|
ACETABULAR SHELL PINNACLE 32MM 62MM 1217-32-062
|
Facility
|
IP
|
$5,054.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6202962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,476.46 |
| Max. Negotiated Rate |
$4,649.68 |
| Rate for Payer: Aetna Commercial |
$4,548.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.62
|
| Rate for Payer: Cash Price |
$1,516.20
|
| Rate for Payer: Cigna Commercial |
$4,649.68
|
| Rate for Payer: Health EOS Commercial |
$4,498.06
|
| Rate for Payer: HFN Commercial |
$4,649.68
|
| Rate for Payer: Multiplan Commercial |
$4,043.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,649.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.46
|
| Rate for Payer: Quartz Commercial |
$3,032.40
|
| Rate for Payer: WEA Trust Commercial |
$2,779.70
|
| Rate for Payer: WPS Commercial |
$3,743.50
|
|
|
ACETABULAR SHELL PINNACLE 32MM 64MM 1217-32-064
|
Facility
|
IP
|
$5,054.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6182536
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,476.46 |
| Max. Negotiated Rate |
$4,649.68 |
| Rate for Payer: Aetna Commercial |
$4,548.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.62
|
| Rate for Payer: Cash Price |
$1,516.20
|
| Rate for Payer: Cigna Commercial |
$4,649.68
|
| Rate for Payer: Health EOS Commercial |
$4,498.06
|
| Rate for Payer: HFN Commercial |
$4,649.68
|
| Rate for Payer: Multiplan Commercial |
$4,043.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,649.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.46
|
| Rate for Payer: Quartz Commercial |
$3,032.40
|
| Rate for Payer: WEA Trust Commercial |
$2,779.70
|
| Rate for Payer: WPS Commercial |
$3,743.50
|
|
|
ACETABULAR SHELL PINNACLE 32MM 64MM 1217-32-064
|
Facility
|
OP
|
$5,054.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6182536
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,415.12 |
| Max. Negotiated Rate |
$20,216.00 |
| Rate for Payer: Aetna Commercial |
$4,548.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,415.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,285.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,527.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,425.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.62
|
| Rate for Payer: Cash Price |
$1,516.20
|
| Rate for Payer: Cigna Commercial |
$4,649.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,828.22
|
| Rate for Payer: Health EOS Commercial |
$4,498.06
|
| Rate for Payer: HFN Commercial |
$4,649.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,790.50
|
| Rate for Payer: Multiplan Commercial |
$4,043.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,649.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.46
|
| Rate for Payer: Quartz Commercial |
$3,285.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,032.40
|
| Rate for Payer: The Alliance Commercial |
$20,216.00
|
| Rate for Payer: WEA Trust Commercial |
$2,779.70
|
| Rate for Payer: WPS Commercial |
$3,743.50
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 48MM 1217-30-048
|
Facility
|
OP
|
$22,068.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603542
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,179.04 |
| Max. Negotiated Rate |
$88,272.00 |
| Rate for Payer: Aetna Commercial |
$19,861.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,978.48
|
| Rate for Payer: Aetna Managed Medicare |
$6,179.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,344.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,034.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,592.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,696.04
|
| Rate for Payer: Cash Price |
$6,620.40
|
| Rate for Payer: Cigna Commercial |
$20,302.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.25
|
| Rate for Payer: Health EOS Commercial |
$19,640.52
|
| Rate for Payer: HFN Commercial |
$20,302.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,551.00
|
| Rate for Payer: Multiplan Commercial |
$17,654.40
|
| Rate for Payer: NAPHCARE Commercial |
$13,240.80
|
| Rate for Payer: Preferred Network Access Commercial |
$20,302.56
|
| Rate for Payer: Quartz Beloit One Network |
$10,813.32
|
| Rate for Payer: Quartz Commercial |
$14,344.20
|
| Rate for Payer: Quartz Medicare Advantage |
$13,240.80
|
| Rate for Payer: The Alliance Commercial |
$88,272.00
|
| Rate for Payer: WEA Trust Commercial |
$12,137.40
|
| Rate for Payer: WPS Commercial |
$16,345.77
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 48MM 1217-30-048
|
Facility
|
IP
|
$22,068.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603542
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,813.32 |
| Max. Negotiated Rate |
$20,302.56 |
| Rate for Payer: Aetna Commercial |
$19,861.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,978.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,696.04
|
| Rate for Payer: Cash Price |
$6,620.40
|
