
$150.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.51
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$402.75
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$349.05
|
| Rate for Payer: Quartz Medicare Advantage |
$322.20
|
| Rate for Payer: The Alliance Commercial |
$2,148.00
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
|
BRA MASTECTOMY KIT MEDEBRA SMALL 32-34 IN A-C MEDEKIT-001W
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611554
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$263.13 |
| Max. Negotiated Rate |
$494.04 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$322.20
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
|
BRA SURGICAL SUPPORT CHEST LARGE FITS 40 M5001-L
|
Facility
|
OP
|
$390.00
|
|
| Hospital Charge Code |
2975054
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$1,560.00 |
| Rate for Payer: Aetna Commercial |
$351.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$335.40
|
| Rate for Payer: Aetna Managed Medicare |
$109.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$253.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$195.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$187.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.70
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$358.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.24
|
| Rate for Payer: Health EOS Commercial |
$347.10
|
| Rate for Payer: HFN Commercial |
$358.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$292.50
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: NAPHCARE Commercial |
$234.00
|
| Rate for Payer: Preferred Network Access Commercial |
$358.80
|
| Rate for Payer: Quartz Beloit One Network |
$191.10
|
| Rate for Payer: Quartz Commercial |
$253.50
|
| Rate for Payer: Quartz Medicare Advantage |
$234.00
|
| Rate for Payer: The Alliance Commercial |
$1,560.00
|
| Rate for Payer: WEA Trust Commercial |
$214.50
|
| Rate for Payer: WPS Commercial |
$288.87
|
|
|
BRA SURGICAL SUPPORT CHEST LARGE FITS 40 M5001-L
|
Facility
|
IP
|
$390.00
|
|
| Hospital Charge Code |
2975054
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$191.10 |
| Max. Negotiated Rate |
$358.80 |
| Rate for Payer: Aetna Commercial |
$351.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$335.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.70
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$358.80
|
| Rate for Payer: Health EOS Commercial |
$347.10
|
| Rate for Payer: HFN Commercial |
$358.80
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: NAPHCARE Commercial |
$234.00
|
| Rate for Payer: Preferred Network Access Commercial |
$358.80
|
| Rate for Payer: Quartz Beloit One Network |
$191.10
|
| Rate for Payer: Quartz Commercial |
$234.00
|
| Rate for Payer: WEA Trust Commercial |
$214.50
|
| Rate for Payer: WPS Commercial |
$288.87
|
|
|
BRA SURGICAL SUPPORT CHEST MEDIUM FITS 36 M5001-M
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
2975053
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$28.68 |
| Max. Negotiated Rate |
$1,560.00 |
| Rate for Payer: Aetna Commercial |
$351.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$335.40
|
| Rate for Payer: Aetna Managed Medicare |
$109.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.70
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$358.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.24
|
| Rate for Payer: Health EOS Commercial |
$347.10
|
| Rate for Payer: HFN Commercial |
$358.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$292.50
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: NAPHCARE Commercial |
$234.00
|
| Rate for Payer: Preferred Network Access Commercial |
$358.80
|
| Rate for Payer: Quartz Beloit One Network |
$191.10
|
| Rate for Payer: Quartz Commercial |
$253.50
|
| Rate for Payer: Quartz Medicare Advantage |
$234.00
|
| Rate for Payer: The Alliance Commercial |
$1,560.00
|
| Rate for Payer: WEA Trust Commercial |
$214.50
|
| Rate for Payer: WPS Commercial |
$288.87
|
|
|
BRA SURGICAL SUPPORT CHEST MEDIUM FITS 36 M5001-M
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
2975053
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$191.10 |
| Max. Negotiated Rate |
$358.80 |
| Rate for Payer: Aetna Commercial |
$351.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$335.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.70
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$358.80
|
| Rate for Payer: Health EOS Commercial |
$347.10
|
| Rate for Payer: HFN Commercial |
$358.80
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: NAPHCARE Commercial |
$234.00
|
| Rate for Payer: Preferred Network Access Commercial |
$358.80
|
| Rate for Payer: Quartz Beloit One Network |
$191.10
|
| Rate for Payer: Quartz Commercial |
$234.00
|
| Rate for Payer: WEA Trust Commercial |
$214.50
|
| Rate for Payer: WPS Commercial |
$288.87
|
|
|
BRA SURGICAL SUPPORT CHEST X-LARGE FITS 44 M5001-XL
|
Facility
|
IP
|
$390.00
|
|
| Hospital Charge Code |
2975055
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$191.10 |
| Max. Negotiated Rate |
$358.80 |
| Rate for Payer: Aetna Commercial |
$351.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$335.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.70
