|
HYSTEROSCOPY, ABLATION 58563
|
Professional
|
Both
|
$10,523.00
|
|
|
Service Code
|
CPT 58563
|
| Hospital Charge Code |
3015122
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$815.50 |
| Max. Negotiated Rate |
$9,996.85 |
| Rate for Payer: Aetna Commercial |
$9,996.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,049.78
|
| Rate for Payer: Cash Price |
$3,156.90
|
| Rate for Payer: Cash Price |
$3,156.90
|
| Rate for Payer: Cash Price |
$3,156.90
|
| Rate for Payer: Cigna Commercial |
$9,996.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,281.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,313.80
|
| Rate for Payer: Health EOS Commercial |
$9,575.93
|
| Rate for Payer: HFN Commercial |
$9,996.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$815.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$815.50
|
| Rate for Payer: Multiplan Commercial |
$8,418.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,996.85
|
| Rate for Payer: Quartz Beloit One Network |
$4,630.12
|
| Rate for Payer: Quartz Commercial |
$5,998.11
|
| Rate for Payer: The Alliance Commercial |
$5,261.50
|
| Rate for Payer: United Healthcare Medicaid |
$1,281.19
|
| Rate for Payer: WEA Trust Commercial |
$5,787.65
|
| Rate for Payer: WPS Commercial |
$7,794.39
|
|
|
HYSTEROSCOPY, BIOPSY 58558
|
Professional
|
Both
|
$3,678.00
|
|
|
Service Code
|
CPT 58558
|
| Hospital Charge Code |
3015119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$177.75 |
| Max. Negotiated Rate |
$3,494.10 |
| Rate for Payer: Aetna Commercial |
$3,494.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,163.08
|
| Rate for Payer: Cash Price |
$1,103.40
|
| Rate for Payer: Cash Price |
$1,103.40
|
| Rate for Payer: Cash Price |
$1,103.40
|
| Rate for Payer: Cigna Commercial |
$3,494.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$177.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,206.80
|
| Rate for Payer: Health EOS Commercial |
$3,346.98
|
| Rate for Payer: HFN Commercial |
$3,494.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$764.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$764.74
|
| Rate for Payer: Multiplan Commercial |
$2,942.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,494.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,618.32
|
| Rate for Payer: Quartz Commercial |
$2,096.46
|
| Rate for Payer: The Alliance Commercial |
$1,839.00
|
| Rate for Payer: United Healthcare Medicaid |
$177.75
|
| Rate for Payer: WEA Trust Commercial |
$2,022.90
|
| Rate for Payer: WPS Commercial |
$2,724.29
|
|
|
HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$12,360.48
|
|
|
Service Code
|
CPT 58555
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$12,360.48 |
| Rate for Payer: Aetna Managed Medicare |
$3,090.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,090.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,090.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,090.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,090.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,090.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,495.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,090.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,090.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,090.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,090.12
|
| Rate for Payer: NAPHCARE Commercial |
$4,635.18
|
| Rate for Payer: Quartz Medicare Advantage |
$3,090.12
|
| Rate for Payer: The Alliance Commercial |
$12,360.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,090.12
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$3,090.12
|
|
|
HYSTEROSCOPY, DX, SEP PROC 58555
|
Professional
|
Both
|
$1,593.00
|
|
|
Service Code
|
CPT 58555
|
| Hospital Charge Code |
3015118
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$162.31 |
| Max. Negotiated Rate |
$1,513.35 |
| Rate for Payer: Aetna Commercial |
$1,513.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,369.98
|
| Rate for Payer: Cash Price |
$477.90
|
| Rate for Payer: Cash Price |
$477.90
|
| Rate for Payer: Cash Price |
$477.90
|
| Rate for Payer: Cigna Commercial |
$1,513.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$162.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,449.63
|
| Rate for Payer: HFN Commercial |
$1,513.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$502.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$502.21
|
| Rate for Payer: Multiplan Commercial |
$1,274.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,513.35
|
| Rate for Payer: Quartz Beloit One Network |
$700.92
|
| Rate for Payer: Quartz Commercial |
$908.01
|
| Rate for Payer: The Alliance Commercial |
$796.50
|
| Rate for Payer: United Healthcare Medicaid |
$162.31
|
| Rate for Payer: WEA Trust Commercial |
$876.15
|
| Rate for Payer: WPS Commercial |
$1,179.94
|
|
|
HYSTEROSCOPY, REMOVE FB 58562
|
Professional
|
Both
|
$1,808.00
|
|
|
Service Code
|
CPT 58562
|
| Hospital Charge Code |
3015121
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$174.79 |
| Max. Negotiated Rate |
$1,717.60 |
| Rate for Payer: Aetna Commercial |
$1,717.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,554.88
|
| Rate for Payer: Cash Price |
$542.40
|
| Rate for Payer: Cash Price |
$542.40
|
| Rate for Payer: Cash Price |
$542.40
|
| Rate for Payer: Cigna Commercial |
$1,717.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$174.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,084.80
|
| Rate for Payer: Health EOS Commercial |
$1,645.28
|
| Rate for Payer: HFN Commercial |
$1,717.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$734.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$734.17
|
| Rate for Payer: Multiplan Commercial |
$1,446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,717.60
|
| Rate for Payer: Quartz Beloit One Network |
$795.52
|
| Rate for Payer: Quartz Commercial |
$1,030.56
|
| Rate for Payer: The Alliance Commercial |