| Rate for Payer: Cigna Commercial |
$20,302.56
|
| Rate for Payer: Health EOS Commercial |
$19,640.52
|
| Rate for Payer: HFN Commercial |
$20,302.56
|
| Rate for Payer: Multiplan Commercial |
$17,654.40
|
| Rate for Payer: NAPHCARE Commercial |
$13,240.80
|
| Rate for Payer: Preferred Network Access Commercial |
$20,302.56
|
| Rate for Payer: Quartz Beloit One Network |
$10,813.32
|
| Rate for Payer: Quartz Commercial |
$13,240.80
|
| Rate for Payer: WEA Trust Commercial |
$12,137.40
|
| Rate for Payer: WPS Commercial |
$16,345.77
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 56MM 1217-30-056
|
Facility
|
OP
|
$19,618.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6181255
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,493.04 |
| Max. Negotiated Rate |
$78,472.00 |
| Rate for Payer: Aetna Commercial |
$17,656.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,871.48
|
| Rate for Payer: Aetna Managed Medicare |
$5,493.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,751.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,809.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,416.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,397.54
|
| Rate for Payer: Cash Price |
$5,885.40
|
| Rate for Payer: Cigna Commercial |
$18,048.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,978.23
|
| Rate for Payer: Health EOS Commercial |
$17,460.02
|
| Rate for Payer: HFN Commercial |
$18,048.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,713.50
|
| Rate for Payer: Multiplan Commercial |
$15,694.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,770.80
|
| Rate for Payer: Preferred Network Access Commercial |
$18,048.56
|
| Rate for Payer: Quartz Beloit One Network |
$9,612.82
|
| Rate for Payer: Quartz Commercial |
$12,751.70
|
| Rate for Payer: Quartz Medicare Advantage |
$11,770.80
|
| Rate for Payer: The Alliance Commercial |
$78,472.00
|
| Rate for Payer: WEA Trust Commercial |
$10,789.90
|
| Rate for Payer: WPS Commercial |
$14,531.05
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 56MM 1217-30-056
|
Facility
|
IP
|
$19,618.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6181255
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,612.82 |
| Max. Negotiated Rate |
$18,048.56 |
| Rate for Payer: Aetna Commercial |
$17,656.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,871.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,397.54
|
| Rate for Payer: Cash Price |
$5,885.40
|
| Rate for Payer: Cigna Commercial |
$18,048.56
|
| Rate for Payer: Health EOS Commercial |
$17,460.02
|
| Rate for Payer: HFN Commercial |
$18,048.56
|
| Rate for Payer: Multiplan Commercial |
$15,694.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,770.80
|
| Rate for Payer: Preferred Network Access Commercial |
$18,048.56
|
| Rate for Payer: Quartz Beloit One Network |
$9,612.82
|
| Rate for Payer: Quartz Commercial |
$11,770.80
|
| Rate for Payer: WEA Trust Commercial |
$10,789.90
|
| Rate for Payer: WPS Commercial |
$14,531.05
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 58MM 1217-30-058
|
Facility
|
OP
|
$21,219.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5895655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,941.32 |
| Max. Negotiated Rate |
$84,876.00 |
| Rate for Payer: Aetna Commercial |
$19,097.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,248.34
|
| Rate for Payer: Aetna Managed Medicare |
$5,941.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,792.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,609.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,185.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,246.07
|
| Rate for Payer: Cash Price |
$6,365.70
|
| Rate for Payer: Cigna Commercial |
$19,521.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.15
|
| Rate for Payer: Health EOS Commercial |
$18,884.91
|
| Rate for Payer: HFN Commercial |
$19,521.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,914.25
|
| Rate for Payer: Multiplan Commercial |
$16,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,731.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,521.48
|
| Rate for Payer: Quartz Beloit One Network |
$10,397.31
|
| Rate for Payer: Quartz Commercial |
$13,792.35
|
| Rate for Payer: Quartz Medicare Advantage |
$12,731.40
|
| Rate for Payer: The Alliance Commercial |
$84,876.00
|
| Rate for Payer: WEA Trust Commercial |
$11,670.45
|
| Rate for Payer: WPS Commercial |
$15,716.91
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 58MM 1217-30-058
|
Facility
|
IP
|
$21,219.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5895655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,397.31 |
| Max. Negotiated Rate |
$19,521.48 |
| Rate for Payer: Aetna Commercial |
$19,097.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,248.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,246.07
|
| Rate for Payer: Cash Price |
$6,365.70
|