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$358.80
|
| Rate for Payer: Health EOS Commercial |
$347.10
|
| Rate for Payer: HFN Commercial |
$358.80
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: NAPHCARE Commercial |
$234.00
|
| Rate for Payer: Preferred Network Access Commercial |
$358.80
|
| Rate for Payer: Quartz Beloit One Network |
$191.10
|
| Rate for Payer: Quartz Commercial |
$234.00
|
| Rate for Payer: WEA Trust Commercial |
$214.50
|
| Rate for Payer: WPS Commercial |
$288.87
|
|
|
BRA SURGICAL SUPPORT CHEST X-LARGE FITS 44 M5001-XL
|
Facility
|
OP
|
$390.00
|
|
| Hospital Charge Code |
2975055
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$1,560.00 |
| Rate for Payer: Aetna Commercial |
$351.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$335.40
|
| Rate for Payer: Aetna Managed Medicare |
$109.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$253.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$195.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$187.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.70
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$358.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.24
|
| Rate for Payer: Health EOS Commercial |
$347.10
|
| Rate for Payer: HFN Commercial |
$358.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$292.50
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: NAPHCARE Commercial |
$234.00
|
| Rate for Payer: Preferred Network Access Commercial |
$358.80
|
| Rate for Payer: Quartz Beloit One Network |
$191.10
|
| Rate for Payer: Quartz Commercial |
$253.50
|
| Rate for Payer: Quartz Medicare Advantage |
$234.00
|
| Rate for Payer: The Alliance Commercial |
$1,560.00
|
| Rate for Payer: WEA Trust Commercial |
$214.50
|
| Rate for Payer: WPS Commercial |
$288.87
|
|
|
BRA SURGICAL SUPPORT CHEST XX-LARGE FITS 48 M5001-XXL
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
2975056
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$191.10 |
| Max. Negotiated Rate |
$358.80 |
| Rate for Payer: Aetna Commercial |
$351.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$335.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.70
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$358.80
|
| Rate for Payer: Health EOS Commercial |
$347.10
|
| Rate for Payer: HFN Commercial |
$358.80
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: NAPHCARE Commercial |
$234.00
|
| Rate for Payer: Preferred Network Access Commercial |
$358.80
|
| Rate for Payer: Quartz Beloit One Network |
$191.10
|
| Rate for Payer: Quartz Commercial |
$234.00
|
| Rate for Payer: WEA Trust Commercial |
$214.50
|
| Rate for Payer: WPS Commercial |
$288.87
|
|
|
BRA SURGICAL SUPPORT CHEST XX-LARGE FITS 48 M5001-XXL
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
2975056
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$28.68 |
| Max. Negotiated Rate |
$1,560.00 |
| Rate for Payer: Aetna Commercial |
$351.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$335.40
|
| Rate for Payer: Aetna Managed Medicare |
$109.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.70
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$358.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.24
|
| Rate for Payer: Health EOS Commercial |
$347.10
|
| Rate for Payer: HFN Commercial |
$358.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$292.50
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: NAPHCARE Commercial |
$234.00
|
| Rate for Payer: Preferred Network Access Commercial |
$358.80
|
| Rate for Payer: Quartz Beloit One Network |
$191.10
|
| Rate for Payer: Quartz Commercial |
$253.50
|
| Rate for Payer: Quartz Medicare Advantage |
$234.00
|
| Rate for Payer: The Alliance Commercial |
$1,560.00
|
| Rate for Payer: WEA Trust Commercial |
$214.50
|
| Rate for Payer: WPS Commercial |
$288.87
|
|
|
BRAVO PH REFLEX PROCEDURE
|
Facility
|
OP
|
$3,212.00
|
|
| Hospital Charge Code |
5404670
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$899.36 |
| Max. Negotiated Rate |
$12,848.00 |
| Rate for Payer: Aetna Commercial |
$2,890.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,762.32
|
| Rate for Payer: Aetna Managed Medicare |
$899.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,087.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,606.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,541.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,702.36
|
| Rate for Payer: Cash Price |
$963.60
|
| Rate for Payer: Cigna Commercial |
$2,955.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,797.44
|
| Rate for Payer: Health EOS Commercial |
$2,858.68
|
| Rate for Payer: HFN Commercial |
$2,955.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,409.00
|
| Rate for Payer: Multiplan Commercial |
$2,569.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,927.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,955.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,573.88
|
| Rate for Payer: Quartz Commercial |
$2,087.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,927.20
|
| Rate for Payer: The Alliance Commercial |
$12,848.00
|
| Rate for Payer: WEA Trust Commercial |
$1,766.60
|
| Rate for Payer: WPS Commercial |
$2,379.13
|
|
|
BRAVO PH REFLEX PROCEDURE
|
Facility
|
IP
|
$3,212.00
|
|
