|
IMPLANT TRANSFIX 3x50
|
Facility
|
OP
|
$2,410.00
|
|
| Hospital Charge Code |
2964683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$701.79 |
| Max. Negotiated Rate |
$2,305.89 |
| Rate for Payer: Aetna Commercial |
$2,255.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,155.50
|
| Rate for Payer: Aetna Managed Medicare |
$701.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,629.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,253.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,203.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,328.39
|
| Rate for Payer: Cash Price |
$723.00
|
| Rate for Payer: Cigna Commercial |
$2,305.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,402.62
|
| Rate for Payer: Health EOS Commercial |
$2,230.70
|
| Rate for Payer: HFN Commercial |
$2,305.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,879.80
|
| Rate for Payer: Multiplan Commercial |
$2,005.12
|
| Rate for Payer: NAPHCARE Commercial |
$1,503.84
|
| Rate for Payer: Preferred Network Access Commercial |
$2,305.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,228.14
|
| Rate for Payer: Quartz Commercial |
$1,629.16
|
| Rate for Payer: Quartz Medicare Advantage |
$1,503.84
|
| Rate for Payer: The Alliance Commercial |
$1,253.20
|
| Rate for Payer: WEA Trust Commercial |
$1,378.52
|
| Rate for Payer: WPS Commercial |
$1,856.42
|
|
|
IMPLANT TRANSFIX 3x50
|
Facility
|
IP
|
$2,410.00
|
|
| Hospital Charge Code |
2964683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,228.14 |
| Max. Negotiated Rate |
$2,305.89 |
| Rate for Payer: Aetna Commercial |
$2,255.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,155.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,328.39
|
| Rate for Payer: Cash Price |
$723.00
|
| Rate for Payer: Cigna Commercial |
$2,305.89
|
| Rate for Payer: Health EOS Commercial |
$2,230.70
|
| Rate for Payer: HFN Commercial |
$2,305.89
|
| Rate for Payer: Multiplan Commercial |
$2,005.12
|
| Rate for Payer: Preferred Network Access Commercial |
$2,305.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,228.14
|
| Rate for Payer: Quartz Commercial |
$1,503.84
|
| Rate for Payer: WEA Trust Commercial |
$1,378.52
|
| Rate for Payer: WPS Commercial |
$1,856.42
|
|
|
IMPLANT X-FUSE 0 DEGREE
|
Facility
|
OP
|
$5,721.00
|
|
| Hospital Charge Code |
2965384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,665.96 |
| Max. Negotiated Rate |
$5,473.85 |
| Rate for Payer: Aetna Commercial |
$5,354.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,116.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,665.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,867.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,974.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,855.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,153.42
|
| Rate for Payer: Cash Price |
$1,716.30
|
| Rate for Payer: Cigna Commercial |
$5,473.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,329.62
|
| Rate for Payer: Health EOS Commercial |
$5,295.36
|
| Rate for Payer: HFN Commercial |
$5,473.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,462.38
|
| Rate for Payer: Multiplan Commercial |
$4,759.87
|
| Rate for Payer: NAPHCARE Commercial |
$3,569.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,473.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,915.42
|
| Rate for Payer: Quartz Commercial |
$3,867.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,569.90
|
| Rate for Payer: The Alliance Commercial |
$2,974.92
|
| Rate for Payer: WEA Trust Commercial |
$3,272.41
|
| Rate for Payer: WPS Commercial |
$4,406.89
|
|
|
IMPLANT X-FUSE 0 DEGREE
|
Facility
|
IP
|
$5,721.00
|
|
| Hospital Charge Code |
2965384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,915.42 |
| Max. Negotiated Rate |
$5,473.85 |
| Rate for Payer: Aetna Commercial |
$5,354.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,116.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,153.42
|
| Rate for Payer: Cash Price |
$1,716.30
|
| Rate for Payer: Cigna Commercial |
$5,473.85
|
| Rate for Payer: Health EOS Commercial |
$5,295.36
|
| Rate for Payer: HFN Commercial |
$5,473.85
|
| Rate for Payer: Multiplan Commercial |
$4,759.87
|
| Rate for Payer: Preferred Network Access Commercial |