| Rate for Payer: Cigna Commercial |
$19,521.48
|
| Rate for Payer: Health EOS Commercial |
$18,884.91
|
| Rate for Payer: HFN Commercial |
$19,521.48
|
| Rate for Payer: Multiplan Commercial |
$16,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,731.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,521.48
|
| Rate for Payer: Quartz Beloit One Network |
$10,397.31
|
| Rate for Payer: Quartz Commercial |
$12,731.40
|
| Rate for Payer: WEA Trust Commercial |
$11,670.45
|
| Rate for Payer: WPS Commercial |
$15,716.91
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 60MM 1217-30-060
|
Facility
|
IP
|
$20,403.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6151644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,997.47 |
| Max. Negotiated Rate |
$18,770.76 |
| Rate for Payer: Aetna Commercial |
$18,362.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,546.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,813.59
|
| Rate for Payer: Cash Price |
$6,120.90
|
| Rate for Payer: Cigna Commercial |
$18,770.76
|
| Rate for Payer: Health EOS Commercial |
$18,158.67
|
| Rate for Payer: HFN Commercial |
$18,770.76
|
| Rate for Payer: Multiplan Commercial |
$16,322.40
|
| Rate for Payer: NAPHCARE Commercial |
$12,241.80
|
| Rate for Payer: Preferred Network Access Commercial |
$18,770.76
|
| Rate for Payer: Quartz Beloit One Network |
$9,997.47
|
| Rate for Payer: Quartz Commercial |
$12,241.80
|
| Rate for Payer: WEA Trust Commercial |
$11,221.65
|
| Rate for Payer: WPS Commercial |
$15,112.50
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 60MM 1217-30-060
|
Facility
|
OP
|
$20,403.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6151644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,712.84 |
| Max. Negotiated Rate |
$81,612.00 |
| Rate for Payer: Aetna Commercial |
$18,362.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,546.58
|
| Rate for Payer: Aetna Managed Medicare |
$5,712.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,261.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,201.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,793.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,813.59
|
| Rate for Payer: Cash Price |
$6,120.90
|
| Rate for Payer: Cigna Commercial |
$18,770.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,417.52
|
| Rate for Payer: Health EOS Commercial |
$18,158.67
|
| Rate for Payer: HFN Commercial |
$18,770.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,302.25
|
| Rate for Payer: Multiplan Commercial |
$16,322.40
|
| Rate for Payer: NAPHCARE Commercial |
$12,241.80
|
| Rate for Payer: Preferred Network Access Commercial |
$18,770.76
|
| Rate for Payer: Quartz Beloit One Network |
$9,997.47
|
| Rate for Payer: Quartz Commercial |
$13,261.95
|
| Rate for Payer: Quartz Medicare Advantage |
$12,241.80
|
| Rate for Payer: The Alliance Commercial |
$81,612.00
|
| Rate for Payer: WEA Trust Commercial |
$11,221.65
|
| Rate for Payer: WPS Commercial |
$15,112.50
|
|
|
ACETABULAR SHELL TRIDENT II TRITANIUM CLUSTERHOLE 50MM D 702-04-50D
|
Facility
|
IP
|
$5,674.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6212957
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,780.26 |
| Max. Negotiated Rate |
$5,220.08 |
| Rate for Payer: Aetna Commercial |
$5,106.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,879.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,007.22
|
| Rate for Payer: Cash Price |
$1,702.20
|
| Rate for Payer: Cigna Commercial |
$5,220.08
|
| Rate for Payer: Health EOS Commercial |
$5,049.86
|
| Rate for Payer: HFN Commercial |
$5,220.08
|
| Rate for Payer: Multiplan Commercial |
$4,539.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,404.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,220.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,780.26
|
| Rate for Payer: Quartz Commercial |
$3,404.40
|
| Rate for Payer: WEA Trust Commercial |
$3,120.70
|
| Rate for Payer: WPS Commercial |
$4,202.73
|
|
|
ACETABULAR SHELL TRIDENT II TRITANIUM CLUSTERHOLE 50MM D 702-04-50D
|
Facility
|
OP
|
$5,674.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6212957
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,588.72 |
| Max. Negotiated Rate |
$22,696.00 |
| Rate for Payer: Aetna Commercial |
$5,106.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,879.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,588.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,688.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,837.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,723.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,007.22
|
| Rate for Payer: Cash Price |
$1,702.20
|
| Rate for Payer: Cigna Commercial |
$5,220.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,175.17
|
| Rate for Payer: Health EOS Commercial |
$5,049.86
|
| Rate for Payer: HFN Commercial |
$5,220.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,255.50
|