| Hospital Charge Code |
5404670
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,573.88 |
| Max. Negotiated Rate |
$2,955.04 |
| Rate for Payer: Aetna Commercial |
$2,890.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,762.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,702.36
|
| Rate for Payer: Cash Price |
$963.60
|
| Rate for Payer: Cigna Commercial |
$2,955.04
|
| Rate for Payer: Health EOS Commercial |
$2,858.68
|
| Rate for Payer: HFN Commercial |
$2,955.04
|
| Rate for Payer: Multiplan Commercial |
$2,569.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,927.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,955.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,573.88
|
| Rate for Payer: Quartz Commercial |
$1,927.20
|
| Rate for Payer: WEA Trust Commercial |
$1,766.60
|
| Rate for Payer: WPS Commercial |
$2,379.13
|
|
|
BRCA1,BRCA2
|
Facility
|
OP
|
$2,534.00
|
|
|
Service Code
|
CPT 81163
|
| Hospital Charge Code |
4500681
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$374.40 |
| Max. Negotiated Rate |
$2,331.28 |
| Rate for Payer: Aetna Commercial |
$2,280.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,179.24
|
| Rate for Payer: Aetna Managed Medicare |
$468.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,755.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$819.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$776.88
|
| Rate for Payer: Anthem Medicaid |
$374.40
|
| Rate for Payer: Anthem Medicare Advantage |
$468.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,343.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$468.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$468.00
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: Cigna Commercial |
$2,331.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$468.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$374.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,418.03
|
| Rate for Payer: Dean Health Medicaid |
$374.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$468.00
|
| Rate for Payer: Health EOS Commercial |
$2,255.26
|
| Rate for Payer: HFN Commercial |
$2,331.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,740.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$468.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$374.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$468.00
|
| Rate for Payer: Managed Health Services Medicaid |
$389.38
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$468.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$468.00
|
| Rate for Payer: Multiplan Commercial |
$2,027.20
|
| Rate for Payer: NAPHCARE Commercial |
$702.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,331.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$374.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,241.66
|
| Rate for Payer: Quartz Commercial |
$1,647.10
|
| Rate for Payer: Quartz Medicare Advantage |
$468.00
|
| Rate for Payer: The Alliance Commercial |
$1,872.00
|
| Rate for Payer: United Healthcare Medicaid |
$374.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$468.00
|
| Rate for Payer: United Healthcare PPO |
$1,900.50
|
| Rate for Payer: WEA Trust Commercial |
$1,393.70
|
| Rate for Payer: Wellcare Medicare |
$468.00
|
| Rate for Payer: WMAP Medicaid |
$374.40
|
| Rate for Payer: WPS Commercial |
$1,876.93
|
|
|
BRCA1,BRCA2
|
Facility
|
IP
|
$2,534.00
|
|
|
Service Code
|
CPT 81163
|
| Hospital Charge Code |
4500681
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,241.66 |
| Max. Negotiated Rate |
$2,331.28 |
| Rate for Payer: Aetna Commercial |
$2,280.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,179.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,343.02
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: Cigna Commercial |
$2,331.28
|
| Rate for Payer: Health EOS Commercial |
$2,255.26
|
| Rate for Payer: HFN Commercial |
$2,331.28
|
| Rate for Payer: Multiplan Commercial |
$2,027.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,520.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,331.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,241.66
|
| Rate for Payer: Quartz Commercial |
$1,520.40
|
| Rate for Payer: WEA Trust Commercial |
$1,393.70
|
| Rate for Payer: WPS Commercial |
$1,876.93
|
|
|
BRCA1,BRCA2
|
Professional
|
Both
|
$2,534.00
|
|
|
Service Code
|
CPT 81163
|
| Hospital Charge Code |
4500681
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,114.96 |
| Max. Negotiated Rate |
$2,407.30 |
| Rate for Payer: Aetna Commercial |
$2,407.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,179.24
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: Cigna Commercial |
$2,407.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,267.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,520.40
|
| Rate for Payer: Health EOS Commercial |
$2,305.94
|
| Rate for Payer: HFN Commercial |
$2,407.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,652.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,652.04
|
| Rate for Payer: Multiplan Commercial |
$2,027.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,407.30
|
| Rate for Payer: Quartz Beloit One Network |
$1,114.96
|
| Rate for Payer: Quartz Commercial |
$1,444.38
|
| Rate for Payer: The Alliance Commercial |
