|
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 |
$6,178.97 |
| Max. Negotiated Rate |
$20,302.34 |
| Rate for Payer: Aetna Commercial |
$19,860.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,978.27
|
| Rate for Payer: Aetna Managed Medicare |
$6,178.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,344.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,033.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,592.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,695.91
|
| Rate for Payer: Cash Price |
$6,365.70
|
| Rate for Payer: Cigna Commercial |
$20,302.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.46
|
| Rate for Payer: Health EOS Commercial |
$19,640.31
|
| Rate for Payer: HFN Commercial |
$20,302.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,550.82
|
| Rate for Payer: Multiplan Commercial |
$17,654.21
|
| Rate for Payer: NAPHCARE Commercial |
$13,240.66
|
| Rate for Payer: Preferred Network Access Commercial |
$20,302.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,813.20
|
| Rate for Payer: Quartz Commercial |
$14,344.04
|
| Rate for Payer: Quartz Medicare Advantage |
$13,240.66
|
| Rate for Payer: The Alliance Commercial |
$11,033.88
|
| Rate for Payer: WEA Trust Commercial |
$12,137.27
|
| Rate for Payer: WPS Commercial |
$16,345.00
|
|
|
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 |
$10,397.37 |
| Max. Negotiated Rate |
$19,521.59 |
| Rate for Payer: Aetna Commercial |
$19,097.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,248.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,246.13
|
| Rate for Payer: Cash Price |
$6,120.90
|
| Rate for Payer: Cigna Commercial |
$19,521.59
|
| Rate for Payer: Health EOS Commercial |
$18,885.02
|
| Rate for Payer: HFN Commercial |
$19,521.59
|
| Rate for Payer: Multiplan Commercial |
$16,975.30
|
| Rate for Payer: Preferred Network Access Commercial |
$19,521.59
|
| Rate for Payer: Quartz Beloit One Network |
$10,397.37
|
| Rate for Payer: Quartz Commercial |
$12,731.47
|
| Rate for Payer: WEA Trust Commercial |
$11,670.52
|
| Rate for Payer: WPS Commercial |
$15,716.43
|
|
|
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 |
$5,941.35 |
| Max. Negotiated Rate |
$19,521.59 |
| Rate for Payer: Aetna Commercial |
$19,097.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,248.44
|
| Rate for Payer: Aetna Managed Medicare |
$5,941.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,792.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,609.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,185.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,246.13
|
| Rate for Payer: Cash Price |
$6,120.90
|
| Rate for Payer: Cigna Commercial |
$19,521.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.55
|
| Rate for Payer: Health EOS Commercial |
$18,885.02
|
| Rate for Payer: HFN Commercial |
$19,521.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,914.34
|
| Rate for Payer: Multiplan Commercial |
$16,975.30
|
| Rate for Payer: NAPHCARE Commercial |
$12,731.47
|
| Rate for Payer: Preferred Network Access Commercial |
$19,521.59
|
| Rate for Payer: Quartz Beloit One Network |
$10,397.37
|
| Rate for Payer: Quartz Commercial |
$13,792.43
|
| Rate for Payer: Quartz Medicare Advantage |
$12,731.47
|
| Rate for Payer: The Alliance Commercial |
$10,609.56
|
| Rate for Payer: WEA Trust Commercial |
$11,670.52
|
| Rate for Payer: WPS Commercial |
$15,716.43
|
|
|
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 |
$2,891.47 |
| Max. Negotiated Rate |
$5,428.88 |
| Rate for Payer: Aetna Commercial |
$5,310.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,074.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,127.51
|
| Rate for Payer: Cash Price |
$1,702.20
|
| Rate for Payer: Cigna Commercial |
$5,428.88
|
| Rate for Payer: Health EOS Commercial |
$5,251.85
|
| Rate for Payer: HFN Commercial |
$5,428.88
|
| Rate for Payer: Multiplan Commercial |
$4,720.77
|
| Rate for Payer: Preferred Network Access Commercial |
$5,428.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,891.47
|
| Rate for Payer: Quartz Commercial |
$3,540.58
|
| Rate for Payer: WEA Trust Commercial |
$3,245.53
|
| Rate for Payer: WPS Commercial |
$4,370.68
|
|
|
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 |
$1,652.27 |
| Max. Negotiated Rate |
$5,428.88 |
| Rate for Payer: Aetna Commercial |
$5,310.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,074.83
|
| Rate for Payer: Aetna Managed Medicare |
$1,652.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,835.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,950.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,832.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,127.51
|
| Rate for Payer: Cash Price |
$1,702.20
|
| Rate for Payer: Cigna Commercial |
$5,428.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,302.27
|
| Rate for Payer: Health EOS Commercial |
$5,251.85
|
| Rate for Payer: HFN Commercial |
$5,428.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,425.72
|
| Rate for Payer: Multiplan Commercial |