| Rate for Payer: Multiplan Commercial |
$4,539.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,404.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,220.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,780.26
|
| Rate for Payer: Quartz Commercial |
$3,688.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,404.40
|
| Rate for Payer: The Alliance Commercial |
$22,696.00
|
| Rate for Payer: WEA Trust Commercial |
$3,120.70
|
| Rate for Payer: WPS Commercial |
$4,202.73
|
|
|
Acetaminaphen, Urine
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
3313619
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.52 |
| Max. Negotiated Rate |
$436.00 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Aetna Managed Medicare |
$30.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.00
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.75
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$70.85
|
| Rate for Payer: Quartz Medicare Advantage |
$65.40
|
| Rate for Payer: The Alliance Commercial |
$436.00
|
| Rate for Payer: United Healthcare PPO |
$81.75
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
Acetaminaphen, Urine
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
3313619
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.41 |
| Max. Negotiated Rate |
$100.28 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$65.40
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
Acetaminaphen, Urine
|
Professional
|
Both
|
$109.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
3313619
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.96 |
| Max. Negotiated Rate |
$103.55 |
| Rate for Payer: Aetna Commercial |
$103.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$103.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.40
|
| Rate for Payer: Health EOS Commercial |
$99.19
|
| Rate for Payer: HFN Commercial |
$103.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: Preferred Network Access Commercial |
$103.55
|
| Rate for Payer: Quartz Beloit One Network |
$47.96
|
| Rate for Payer: Quartz Commercial |
$62.13
|
| Rate for Payer: The Alliance Commercial |
$54.50
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
Acetaminophen Level
|
Facility
|
OP
|
$430.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
633629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$120.40 |
| Max. Negotiated Rate |
$1,720.00 |
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.80
|
| Rate for Payer: Aetna Managed Medicare |
$120.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$279.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$215.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$206.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.63
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$322.50
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$258.00
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$279.50
|
| Rate for Payer: Quartz Medicare Advantage |
$258.00
|
| Rate for Payer: The Alliance Commercial |
$1,720.00
|
| Rate for Payer: United Healthcare PPO |
$322.50
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
Acetaminophen Level
|
Facility
|
IP
|
$414.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
1037118
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$202.86 |
| Max. Negotiated Rate |
$380.88 |
| Rate for Payer: Aetna Commercial |
$372.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$356.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.42
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$380.88
|
| Rate for Payer: Health EOS Commercial |
$368.46
|
| Rate for Payer: HFN Commercial |
$380.88
|
| Rate for Payer: Multiplan Commercial |
$331.20
|
| Rate for Payer: NAPHCARE Commercial |
$248.40
|
| Rate for Payer: Preferred Network Access Commercial |
$380.88
|
| Rate for Payer: Quartz Beloit One Network |
$202.86
|
| Rate for Payer: Quartz Commercial |
$248.40
|
| Rate for Payer: WEA Trust Commercial |
$227.70
|
| Rate for Payer: WPS Commercial |
$306.65
|
|
|
Acetaminophen Level
|
Professional
|
Both
|
$414.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
1037118
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna Commercial |
$393.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$356.04
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$393.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$207.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$248.40
|
| Rate for Payer: Health EOS Commercial |
$376.74
|
| Rate for Payer: HFN Commercial |
$393.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$331.20
|
| Rate for Payer: Preferred Network Access Commercial |
$393.30
|
| Rate for Payer: Quartz Beloit One Network |
$182.16
|
| Rate for Payer: Quartz Commercial |
$235.98
|
| Rate for Payer: The Alliance Commercial |
$207.00
|
| Rate for Payer: WEA Trust Commercial |
$227.70
|
| Rate for Payer: WPS Commercial |
$306.65
|
|
|
Acetaminophen Level