$1,267.00
|
| Rate for Payer: WEA Trust Commercial |
$1,393.70
|
| Rate for Payer: WPS Commercial |
$1,876.93
|
|
|
BRCAvantage, Comprehensive
|
Professional
|
Both
|
$5,039.00
|
|
|
Service Code
|
CPT 81162
|
| Hospital Charge Code |
4500577
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2,217.16 |
| Max. Negotiated Rate |
$6,441.83 |
| Rate for Payer: Aetna Commercial |
$4,787.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,333.54
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cigna Commercial |
$4,787.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,519.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,023.40
|
| Rate for Payer: Health EOS Commercial |
$4,585.49
|
| Rate for Payer: HFN Commercial |
$4,787.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,441.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,441.83
|
| Rate for Payer: Multiplan Commercial |
$4,031.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,787.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,217.16
|
| Rate for Payer: Quartz Commercial |
$2,872.23
|
| Rate for Payer: The Alliance Commercial |
$2,519.50
|
| Rate for Payer: WEA Trust Commercial |
$2,771.45
|
| Rate for Payer: WPS Commercial |
$3,732.39
|
|
|
BRCAvantage, Comprehensive
|
Facility
|
IP
|
$5,039.00
|
|
|
Service Code
|
CPT 81162
|
| Hospital Charge Code |
4500577
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2,469.11 |
| Max. Negotiated Rate |
$4,635.88 |
| Rate for Payer: Aetna Commercial |
$4,535.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,333.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,670.67
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cigna Commercial |
$4,635.88
|
| Rate for Payer: Health EOS Commercial |
$4,484.71
|
| Rate for Payer: HFN Commercial |
$4,635.88
|
| Rate for Payer: Multiplan Commercial |
$4,031.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,023.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,635.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,469.11
|
| Rate for Payer: Quartz Commercial |
$3,023.40
|
| Rate for Payer: WEA Trust Commercial |
$2,771.45
|
| Rate for Payer: WPS Commercial |
$3,732.39
|
|
|
BRCAvantage, Comprehensive
|
Facility
|
OP
|
$5,039.00
|
|
|
Service Code
|
CPT 81162
|
| Hospital Charge Code |
4500577
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,471.63 |
| Max. Negotiated Rate |
$7,299.52 |
| Rate for Payer: Aetna Commercial |
$4,535.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,333.54
|
| Rate for Payer: Aetna Managed Medicare |
$1,824.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,843.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,193.54
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,029.30
|
| Rate for Payer: Anthem Medicaid |
$1,471.63
|
| Rate for Payer: Anthem Medicare Advantage |
$1,824.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,670.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,824.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,824.88
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cigna Commercial |
$4,635.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,824.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,471.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,819.82
|
| Rate for Payer: Dean Health Medicaid |
$1,471.63
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,824.88
|
| Rate for Payer: Health EOS Commercial |
$4,484.71
|
| Rate for Payer: HFN Commercial |
$4,635.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,788.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,824.88
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$1,471.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,824.88
|
| Rate for Payer: Managed Health Services Medicaid |
$1,530.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,824.88
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,824.88
|
| Rate for Payer: Multiplan Commercial |
$4,031.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,737.32
|
| Rate for Payer: Preferred Network Access Commercial |
$4,635.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$1,471.63
|
| Rate for Payer: Quartz Beloit One Network |
$2,469.11
|
| Rate for Payer: Quartz Commercial |
$3,275.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,824.88
|
| Rate for Payer: The Alliance Commercial |
$7,299.52
|
| Rate for Payer: United Healthcare Medicaid |
$1,471.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,824.88
|
| Rate for Payer: United Healthcare PPO |
$3,779.25
|
| Rate for Payer: WEA Trust Commercial |
$2,771.45
|
| Rate for Payer: Wellcare Medicare |
$1,824.88
|
| Rate for Payer: WMAP Medicaid |
$1,471.63
|
| Rate for Payer: WPS Commercial |
$3,732.39
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$52,392.00
|
|
|
Service Code
|
MSDRG 584
|
| Min. Negotiated Rate |
$18,845.94 |
| Max. Negotiated Rate |
$52,392.00 |
| Rate for Payer: Aetna Managed Medicare |
$18,845.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41,120.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31,518.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29,944.88
|
| Rate for Payer: Anthem Medicare Advantage |