$4,720.77
|
| Rate for Payer: NAPHCARE Commercial |
$3,540.58
|
| Rate for Payer: Preferred Network Access Commercial |
$5,428.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,891.47
|
| Rate for Payer: Quartz Commercial |
$3,835.62
|
| Rate for Payer: Quartz Medicare Advantage |
$3,540.58
|
| Rate for Payer: The Alliance Commercial |
$2,950.48
|
| Rate for Payer: WEA Trust Commercial |
$3,245.53
|
| Rate for Payer: WPS Commercial |
$4,370.68
|
|
|
Acetaminaphen, Urine
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
3313619
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.74 |
| Max. Negotiated Rate |
$104.29 |
| Rate for Payer: Aetna Commercial |
$102.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97.49
|
| Rate for Payer: Aetna Managed Medicare |
$31.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$73.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.08
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$104.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.44
|
| Rate for Payer: Health EOS Commercial |
$100.89
|
| Rate for Payer: HFN Commercial |
$104.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.02
|
| Rate for Payer: Multiplan Commercial |
$90.69
|
| Rate for Payer: NAPHCARE Commercial |
$68.02
|
| Rate for Payer: Preferred Network Access Commercial |
$104.29
|
| Rate for Payer: Quartz Beloit One Network |
$55.55
|
| Rate for Payer: Quartz Commercial |
$73.68
|
| Rate for Payer: Quartz Medicare Advantage |
$68.02
|
| Rate for Payer: The Alliance Commercial |
$56.68
|
| Rate for Payer: United Healthcare PPO |
$85.02
|
| Rate for Payer: WEA Trust Commercial |
$62.35
|
| Rate for Payer: WPS Commercial |
$83.96
|
|
|
Acetaminaphen, Urine
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
3313619
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$55.55 |
| Max. Negotiated Rate |
$104.29 |
| Rate for Payer: Aetna Commercial |
$102.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.08
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$104.29
|
| Rate for Payer: Health EOS Commercial |
$100.89
|
| Rate for Payer: HFN Commercial |
$104.29
|
| Rate for Payer: Multiplan Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$104.29
|
| Rate for Payer: Quartz Beloit One Network |
$55.55
|
| Rate for Payer: Quartz Commercial |
$68.02
|
| Rate for Payer: WEA Trust Commercial |
$62.35
|
| Rate for Payer: WPS Commercial |
$83.96
|
|
|
Acetaminaphen, Urine
|
Professional
|
Both
|
$109.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
3313619
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.88 |
| Max. Negotiated Rate |
$107.69 |
| Rate for Payer: Aetna Commercial |
$107.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97.49
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$107.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.02
|
| Rate for Payer: Health EOS Commercial |
$103.16
|
| Rate for Payer: HFN Commercial |
$107.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$107.69
|
| Rate for Payer: Quartz Beloit One Network |
$49.88
|
| Rate for Payer: Quartz Commercial |
$64.62
|
| Rate for Payer: The Alliance Commercial |
$56.68
|
| Rate for Payer: WEA Trust Commercial |
$62.35
|
| Rate for Payer: WPS Commercial |
$83.96
|
|
|
Acetaminophen Level
|
Facility
|
OP
|
$430.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
633629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$125.22 |
| Max. Negotiated Rate |
$411.42 |
| Rate for Payer: Aetna Commercial |
$402.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.59
|
| Rate for Payer: Aetna Managed Medicare |
$125.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$290.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$223.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$214.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.02
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$411.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.26
|
| Rate for Payer: Health EOS Commercial |
$398.01
|
| Rate for Payer: HFN Commercial |
$411.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$335.40
|
| Rate for Payer: Multiplan Commercial |
$357.76
|
| Rate for Payer: NAPHCARE Commercial |
$268.32
|
| Rate for Payer: Preferred Network Access Commercial |
$411.42
|
| Rate for Payer: Quartz Beloit One Network |
$219.13
|
| Rate for Payer: Quartz Commercial |
$290.68
|
| Rate for Payer: Quartz Medicare Advantage |
$268.32
|
| Rate for Payer: The Alliance Commercial |
$223.60
|
| Rate for Payer: United Healthcare PPO |
$335.40
|
| Rate for Payer: WEA Trust Commercial |
$245.96
|
| Rate for Payer: WPS Commercial |
$331.23
|
|
|
Acetaminophen Level
|
Professional
|
Both
|
$414.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
1037118
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$409.03 |
| Rate for Payer: Aetna Commercial |
$409.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$370.28
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$409.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$215.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.34