$904.00
|
| Rate for Payer: United Healthcare Medicaid |
$174.79
|
| Rate for Payer: WEA Trust Commercial |
$994.40
|
| Rate for Payer: WPS Commercial |
$1,339.19
|
|
|
HYSTEROSCOPY, STERILIZATION 58565
|
Professional
|
Both
|
$8,527.00
|
|
|
Service Code
|
CPT 58565
|
| Hospital Charge Code |
3015123
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$386.75 |
| Max. Negotiated Rate |
$8,100.65 |
| Rate for Payer: Aetna Commercial |
$8,100.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,333.22
|
| Rate for Payer: Cash Price |
$2,558.10
|
| Rate for Payer: Cash Price |
$2,558.10
|
| Rate for Payer: Cash Price |
$2,558.10
|
| Rate for Payer: Cigna Commercial |
$8,100.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$386.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,116.20
|
| Rate for Payer: Health EOS Commercial |
$7,759.57
|
| Rate for Payer: HFN Commercial |
$8,100.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,518.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,518.43
|
| Rate for Payer: Multiplan Commercial |
$6,821.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,100.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,751.88
|
| Rate for Payer: Quartz Commercial |
$4,860.39
|
| Rate for Payer: The Alliance Commercial |
$4,263.50
|
| Rate for Payer: United Healthcare Medicaid |
$386.75
|
| Rate for Payer: WEA Trust Commercial |
$4,689.85
|
| Rate for Payer: WPS Commercial |
$6,315.95
|
|
|
HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)
|
Facility
|
OP
|
$19,665.00
|
|
|
Service Code
|
CPT 58563
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,240.00 |
| Max. Negotiated Rate |
$19,665.00 |
| Rate for Payer: Aetna Managed Medicare |
$4,916.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,238.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,914.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,367.00
|
| Rate for Payer: Anthem Medicare Advantage |
$4,916.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4,916.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4,916.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4,916.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,795.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4,916.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,288.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4,916.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4,916.25
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4,916.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4,916.25
|
| Rate for Payer: NAPHCARE Commercial |
$7,374.38
|
| Rate for Payer: Quartz Medicare Advantage |
$4,916.25
|
| Rate for Payer: The Alliance Commercial |
$19,665.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,916.25
|
| Rate for Payer: United Healthcare PPO |
$4,240.00
|
| Rate for Payer: Wellcare Medicare |
$4,916.25
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY
|
Facility
|
OP
|
$12,360.48
|
|
|
Service Code
|
CPT 58562
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$12,360.48 |
| Rate for Payer: Aetna Managed Medicare |
$3,090.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,090.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,090.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,090.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,090.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,090.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,495.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,090.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,090.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,090.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,090.12
|
| Rate for Payer: NAPHCARE Commercial |
$4,635.18
|
| Rate for Payer: Quartz Medicare Advantage |
$3,090.12
|
| Rate for Payer: The Alliance Commercial |
$12,360.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,090.12
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$3,090.12
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA
|
Facility
|
OP
|
$19,665.00
|
|
|
Service Code
|
CPT 58561
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,240.00 |
| Max. Negotiated Rate |
$19,665.00 |
| Rate for Payer: Aetna Managed Medicare |
$4,916.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,238.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,914.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,367.00
|
| Rate for Payer: Anthem Medicare Advantage |
$4,916.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4,916.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4,916.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4,916.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4,916.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,288.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4,916.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4,916.25
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4,916.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4,916.25
|
| Rate for Payer: NAPHCARE Commercial |
$7,374.38
|
| Rate for Payer: Quartz Medicare Advantage |
$4,916.25
|
| Rate for Payer: The Alliance Commercial |
$19,665.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,916.25
|
| Rate for Payer: United Healthcare PPO |
$4,240.00
|
| Rate for Payer: Wellcare Medicare |
$4,916.25
|
|
|
HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C
|
Facility
|
OP
|
$12,360.48
|
|
|
Service Code
|
CPT 58558
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$12,360.48 |
| Rate for Payer: Aetna Managed Medicare |
$3,090.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,090.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,090.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,090.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,090.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,090.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,495.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,090.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,090.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,090.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,090.12