$18,845.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18,845.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18,845.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18,845.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33,241.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18,845.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38,192.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18,845.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18,845.94
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18,845.94
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18,845.94
|
| Rate for Payer: NAPHCARE Commercial |
$28,268.91
|
| Rate for Payer: Quartz Medicare Advantage |
$18,845.94
|
| Rate for Payer: The Alliance Commercial |
$52,392.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18,845.94
|
| Rate for Payer: United Healthcare PPO |
$29,733.51
|
| Rate for Payer: Wellcare Medicare |
$18,845.94
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$45,091.00
|
|
|
Service Code
|
MSDRG 585
|
| Min. Negotiated Rate |
$16,219.85 |
| Max. Negotiated Rate |
$45,091.00 |
| Rate for Payer: Aetna Managed Medicare |
$16,219.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35,246.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27,016.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,667.04
|
| Rate for Payer: Anthem Medicare Advantage |
$16,219.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,219.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,219.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,219.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28,492.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,219.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,838.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,219.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,219.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,219.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,219.85
|
| Rate for Payer: NAPHCARE Commercial |
$24,329.78
|
| Rate for Payer: Quartz Medicare Advantage |
$16,219.85
|
| Rate for Payer: The Alliance Commercial |
$45,091.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,219.85
|
| Rate for Payer: United Healthcare PPO |
$25,564.80
|
| Rate for Payer: Wellcare Medicare |
$16,219.85
|
|
|
Breast Cancer Panel
|
Facility
|
IP
|
$1,482.00
|
|
|
Service Code
|
CPT 81433
|
| Hospital Charge Code |
4924642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$726.18 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$889.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$889.20
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.72
|
|
|
Breast Cancer Panel
|
Professional
|
Both
|
$1,482.00
|
|
|
Service Code
|
CPT 81433
|
| Hospital Charge Code |
4924642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$652.08 |
| Max. Negotiated Rate |
$1,549.42 |
| Rate for Payer: Aetna Commercial |
$1,407.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cigna Commercial |
$1,407.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$741.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$889.20
|
| Rate for Payer: Health EOS Commercial |
$1,348.62
|
| Rate for Payer: HFN Commercial |
$1,407.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,549.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,549.42
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,407.90
|
| Rate for Payer: Quartz Beloit One Network |
$652.08
|
| Rate for Payer: Quartz Commercial |
$844.74
|
| Rate for Payer: The Alliance Commercial |
$741.00
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.72
|
|
|
Breast Cancer Panel
|
Facility
|
OP
|
$1,482.00
|
|
|
Service Code
|
CPT 81433
|
| Hospital Charge Code |
4924642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$438.93 |
| Max. Negotiated Rate |
$1,755.72 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Aetna Managed Medicare |
$438.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,645.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$768.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$728.62
|
| Rate for Payer: Anthem Medicare Advantage |
$438.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$438.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$438.93
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$438.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$829.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$438.93
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,632.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$438.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$438.93
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$438.93
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$438.93
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$658.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$963.30
|
| Rate for Payer: Quartz Medicare Advantage |
$438.93
|
| Rate for Payer: The Alliance Commercial |
$1,755.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$438.93
|
| Rate for Payer: United Healthcare PPO |
$1,111.50
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: Wellcare Medicare |
$438.93
|
| Rate for Payer: WPS Commercial |
$1,097.72
|
|
|
BREAST EXPANDERS PLACEMENT
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2959878
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
