|
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: 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: 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 |
$18,770.76 |
| 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: 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: 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 |
$5,220.08 |
| 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: WEA Trust Commercial |
$3,120.70
|
| Rate for Payer: WPS Commercial |
$4,202.73
|
|
|
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: 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
|
$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: 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
|
|
|
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 |
$100.28 |
| 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: 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: 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: United Healthcare PPO |
$81.75
|
| 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 |
$395.60 |
| 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: 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: 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: United Healthcare PPO |
$322.50
|
| 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: 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
|
|
|
Acetaminophen Level
|
Professional
|
$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: 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
|
Professional
|
$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: 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 |
$380.88 |
| 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: 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: 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: United Healthcare PPO |
$310.50
|
| Rate for Payer: WEA Trust Commercial |
$227.70
|
| Rate for Payer: WPS Commercial |
$306.65
|
|
|
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: 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
|
|
|
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: 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
|
|
|
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 |
$700.24 |
| 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 |
$700.24
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$65.58
|
|
|
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 |
$21.16 |
| 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: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Acetic Acid 0.25% Irrigation 250ml [MED]
|
Facility
IP
|
$23.00
|
|
|
Service Code
|
HCPCS A4321
|
| Hospital Charge Code |
2974895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| 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: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| 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 |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Acetylcholine Ophth Solution 2ml [Med]
|
Facility
OP
|
$327.00
|
|
| Hospital Charge Code |
2974965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.56 |
| Max. Negotiated Rate |
$1,308.00 |
| Rate for Payer: Aetna Commercial |
$294.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.22
|
| Rate for Payer: Aetna Managed Medicare |
$91.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$212.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$163.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$156.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$173.31
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$300.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.99
|
| Rate for Payer: Health EOS Commercial |
$291.03
|
| Rate for Payer: HFN Commercial |
$300.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$245.25
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: NAPHCARE Commercial |
$196.20
|
| Rate for Payer: Preferred Network Access Commercial |
$300.84
|
| Rate for Payer: Quartz Beloit One Network |
$160.23
|
| Rate for Payer: Quartz Commercial |
$212.55
|
| Rate for Payer: Quartz Medicare Advantage |
$196.20
|
| Rate for Payer: The Alliance Commercial |
$1,308.00
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: WPS Commercial |
$242.21
|
|
|
Acetylcholine Ophth Solution 2ml [Med]
|
Facility
IP
|
$327.00
|
|
| Hospital Charge Code |
2974965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$160.23 |
| Max. Negotiated Rate |
$300.84 |
| Rate for Payer: Aetna Commercial |
$294.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$173.31
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$300.84
|
| Rate for Payer: Health EOS Commercial |
$291.03
|
| Rate for Payer: HFN Commercial |
$300.84
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: NAPHCARE Commercial |
$196.20
|
| Rate for Payer: Preferred Network Access Commercial |
$300.84
|
| Rate for Payer: Quartz Beloit One Network |
$160.23
|
| Rate for Payer: Quartz Commercial |
$196.20
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: WPS Commercial |
$242.21
|
|
|
Acetylcholine Receptor Binding Antibody
|
Professional
|
$140.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
2942963
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$133.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.00
|
| Rate for Payer: Health EOS Commercial |
$127.40
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.60
|
| Rate for Payer: Quartz Commercial |
$79.80
|
| Rate for Payer: The Alliance Commercial |
$70.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
Acetylcholine Receptor Binding Antibody
|
Facility
IP
|
$140.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
2942963
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$128.80 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$128.80
|
| Rate for Payer: Health EOS Commercial |
$124.60
|
| Rate for Payer: HFN Commercial |
$128.80
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: NAPHCARE Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$128.80
|
| Rate for Payer: Quartz Beloit One Network |
$68.60
|
| Rate for Payer: Quartz Commercial |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
Acetylcholine Receptor Binding Antibody
|
Facility
OP
|
$140.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
2942963
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$560.00 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Aetna Managed Medicare |
$39.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$91.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$70.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$67.20
|
| Rate for Payer: Anthem Medicaid |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$128.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.72
|
| Rate for Payer: Dean Health Medicaid |
$14.72
|
| Rate for Payer: Health EOS Commercial |
$124.60
|
| Rate for Payer: HFN Commercial |
$128.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.72
|
| Rate for Payer: Managed Health Services Medicaid |
$15.31
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: NAPHCARE Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$128.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.72
|
| Rate for Payer: Quartz Beloit One Network |
$68.60
|
| Rate for Payer: Quartz Commercial |
$91.00
|
| Rate for Payer: Quartz Medicare Advantage |
$84.00
|
| Rate for Payer: The Alliance Commercial |
$560.00
|
| Rate for Payer: United Healthcare Medicaid |
$14.72
|
| Rate for Payer: United Healthcare PPO |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WMAP Medicaid |
$14.72
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
Acetylcholine Receptor Blocking Antibody
|
Facility
OP
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
5546927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Aetna Managed Medicare |
$44.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.80
|
| Rate for Payer: Anthem Medicaid |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.72
|
| Rate for Payer: Dean Health Medicaid |
$14.72
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.72
|
| Rate for Payer: Managed Health Services Medicaid |
$15.31
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.72
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$104.00
|
| Rate for Payer: Quartz Medicare Advantage |
$96.00
|
| Rate for Payer: The Alliance Commercial |
$640.00
|
| Rate for Payer: United Healthcare Medicaid |
$14.72
|
| Rate for Payer: United Healthcare PPO |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WMAP Medicaid |
$14.72
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
Acetylcholine Receptor Blocking Antibody
|
Facility
IP
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
5546927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$147.20 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