$5,473.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,915.42
|
| Rate for Payer: Quartz Commercial |
$3,569.90
|
| Rate for Payer: WEA Trust Commercial |
$3,272.41
|
| Rate for Payer: WPS Commercial |
$4,406.89
|
|
|
IMPLANT X-FUSE 15 DEGREE
|
Facility
|
IP
|
$5,721.00
|
|
| Hospital Charge Code |
2965385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,915.42 |
| Max. Negotiated Rate |
$5,473.85 |
| Rate for Payer: Aetna Commercial |
$5,354.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,116.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,153.42
|
| Rate for Payer: Cash Price |
$1,716.30
|
| Rate for Payer: Cigna Commercial |
$5,473.85
|
| Rate for Payer: Health EOS Commercial |
$5,295.36
|
| Rate for Payer: HFN Commercial |
$5,473.85
|
| Rate for Payer: Multiplan Commercial |
$4,759.87
|
| Rate for Payer: Preferred Network Access Commercial |
$5,473.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,915.42
|
| Rate for Payer: Quartz Commercial |
$3,569.90
|
| Rate for Payer: WEA Trust Commercial |
$3,272.41
|
| Rate for Payer: WPS Commercial |
$4,406.89
|
|
|
IMPLANT X-FUSE 15 DEGREE
|
Facility
|
OP
|
$5,721.00
|
|
| Hospital Charge Code |
2965385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,665.96 |
| Max. Negotiated Rate |
$5,473.85 |
| Rate for Payer: Aetna Commercial |
$5,354.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,116.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,665.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,867.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,974.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,855.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,153.42
|
| Rate for Payer: Cash Price |
$1,716.30
|
| Rate for Payer: Cigna Commercial |
$5,473.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,329.62
|
| Rate for Payer: Health EOS Commercial |
$5,295.36
|
| Rate for Payer: HFN Commercial |
$5,473.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,462.38
|
| Rate for Payer: Multiplan Commercial |
$4,759.87
|
| Rate for Payer: NAPHCARE Commercial |
$3,569.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,473.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,915.42
|
| Rate for Payer: Quartz Commercial |
$3,867.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,569.90
|
| Rate for Payer: The Alliance Commercial |
$2,974.92
|
| Rate for Payer: WEA Trust Commercial |
$3,272.41
|
| Rate for Payer: WPS Commercial |
$4,406.89
|
|
|
Impression casting ft S0395
|
Professional
|
Both
|
$96.00
|
|
|
Service Code
|
HCPCS S0395
|
| Hospital Charge Code |
3133687
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$43.93 |
| Max. Negotiated Rate |
$94.85 |
| Rate for Payer: Aetna Commercial |
$94.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$94.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.90
|
| Rate for Payer: Health EOS Commercial |
$90.85
|
| Rate for Payer: HFN Commercial |
$94.85
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: Preferred Network Access Commercial |
$94.85
|
| Rate for Payer: Quartz Beloit One Network |
$43.93
|
| Rate for Payer: Quartz Commercial |
$56.91
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
Impression casting ft S0395
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
HCPCS S0395
|
| Hospital Charge Code |
3133687
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$27.96 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Aetna Managed Medicare |
$27.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.87
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$74.88
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: NAPHCARE Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: Quartz Medicare Advantage |
$59.90
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
Impression casting ft S0395
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS S0395
|
| Hospital Charge Code |
3133687
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$48.92 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$59.90
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
IMRT Radiotherapy Plan
|
Facility
|
IP
|
$11,981.00
|
|
|
Service Code
|
CPT 77301
|
| Hospital Charge Code |
3040380
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$6,105.52 |
| Max. Negotiated Rate |
$11,463.42 |
| Rate for Payer: Aetna Commercial |