|
| Rate for Payer: Health EOS Commercial |
$391.81
|
| Rate for Payer: HFN Commercial |
$409.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$344.45
|
| Rate for Payer: Preferred Network Access Commercial |
$409.03
|
| Rate for Payer: Quartz Beloit One Network |
$189.45
|
| Rate for Payer: Quartz Commercial |
$245.42
|
| Rate for Payer: The Alliance Commercial |
$215.28
|
| Rate for Payer: WEA Trust Commercial |
$236.81
|
| Rate for Payer: WPS Commercial |
$318.90
|
|
|
Acetaminophen Level
|
Facility
|
IP
|
$430.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
633629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$219.13 |
| Max. Negotiated Rate |
$411.42 |
| Rate for Payer: Aetna Commercial |
$402.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.02
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$411.42
|
| Rate for Payer: Health EOS Commercial |
$398.01
|
| Rate for Payer: HFN Commercial |
$411.42
|
| Rate for Payer: Multiplan Commercial |
$357.76
|
| Rate for Payer: Preferred Network Access Commercial |
$411.42
|
| Rate for Payer: Quartz Beloit One Network |
$219.13
|
| Rate for Payer: Quartz Commercial |
$268.32
|
| Rate for Payer: WEA Trust Commercial |
$245.96
|
| Rate for Payer: WPS Commercial |
$331.23
|
|
|
Acetaminophen Level
|
Facility
|
OP
|
$414.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
1037118
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$120.56 |
| Max. Negotiated Rate |
$396.12 |
| Rate for Payer: Aetna Commercial |
$387.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$370.28
|
| Rate for Payer: Aetna Managed Medicare |
$120.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$279.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$215.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$206.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$228.20
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$396.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.95
|
| Rate for Payer: Health EOS Commercial |
$383.20
|
| Rate for Payer: HFN Commercial |
$396.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$322.92
|
| Rate for Payer: Multiplan Commercial |
$344.45
|
| Rate for Payer: NAPHCARE Commercial |
$258.34
|
| Rate for Payer: Preferred Network Access Commercial |
$396.12
|
| Rate for Payer: Quartz Beloit One Network |
$210.97
|
| Rate for Payer: Quartz Commercial |
$279.86
|
| Rate for Payer: Quartz Medicare Advantage |
$258.34
|
| Rate for Payer: The Alliance Commercial |
$215.28
|
| Rate for Payer: United Healthcare PPO |
$322.92
|
| Rate for Payer: WEA Trust Commercial |
$236.81
|
| Rate for Payer: WPS Commercial |
$318.90
|
|
|
Acetaminophen Level
|
Professional
|
Both
|
$430.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
633629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$424.84 |
| Rate for Payer: Aetna Commercial |
$424.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.59
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$424.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$223.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.32
|
| Rate for Payer: Health EOS Commercial |
$406.95
|
| Rate for Payer: HFN Commercial |
$424.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$357.76
|
| Rate for Payer: Preferred Network Access Commercial |
$424.84
|
| Rate for Payer: Quartz Beloit One Network |
$196.77
|
| Rate for Payer: Quartz Commercial |
$254.90
|
| Rate for Payer: The Alliance Commercial |
$223.60
|
| Rate for Payer: WEA Trust Commercial |
$245.96
|
| Rate for Payer: WPS Commercial |
$331.23
|
|
|
Acetaminophen Level
|
Facility
|
IP
|
$414.00
|
|
|
Service Code
|
CPT 80329
|
| Hospital Charge Code |
1037118
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$210.97 |
| Max. Negotiated Rate |
$396.12 |
| Rate for Payer: Aetna Commercial |
$387.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$370.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$228.20
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$396.12
|
| Rate for Payer: Health EOS Commercial |
$383.20
|
| Rate for Payer: HFN Commercial |
$396.12
|
| Rate for Payer: Multiplan Commercial |
$344.45
|
| Rate for Payer: Preferred Network Access Commercial |
$396.12
|
| Rate for Payer: Quartz Beloit One Network |
$210.97
|
| Rate for Payer: Quartz Commercial |
$258.34
|
| Rate for Payer: WEA Trust Commercial |
$236.81
|
| Rate for Payer: WPS Commercial |
$318.90
|
|
|
Acetazolamide 500mg [Med]
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
2974931
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.10 |
| Max. Negotiated Rate |
$237.29 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Aetna Managed Medicare |
$72.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$167.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$128.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$123.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.10
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$193.44