|
| Rate for Payer: NAPHCARE Commercial |
$4,635.18
|
| Rate for Payer: Quartz Medicare Advantage |
$3,090.12
|
| Rate for Payer: The Alliance Commercial |
$12,360.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,090.12
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$3,090.12
|
|
|
I-123 Iobenguane(MIBG)
|
Facility
|
OP
|
$15,177.00
|
|
|
Service Code
|
HCPCS A9582
|
| Hospital Charge Code |
1486836
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,249.56 |
| Max. Negotiated Rate |
$60,708.00 |
| Rate for Payer: Aetna Commercial |
$13,659.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,052.22
|
| Rate for Payer: Aetna Managed Medicare |
$4,249.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,865.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,588.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,284.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,043.81
|
| Rate for Payer: Cash Price |
$4,553.10
|
| Rate for Payer: Cigna Commercial |
$13,962.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,493.05
|
| Rate for Payer: Health EOS Commercial |
$13,507.53
|
| Rate for Payer: HFN Commercial |
$13,962.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,382.75
|
| Rate for Payer: Multiplan Commercial |
$12,141.60
|
| Rate for Payer: NAPHCARE Commercial |
$9,106.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,962.84
|
| Rate for Payer: Quartz Beloit One Network |
$7,436.73
|
| Rate for Payer: Quartz Commercial |
$9,865.05
|
| Rate for Payer: Quartz Medicare Advantage |
$9,106.20
|
| Rate for Payer: The Alliance Commercial |
$60,708.00
|
| Rate for Payer: WEA Trust Commercial |
$8,347.35
|
| Rate for Payer: WPS Commercial |
$11,241.60
|
|
|
I-123 Iobenguane(MIBG)
|
Facility
|
IP
|
$15,177.00
|
|
|
Service Code
|
HCPCS A9582
|
| Hospital Charge Code |
1486836
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,436.73 |
| Max. Negotiated Rate |
$13,962.84 |
| Rate for Payer: Aetna Commercial |
$13,659.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,052.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,043.81
|
| Rate for Payer: Cash Price |
$4,553.10
|
| Rate for Payer: Cigna Commercial |
$13,962.84
|
| Rate for Payer: Health EOS Commercial |
$13,507.53
|
| Rate for Payer: HFN Commercial |
$13,962.84
|
| Rate for Payer: Multiplan Commercial |
$12,141.60
|
| Rate for Payer: NAPHCARE Commercial |
$9,106.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,962.84
|
| Rate for Payer: Quartz Beloit One Network |
$7,436.73
|
| Rate for Payer: Quartz Commercial |
$9,106.20
|
| Rate for Payer: WEA Trust Commercial |
$8,347.35
|
| Rate for Payer: WPS Commercial |
$11,241.60
|
|
|
I-123 Iobenguane(MIBG)
|
Professional
|
Both
|
$15,177.00
|
|
|
Service Code
|
HCPCS A9582
|
| Hospital Charge Code |
1486836
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,677.88 |
| Max. Negotiated Rate |
$14,418.15 |
| Rate for Payer: Aetna Commercial |
$14,418.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,052.22
|
| Rate for Payer: Cash Price |
$4,553.10
|
| Rate for Payer: Cash Price |
$4,553.10
|
| Rate for Payer: Cigna Commercial |
$14,418.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,588.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,106.20
|
| Rate for Payer: Health EOS Commercial |
$13,811.07
|
| Rate for Payer: HFN Commercial |
$14,418.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,344.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,344.11
|
| Rate for Payer: Multiplan Commercial |
$12,141.60
|
| Rate for Payer: Preferred Network Access Commercial |
$14,418.15
|
| Rate for Payer: Quartz Beloit One Network |
$6,677.88
|
| Rate for Payer: Quartz Commercial |
$8,650.89
|
| Rate for Payer: The Alliance Commercial |
$7,588.50
|
| Rate for Payer: WEA Trust Commercial |
$8,347.35
|
| Rate for Payer: WPS Commercial |
$11,241.60
|
|
|
I-123 sodium iodide(per 100 uCi)
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS A9509
|
| Hospital Charge Code |
1486824
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.60
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
I-123 sodium iodide(per 100 uCi)
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS A9509
|
| Hospital Charge Code |
1486824
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Aetna Managed Medicare |
$0.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.56
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.65
|
| Rate for Payer: Quartz Medicare Advantage |
$0.60
|
| Rate for Payer: The Alliance Commercial |
$4.00
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
I-123 sodium iodide(per 100 uCi)
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
HCPCS A9509
|
| Hospital Charge Code |
1486824
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$3,168.49 |
| Rate for Payer: Aetna Commercial |
$0.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.60
|
| Rate for Payer: Health EOS Commercial |
$0.91
|
| Rate for Payer: HFN Commercial |
$0.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,168.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,168.49
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: Preferred Network Access Commercial |
$0.95
|
| Rate for Payer: Quartz Beloit One Network |
$0.44
|
| Rate for Payer: Quartz Commercial |
$0.57
|
| Rate for Payer: The Alliance Commercial |
$0.50
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
I-131 Per mCi
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
HCPCS A9528
|
| Hospital Charge Code |
1158892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$56.12 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$36.60
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
I-131 Per mCi
|
Professional
|
Both