$11,214.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,715.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,603.93
|
| Rate for Payer: Cash Price |
$3,594.30
|
| Rate for Payer: Cigna Commercial |
$11,463.42
|
| Rate for Payer: Health EOS Commercial |
$11,089.61
|
| Rate for Payer: HFN Commercial |
$11,463.42
|
| Rate for Payer: Multiplan Commercial |
$9,968.19
|
| Rate for Payer: Preferred Network Access Commercial |
$11,463.42
|
| Rate for Payer: Quartz Beloit One Network |
$6,105.52
|
| Rate for Payer: Quartz Commercial |
$7,476.14
|
| Rate for Payer: WEA Trust Commercial |
$6,853.13
|
| Rate for Payer: WPS Commercial |
$9,228.96
|
|
|
IMRT Radiotherapy Plan
|
Facility
|
OP
|
$11,981.00
|
|
|
Service Code
|
CPT 77301
|
| Hospital Charge Code |
3040380
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,456.64 |
| Max. Negotiated Rate |
$11,463.42 |
| Rate for Payer: Aetna Commercial |
$11,214.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,715.81
|
| Rate for Payer: Aetna Managed Medicare |
$1,456.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,341.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,273.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,059.38
|
| Rate for Payer: Anthem Medicare Advantage |
$1,456.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,603.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,456.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,456.64
|
| Rate for Payer: Cash Price |
$3,594.30
|
| Rate for Payer: Cash Price |
$3,594.30
|
| Rate for Payer: Cigna Commercial |
$11,463.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,456.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,972.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,456.64
|
| Rate for Payer: Health EOS Commercial |
$11,089.61
|
| Rate for Payer: HFN Commercial |
$11,463.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,418.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,456.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,456.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,456.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,456.64
|
| Rate for Payer: Multiplan Commercial |
$9,968.19
|
| Rate for Payer: NAPHCARE Commercial |
$2,184.97
|
| Rate for Payer: Preferred Network Access Commercial |
$11,463.42
|
| Rate for Payer: Quartz Beloit One Network |
$6,105.52
|
| Rate for Payer: Quartz Commercial |
$8,099.16
|
| Rate for Payer: Quartz Medicare Advantage |
$1,456.64
|
| Rate for Payer: The Alliance Commercial |
$5,826.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,456.64
|
| Rate for Payer: United Healthcare PPO |
$9,345.18
|
| Rate for Payer: WEA Trust Commercial |
$6,853.13
|
| Rate for Payer: Wellcare Medicare |
$1,456.64
|
| Rate for Payer: WPS Commercial |
$9,228.96
|
|
|
IMRT Treatment Complex (all other areas)
|
Facility
|
OP
|
$5,709.00
|
|
|
Service Code
|
CPT 77386
|
| Hospital Charge Code |
3040396
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,662.46 |
| Max. Negotiated Rate |
$5,462.37 |
| Rate for Payer: Aetna Commercial |
$5,343.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,106.13
|
| Rate for Payer: Aetna Managed Medicare |
$1,662.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,269.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,815.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,724.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,146.80
|
| Rate for Payer: Cash Price |
$1,712.70
|
| Rate for Payer: Cash Price |
$1,712.70
|
| Rate for Payer: Cigna Commercial |
$5,462.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,322.64
|
| Rate for Payer: Health EOS Commercial |
$5,284.25
|
| Rate for Payer: HFN Commercial |
$5,462.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,453.02
|
| Rate for Payer: Multiplan Commercial |
$4,749.89
|
| Rate for Payer: NAPHCARE Commercial |
$3,562.42
|
| Rate for Payer: Preferred Network Access Commercial |
$5,462.37
|
| Rate for Payer: Quartz Beloit One Network |
$2,909.31
|
| Rate for Payer: Quartz Commercial |
$3,859.28
|
| Rate for Payer: Quartz Medicare Advantage |
$3,562.42
|
| Rate for Payer: The Alliance Commercial |
$2,968.68
|
| Rate for Payer: United Healthcare PPO |
$4,453.02
|
| Rate for Payer: WEA Trust Commercial |
$3,265.55
|
| Rate for Payer: WPS Commercial |