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: NAPHCARE Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$167.65
|
| Rate for Payer: Quartz Medicare Advantage |
$154.75
|
| Rate for Payer: The Alliance Commercial |
$106.45
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$68.21
|
|
|
Acetazolamide 500mg [Med]
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
2974931
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.38 |
| Max. Negotiated Rate |
$237.29 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$154.75
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
|
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 |
$6.70 |
| Max. Negotiated Rate |
$22.01 |
| Rate for Payer: Aetna Commercial |
$21.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.57
|
| Rate for Payer: Aetna Managed Medicare |
$6.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.68
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$22.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.39
|
| Rate for Payer: Health EOS Commercial |
$21.29
|
| Rate for Payer: HFN Commercial |
$22.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.94
|
| Rate for Payer: Multiplan Commercial |
$19.14
|
| Rate for Payer: NAPHCARE Commercial |
$14.35
|
| Rate for Payer: Preferred Network Access Commercial |
$22.01
|
| Rate for Payer: Quartz Beloit One Network |
$11.72
|
| Rate for Payer: Quartz Commercial |
$15.55
|
| Rate for Payer: Quartz Medicare Advantage |
$14.35
|
| Rate for Payer: WEA Trust Commercial |
$13.16
|
| Rate for Payer: WPS Commercial |
$17.72
|
|
|
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 |
$11.72 |
| Max. Negotiated Rate |
$22.01 |
| Rate for Payer: Aetna Commercial |
$21.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.68
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$22.01
|
| Rate for Payer: Health EOS Commercial |
$21.29
|
| Rate for Payer: HFN Commercial |
$22.01
|
| Rate for Payer: Multiplan Commercial |
$19.14
|
| Rate for Payer: Preferred Network Access Commercial |
$22.01
|
| Rate for Payer: Quartz Beloit One Network |
$11.72
|
| Rate for Payer: Quartz Commercial |
$14.35
|
| Rate for Payer: WEA Trust Commercial |
$13.16
|
| Rate for Payer: WPS Commercial |
$17.72
|
|
|
Acetylcholine Ophth Solution 2ml [Med]
|
Facility
|
OP
|
$327.00
|
|
| Hospital Charge Code |
2974965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$95.22 |
| Max. Negotiated Rate |
$312.87 |
| Rate for Payer: Aetna Commercial |
$306.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.47
|
| Rate for Payer: Aetna Managed Medicare |
$95.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$221.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$170.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$163.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.24
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$312.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$190.31
|
| Rate for Payer: Health EOS Commercial |
$302.67
|
| Rate for Payer: HFN Commercial |
$312.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$255.06
|
| Rate for Payer: Multiplan Commercial |
$272.06
|
| Rate for Payer: NAPHCARE Commercial |
$204.05
|
| Rate for Payer: Preferred Network Access Commercial |
$312.87
|
| Rate for Payer: Quartz Beloit One Network |
$166.64
|
| Rate for Payer: Quartz Commercial |
$221.05
|
| Rate for Payer: Quartz Medicare Advantage |
$204.05
|
| Rate for Payer: The Alliance Commercial |
$170.04
|
| Rate for Payer: WEA Trust Commercial |
$187.04
|
| Rate for Payer: WPS Commercial |
$251.89
|
|
|
Acetylcholine Ophth Solution 2ml [Med]
|
Facility
|
IP
|
$327.00
|
|
| Hospital Charge Code |
2974965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$166.64 |
| Max. Negotiated Rate |
$312.87 |
| Rate for Payer: Aetna Commercial |
$306.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.24
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$312.87
|
| Rate for Payer: Health EOS Commercial |
$302.67
|
| Rate for Payer: HFN Commercial |
$312.87
|
| Rate for Payer: Multiplan Commercial |
$272.06
|
| Rate for Payer: Preferred Network Access Commercial |
$312.87
|
| Rate for Payer: Quartz Beloit One Network |
$166.64
|
| Rate for Payer: Quartz Commercial |
$204.05
|
| Rate for Payer: WEA Trust Commercial |
$187.04
|
| Rate for Payer: WPS Commercial |
$251.89
|
|
|
Acetylcholine Receptor Binding Antibody
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
2942963
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$133.95 |
| Rate for Payer: Aetna Commercial |
$131.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.22
|
| Rate for Payer: Aetna Managed Medicare |
$19.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.89
|
| Rate for Payer: Anthem Medicare Advantage |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.14
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$133.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.48
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$129.58
|
| Rate for Payer: HFN Commercial |
$133.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$116.48
|