|
Facility
|
OP
|
$414.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
1037118
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$115.92 |
| Max. Negotiated Rate |
$1,656.00 |
| Rate for Payer: Aetna Commercial |
$372.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$356.04
|
| Rate for Payer: Aetna Managed Medicare |
$115.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$269.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$207.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$198.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.42
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$380.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.67
|
| Rate for Payer: Health EOS Commercial |
$368.46
|
| Rate for Payer: HFN Commercial |
$380.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$310.50
|
| Rate for Payer: Multiplan Commercial |
$331.20
|
| Rate for Payer: NAPHCARE Commercial |
$248.40
|
| Rate for Payer: Preferred Network Access Commercial |
$380.88
|
| Rate for Payer: Quartz Beloit One Network |
$202.86
|
| Rate for Payer: Quartz Commercial |
$269.10
|
| Rate for Payer: Quartz Medicare Advantage |
$248.40
|
| Rate for Payer: The Alliance Commercial |
$1,656.00
|
| Rate for Payer: United Healthcare PPO |
$310.50
|
| Rate for Payer: WEA Trust Commercial |
$227.70
|
| Rate for Payer: WPS Commercial |
$306.65
|
|
|
Acetaminophen Level
|
Professional
|
Both
|
$430.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
633629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$408.50 |
| Rate for Payer: Aetna Commercial |
$408.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.80
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$408.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$215.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.00
|
| Rate for Payer: Health EOS Commercial |
$391.30
|
| Rate for Payer: HFN Commercial |
$408.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: Preferred Network Access Commercial |
$408.50
|
| Rate for Payer: Quartz Beloit One Network |
$189.20
|
| Rate for Payer: Quartz Commercial |
$245.10
|
| Rate for Payer: The Alliance Commercial |
$215.00
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
Acetaminophen Level
|
Facility
|
IP
|
$430.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
633629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$210.70 |
| Max. Negotiated Rate |
$395.60 |
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$258.00
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$258.00
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
Acetazolamide 500mg [Med]
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
2974931
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.71 |
| Max. Negotiated Rate |
$992.00 |
| Rate for Payer: Aetna Commercial |
$223.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Aetna Managed Medicare |
$69.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$161.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$124.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$119.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.44
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$228.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.71
|
| Rate for Payer: Health EOS Commercial |
$220.72
|
| Rate for Payer: HFN Commercial |
$228.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$186.00
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: NAPHCARE Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.16
|
| Rate for Payer: Quartz Beloit One Network |
$121.52
|
| Rate for Payer: Quartz Commercial |
$161.20
|
| Rate for Payer: Quartz Medicare Advantage |
$148.80
|
| Rate for Payer: The Alliance Commercial |
$992.00
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$65.58
|
|
|
Acetazolamide 500mg [Med]
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
2974931
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$121.52 |
| Max. Negotiated Rate |
$228.16 |
| Rate for Payer: Aetna Commercial |
$223.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.44
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$228.16
|
| Rate for Payer: Health EOS Commercial |
$220.72
|
| Rate for Payer: HFN Commercial |
$228.16
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: NAPHCARE Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.16
|
| Rate for Payer: Quartz Beloit One Network |
$121.52
|
| Rate for Payer: Quartz Commercial |
$148.80
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
Acetic Acid 0.25% Irrigation 250ml [MED]
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS A4321
|
| Hospital Charge Code |
2974895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$6.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.25
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$13.80
|
| Rate for Payer: The Alliance Commercial |
$92.00
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