$4,397.64
|
|
|
IMRT Treatment Complex (all other areas)
|
Facility
|
IP
|
$5,709.00
|
|
|
Service Code
|
CPT 77386
|
| Hospital Charge Code |
3040396
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$2,909.31 |
| Max. Negotiated Rate |
$5,462.37 |
| Rate for Payer: Aetna Commercial |
$5,343.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,106.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,146.80
|
| Rate for Payer: Cash Price |
$1,712.70
|
| Rate for Payer: Cigna Commercial |
$5,462.37
|
| Rate for Payer: Health EOS Commercial |
$5,284.25
|
| Rate for Payer: HFN Commercial |
$5,462.37
|
| Rate for Payer: Multiplan Commercial |
$4,749.89
|
| Rate for Payer: Preferred Network Access Commercial |
$5,462.37
|
| Rate for Payer: Quartz Beloit One Network |
$2,909.31
|
| Rate for Payer: Quartz Commercial |
$3,562.42
|
| Rate for Payer: WEA Trust Commercial |
$3,265.55
|
| Rate for Payer: WPS Commercial |
$4,397.64
|
|
|
IMRT Treatment Simplex (Breast & Prostate)
|
Facility
|
IP
|
$6,079.00
|
|
|
Service Code
|
CPT 77385
|
| Hospital Charge Code |
3040408
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$3,097.86 |
| Max. Negotiated Rate |
$5,816.39 |
| Rate for Payer: Aetna Commercial |
$5,689.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,350.74
|
| Rate for Payer: Cash Price |
$1,823.70
|
| Rate for Payer: Cigna Commercial |
$5,816.39
|
| Rate for Payer: Health EOS Commercial |
$5,626.72
|
| Rate for Payer: HFN Commercial |
$5,816.39
|
| Rate for Payer: Multiplan Commercial |
$5,057.73
|
| Rate for Payer: Preferred Network Access Commercial |
$5,816.39
|
| Rate for Payer: Quartz Beloit One Network |
$3,097.86
|
| Rate for Payer: Quartz Commercial |
$3,793.30
|
| Rate for Payer: WEA Trust Commercial |
$3,477.19
|
| Rate for Payer: WPS Commercial |
$4,682.65
|
|
|
IMRT Treatment Simplex (Breast & Prostate)
|
Facility
|
OP
|
$6,079.00
|
|
|
Service Code
|
CPT 77385
|
| Hospital Charge Code |
3040408
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,724.57 |
| Max. Negotiated Rate |
$5,816.39 |
| Rate for Payer: Aetna Commercial |
$5,689.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.06
|
| Rate for Payer: Aetna Managed Medicare |
$1,770.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,269.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,815.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,724.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,350.74
|
| Rate for Payer: Cash Price |
$1,823.70
|
| Rate for Payer: Cash Price |
$1,823.70
|
| Rate for Payer: Cigna Commercial |
$5,816.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,537.98
|
| Rate for Payer: Health EOS Commercial |
$5,626.72
|
| Rate for Payer: HFN Commercial |
$5,816.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,741.62
|
| Rate for Payer: Multiplan Commercial |
$5,057.73
|
| Rate for Payer: NAPHCARE Commercial |
$3,793.30
|
| Rate for Payer: Preferred Network Access Commercial |
$5,816.39
|
| Rate for Payer: Quartz Beloit One Network |
$3,097.86
|
| Rate for Payer: Quartz Commercial |
$4,109.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,793.30
|
| Rate for Payer: The Alliance Commercial |
$3,161.08
|
| Rate for Payer: United Healthcare PPO |
$4,741.62
|
| Rate for Payer: WEA Trust Commercial |
$3,477.19
|
| Rate for Payer: WPS Commercial |
$4,682.65
|
|
|
IM/Subsq Injection
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3040225
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$113.64 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$139.15
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
IM/Subsq Injection
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3040225
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.32
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$150.75
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$173.94
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
IM/Subsq Injection - 96372
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
5516709
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.32
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$150.75
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$173.94
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
IM/Subsq Injection - 96372
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