|
$61.00
|
|
|
Service Code
|
HCPCS A9528
|
| Hospital Charge Code |
1158892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.84 |
| Max. Negotiated Rate |
$59.39 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$57.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.60
|
| Rate for Payer: Health EOS Commercial |
$55.51
|
| Rate for Payer: HFN Commercial |
$57.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.39
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.95
|
| Rate for Payer: Quartz Beloit One Network |
$26.84
|
| Rate for Payer: Quartz Commercial |
$34.77
|
| Rate for Payer: The Alliance Commercial |
$30.50
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
I-131 Per mCi
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
HCPCS A9528
|
| Hospital Charge Code |
1158892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.08 |
| Max. Negotiated Rate |
$244.00 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Aetna Managed Medicare |
$17.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.14
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.75
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$39.65
|
| Rate for Payer: Quartz Medicare Advantage |
$36.60
|
| Rate for Payer: The Alliance Commercial |
$244.00
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
I-131 sodium iodide(per mCi)
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS A9517
|
| Hospital Charge Code |
1486826
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$62.55 |
| Rate for Payer: Aetna Commercial |
$28.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.00
|
| Rate for Payer: Health EOS Commercial |
$27.30
|
| Rate for Payer: HFN Commercial |
$28.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.55
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: Preferred Network Access Commercial |
$28.50
|
| Rate for Payer: Quartz Beloit One Network |
$13.20
|
| Rate for Payer: Quartz Commercial |
$17.10
|
| Rate for Payer: The Alliance Commercial |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
I-131 sodium iodide(per mCi)
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS A9517
|
| Hospital Charge Code |
1486826
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Aetna Managed Medicare |
$21.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.40
|
| Rate for Payer: Anthem Medicare Advantage |
$21.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.34
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.34
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.34
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$32.01
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$19.50
|
| Rate for Payer: Quartz Medicare Advantage |
$21.34
|
| Rate for Payer: The Alliance Commercial |
$85.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.34
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: Wellcare Medicare |
$21.34
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
I-131 sodium iodide(per mCi)
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS A9517
|
| Hospital Charge Code |
1486826
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$18.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
IA-2 Antibody
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
4163506
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$135.73 |
| Max. Negotiated Rate |
$254.84 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$166.20
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
IA-2 Antibody
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
4163506
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.88 |
| Max. Negotiated Rate |
$254.84 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Aetna Managed Medicare |
$23.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$88.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.13
|
| Rate for Payer: Anthem Medicaid |
$19.88
|
| Rate for Payer: Anthem Medicare Advantage |
$23.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23.57
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$23.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.01
|
| Rate for Payer: Dean Health Medicaid |
$19.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$23.57
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.57
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23.57
|
| Rate for Payer: Managed Health Services Medicaid |
$20.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$23.57
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$23.57
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$35.36
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.88
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$180.05
|
| Rate for Payer: Quartz Medicare Advantage |
$23.57
|
| Rate for Payer: The Alliance Commercial |
$94.28
|
| Rate for Payer: United Healthcare Medicaid |
$19.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.57
|
| Rate for Payer: United Healthcare PPO |
$207.75
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: Wellcare Medicare |
$23.57
|
| Rate for Payer: WMAP Medicaid |
$19.88
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
IA-2 Antibody
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
4163506
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.20 |
| Max. Negotiated Rate |
$263.15 |
| Rate for Payer: Aetna Commercial |
$263.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$263.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$138.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$166.20
|
| Rate for Payer: Health EOS Commercial |
$252.07
|
| Rate for Payer: HFN Commercial |
$263.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.20
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.15
|
| Rate for Payer: Quartz Beloit One Network |
$121.88
|
| Rate for Payer: Quartz Commercial |
$157.89
|
| Rate for Payer: The Alliance Commercial |
$138.50
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