| Rate for Payer: NAPHCARE Commercial |
$28.70
|
| Rate for Payer: Preferred Network Access Commercial |
$133.95
|
| Rate for Payer: Quartz Beloit One Network |
$71.34
|
| Rate for Payer: Quartz Commercial |
$94.64
|
| Rate for Payer: Quartz Medicare Advantage |
$19.14
|
| Rate for Payer: The Alliance Commercial |
$76.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.14
|
| Rate for Payer: United Healthcare PPO |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$80.08
|
| Rate for Payer: Wellcare Medicare |
$19.14
|
| Rate for Payer: WPS Commercial |
$107.84
|
|
|
Acetylcholine Receptor Binding Antibody
|
Professional
|
Both
|
$140.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
2942963
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$138.32 |
| Rate for Payer: Aetna Commercial |
$138.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.22
|
| Rate for Payer: Aetna Managed Medicare |
$19.14
|
| Rate for Payer: Anthem Medicare Advantage |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.14
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$138.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$132.50
|
| Rate for Payer: HFN Commercial |
$138.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$116.48
|
| Rate for Payer: NAPHCARE Commercial |
$28.70
|
| Rate for Payer: Preferred Network Access Commercial |
$138.32
|
| Rate for Payer: Quartz Beloit One Network |
$64.06
|
| Rate for Payer: Quartz Commercial |
$82.99
|
| Rate for Payer: Quartz Medicare Advantage |
$19.14
|
| Rate for Payer: The Alliance Commercial |
$75.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.14
|
| Rate for Payer: WEA Trust Commercial |
$80.08
|
| Rate for Payer: WPS Commercial |
$84.20
|
|
|
Acetylcholine Receptor Binding Antibody
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
2942963
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$71.34 |
| Max. Negotiated Rate |
$133.95 |
| Rate for Payer: Aetna Commercial |
$131.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.17
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$133.95
|
| Rate for Payer: Health EOS Commercial |
$129.58
|
| Rate for Payer: HFN Commercial |
$133.95
|
| Rate for Payer: Multiplan Commercial |
$116.48
|
| Rate for Payer: Preferred Network Access Commercial |
$133.95
|
| Rate for Payer: Quartz Beloit One Network |
$71.34
|
| Rate for Payer: Quartz Commercial |
$87.36
|
| Rate for Payer: WEA Trust Commercial |
$80.08
|
| Rate for Payer: WPS Commercial |
$107.84
|
|
|
Acetylcholine Receptor Blocking Antibody
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
5546927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$153.09 |
| Rate for Payer: Aetna Commercial |
$149.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.10
|
| Rate for Payer: Aetna Managed Medicare |
$19.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$108.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$83.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.87
|
| Rate for Payer: Anthem Medicare Advantage |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.14
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$153.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$148.10
|
| Rate for Payer: HFN Commercial |
$153.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$133.12
|
| Rate for Payer: NAPHCARE Commercial |
$28.70
|
| Rate for Payer: Preferred Network Access Commercial |
$153.09
|
| Rate for Payer: Quartz Beloit One Network |
$81.54
|
| Rate for Payer: Quartz Commercial |
$108.16
|
| Rate for Payer: Quartz Medicare Advantage |
$19.14
|
| Rate for Payer: The Alliance Commercial |
$76.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.14
|
| Rate for Payer: United Healthcare PPO |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$91.52
|
| Rate for Payer: Wellcare Medicare |
$19.14
|
| Rate for Payer: WPS Commercial |
$123.25
|
|
|
Acetylcholine Receptor Blocking Antibody
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
5546927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$158.08 |
| Rate for Payer: Aetna Commercial |
$158.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.10
|
| Rate for Payer: Aetna Managed Medicare |
$19.14
|
| Rate for Payer: Anthem Medicare Advantage |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.14
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$158.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$83.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$151.42
|
| Rate for Payer: HFN Commercial |
$158.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$133.12
|
| Rate for Payer: NAPHCARE Commercial |
$28.70
|
| Rate for Payer: Preferred Network Access Commercial |
$158.08
|
| Rate for Payer: Quartz Beloit One Network |
$73.22
|
| Rate for Payer: Quartz Commercial |
$94.85
|
| Rate for Payer: Quartz Medicare Advantage |
$19.14
|
| Rate for Payer: The Alliance Commercial |
$75.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.14
|
| Rate for Payer: WEA Trust Commercial |
$91.52
|
| Rate for Payer: WPS Commercial |
$84.20
|
|