5516709
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$113.64 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$139.15
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
In-111 Oxyquinoline(WBC labeling)
|
Facility
|
OP
|
$11,190.00
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
1486828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,147.32 |
| Max. Negotiated Rate |
$10,706.59 |
| Rate for Payer: Aetna Commercial |
$10,473.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,008.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,147.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,564.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,818.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,586.05
|
| Rate for Payer: Anthem Medicare Advantage |
$1,147.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,167.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,147.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,147.32
|
| Rate for Payer: Cash Price |
$3,357.00
|
| Rate for Payer: Cash Price |
$3,357.00
|
| Rate for Payer: Cigna Commercial |
$10,706.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,147.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,512.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,147.32
|
| Rate for Payer: Health EOS Commercial |
$10,357.46
|
| Rate for Payer: HFN Commercial |
$10,706.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,268.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,147.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,147.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,147.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,147.32
|
| Rate for Payer: Multiplan Commercial |
$9,310.08
|
| Rate for Payer: NAPHCARE Commercial |
$1,720.98
|
| Rate for Payer: Preferred Network Access Commercial |
$10,706.59
|
| Rate for Payer: Quartz Beloit One Network |
$5,702.42
|
| Rate for Payer: Quartz Commercial |
$7,564.44
|
| Rate for Payer: Quartz Medicare Advantage |
$1,147.32
|
| Rate for Payer: The Alliance Commercial |
$4,589.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,147.32
|
| Rate for Payer: WEA Trust Commercial |
$6,400.68
|
| Rate for Payer: Wellcare Medicare |
$1,147.32
|
| Rate for Payer: WPS Commercial |
$8,619.66
|
|
|
In-111 Oxyquinoline(WBC labeling)
|
Facility
|
IP
|
$11,190.00
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
1486828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,702.42 |
| Max. Negotiated Rate |
$10,706.59 |
| Rate for Payer: Aetna Commercial |
$10,473.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,008.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,167.93
|
| Rate for Payer: Cash Price |
$3,357.00
|
| Rate for Payer: Cigna Commercial |
$10,706.59
|
| Rate for Payer: Health EOS Commercial |
$10,357.46
|
| Rate for Payer: HFN Commercial |
$10,706.59
|
| Rate for Payer: Multiplan Commercial |
$9,310.08
|
| Rate for Payer: Preferred Network Access Commercial |
$10,706.59
|
| Rate for Payer: Quartz Beloit One Network |
$5,702.42
|
| Rate for Payer: Quartz Commercial |
$6,982.56
|
| Rate for Payer: WEA Trust Commercial |
$6,400.68
|
| Rate for Payer: WPS Commercial |
$8,619.66
|
|
|
In-111 Oxyquinoline(WBC labeling)
|
Professional
|
Both
|
$11,190.00
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
1486828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,120.54 |
| Max. Negotiated Rate |
$11,055.72 |
| Rate for Payer: Aetna Commercial |
$11,055.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,008.34
|
| Rate for Payer: Cash Price |
$3,357.00
|
| Rate for Payer: Cash Price |
$3,357.00
|
| Rate for Payer: Cigna Commercial |
$11,055.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,818.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,982.56
|
| Rate for Payer: Health EOS Commercial |
$10,590.22
|
| Rate for Payer: HFN Commercial |
$11,055.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,516.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,516.21
|
| Rate for Payer: Multiplan Commercial |
$9,310.08
|
| Rate for Payer: Preferred Network Access Commercial |
$11,055.72
|
| Rate for Payer: Quartz Beloit One Network |
$5,120.54
|
| Rate for Payer: Quartz Commercial |
$6,633.43
|
| Rate for Payer: The Alliance Commercial |
$5,818.80
|
| Rate for Payer: WEA Trust Commercial |
$6,400.68
|
| Rate for Payer: WPS Commercial |
$8,619.66
|
|
|
In-111 Pentetreotide(Octreoscan)
|
Facility
|
OP
|
$5,883.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
1486842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,080.98 |
| Max. Negotiated Rate |
$8,323.91 |
| Rate for Payer: Aetna Commercial |
$5,506.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,261.76
|
| Rate for Payer: Aetna Managed Medicare |
$2,080.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,976.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,059.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,936.79
|
| Rate for Payer: Anthem Medicare Advantage |
$2,080.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,242.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,080.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,080.98
|
| Rate for Payer: Cash Price |
$1,764.90
|
| Rate for Payer: Cash Price |
$1,764.90
|
| Rate for Payer: Cigna Commercial |
$5,628.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,080.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,423.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,080.98
|
| Rate for Payer: Health EOS Commercial |
$5,445.30
|
| Rate for Payer: HFN Commercial |
$5,628.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,741.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,080.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,080.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,080.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,080.98
|
| Rate for Payer: Multiplan Commercial |
$4,894.66
|
| Rate for Payer: NAPHCARE Commercial |
$3,121.47
|
| Rate for Payer: Preferred Network Access Commercial |
$5,628.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,997.98
|
| Rate for Payer: Quartz Commercial |
$3,976.91
|
| Rate for Payer: Quartz Medicare Advantage |
$2,080.98
|
| Rate for Payer: The Alliance Commercial |
$8,323.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,080.98
|
| Rate for Payer: WEA Trust Commercial |
$3,365.08
|
| Rate for Payer: Wellcare Medicare |
$2,080.98
|
| Rate for Payer: WPS Commercial |
$4,531.67
|
|
|
In-111 Pentetreotide(Octreoscan)
|
Facility
|
IP
|
$5,883.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
1486842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,997.98 |
| Max. Negotiated Rate |
$5,628.85 |
| Rate for Payer: Aetna Commercial |
$5,506.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,261.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,242.71
|
| Rate for Payer: Cash Price |
$1,764.90
|
| Rate for Payer: Cigna Commercial |
$5,628.85
|
| Rate for Payer: Health EOS Commercial |
$5,445.30
|
| Rate for Payer: HFN Commercial |
$5,628.85
|
| Rate for Payer: Multiplan Commercial |
$4,894.66
|
| Rate for Payer: Preferred Network Access Commercial |
$5,628.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,997.98
|
| Rate for Payer: Quartz Commercial |
$3,670.99
|
| Rate for Payer: WEA Trust Commercial |
$3,365.08
|
| Rate for Payer: WPS Commercial |
$4,531.67
|
|
|
In-111 Pentetreotide(Octreoscan)
|
Professional
|
Both
|
$5,883.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
1486842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,692.06 |
| Max. Negotiated Rate |
$10,342.12 |
| Rate for Payer: Aetna Commercial |
$5,812.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,261.76
|
| Rate for Payer: Cash Price |
$1,764.90
|
| Rate for Payer: Cash Price |
$1,764.90
|
| Rate for Payer: Cigna Commercial |
$5,812.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,366.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,670.99
|
| Rate for Payer: Health EOS Commercial |
$5,567.67
|
| Rate for Payer: HFN Commercial |
$5,812.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,342.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,342.12
|
| Rate for Payer: Multiplan Commercial |
$4,894.66
|
| Rate for Payer: Preferred Network Access Commercial |
$5,812.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,692.06
|
| Rate for Payer: Quartz Commercial |
$3,487.44
|
| Rate for Payer: The Alliance Commercial |
$3,059.16
|
| Rate for Payer: United Healthcare Medicaid |
$5,366.50
|
| Rate for Payer: WEA Trust Commercial |
$3,365.08
|
| Rate for Payer: WPS Commercial |
$4,531.67
|
|
