|
FEMUR TRIATHLON PS SZ 7 LT 5515-F-701
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,677.14 |
| Max. Negotiated Rate |
$10,659.12 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$6,951.60
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON PS SZ 7 LT 5515-F-701
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,244.08 |
| Max. Negotiated Rate |
$46,344.00 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Aetna Managed Medicare |
$3,244.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,530.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,561.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,483.53
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,689.50
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$7,530.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,951.60
|
| Rate for Payer: The Alliance Commercial |
$46,344.00
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON PS SZ 7 RT 5515-F-702
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,677.14 |
| Max. Negotiated Rate |
$10,659.12 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$6,951.60
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON PS SZ 7 RT 5515-F-702
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,244.08 |
| Max. Negotiated Rate |
$46,344.00 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Aetna Managed Medicare |
$3,244.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,530.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,561.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,483.53
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,689.50
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$7,530.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,951.60
|
| Rate for Payer: The Alliance Commercial |
$46,344.00
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON PS SZ 8 LT 5515-F-801
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,244.08 |
| Max. Negotiated Rate |
$46,344.00 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Aetna Managed Medicare |
$3,244.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,530.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,561.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,483.53
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,689.50
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$7,530.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,951.60
|
| Rate for Payer: The Alliance Commercial |
$46,344.00
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON PS SZ 8 LT 5515-F-801
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,677.14 |
| Max. Negotiated Rate |
$10,659.12 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$6,951.60
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON PS SZ 8 RT 5515-F-802
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493877
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,244.08 |
| Max. Negotiated Rate |
$46,344.00 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Aetna Managed Medicare |
$3,244.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,530.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,561.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,483.53
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,689.50
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$7,530.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,951.60
|
| Rate for Payer: The Alliance Commercial |
$46,344.00
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON PS SZ 8 RT 5515-F-802
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493877
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,677.14 |
| Max. Negotiated Rate |
$10,659.12 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$6,951.60
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR ZUK HIGH FLEX SZ B RT MED/LT LAT 5842-12-02
|
Facility
|
IP
|
$8,140.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,988.60 |
| Max. Negotiated Rate |
$7,488.80 |
| Rate for Payer: Aetna Commercial |
$7,326.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,000.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,314.20
|
| Rate for Payer: Cash Price |
$2,442.00
|
| Rate for Payer: Cigna Commercial |
$7,488.80
|
| Rate for Payer: Health EOS Commercial |
$7,244.60
|
| Rate for Payer: HFN Commercial |
$7,488.80
|
| Rate for Payer: Multiplan Commercial |
$6,512.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,884.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,488.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,988.60
|
| Rate for Payer: Quartz Commercial |
$4,884.00
|
| Rate for Payer: WEA Trust Commercial |
$4,477.00
|
| Rate for Payer: WPS Commercial |
$6,029.30
|
|
|
FEMUR ZUK HIGH FLEX SZ B RT MED/LT LAT 5842-12-02
|
Facility
|
OP
|
$8,140.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.20 |
| Max. Negotiated Rate |
$32,560.00 |
| Rate for Payer: Aetna Commercial |
$7,326.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,000.40
|
| Rate for Payer: Aetna Managed Medicare |
$2,279.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,291.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,070.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,907.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,314.20
|
| Rate for Payer: Cash Price |
$2,442.00
|
| Rate for Payer: Cigna Commercial |
$7,488.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,555.14
|
| Rate for Payer: Health EOS Commercial |
$7,244.60
|
| Rate for Payer: HFN Commercial |
$7,488.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,105.00
|
| Rate for Payer: Multiplan Commercial |
$6,512.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,884.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,488.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,988.60
|
| Rate for Payer: Quartz Commercial |
$5,291.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,884.00
|
| Rate for Payer: The Alliance Commercial |
$32,560.00
|
| Rate for Payer: WEA Trust Commercial |
$4,477.00
|
| Rate for Payer: WPS Commercial |
$6,029.30
|
|
|
fentanyl 100mcg/2ml syringe [Med]
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
2983104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$138.92 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$90.60
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
fentanyl 100mcg/2ml syringe [Med]
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
2983104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$42.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.31
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.25
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$98.15
|
| Rate for Payer: Quartz Medicare Advantage |
$90.60
|
| Rate for Payer: The Alliance Commercial |
$604.00
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$2.48
|
|
|
Fentanyl 50mcg/2ml syringe [Med]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
5286879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.88
|
| Rate for Payer: Aetna Managed Medicare |
$2.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.31
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$5.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4.80
|
| Rate for Payer: The Alliance Commercial |
$32.00
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$2.48
|
|
|
Fentanyl 50mcg/2ml syringe [Med]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
5286879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$4.80
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$5.93
|
|
|
Fentanyl, Qualitative, Serum
|
Professional
|
Both
|
$171.00
|
|
|
Service Code
|
CPT 80354
|
| Hospital Charge Code |
5605738
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$75.24 |
| Max. Negotiated Rate |
$162.45 |
| Rate for Payer: Aetna Commercial |
$162.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.06
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$162.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$85.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.60
|
| Rate for Payer: Health EOS Commercial |
$155.61
|
| Rate for Payer: HFN Commercial |
$162.45
|
| 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 |
$136.80
|
| Rate for Payer: Preferred Network Access Commercial |
$162.45
|
| Rate for Payer: Quartz Beloit One Network |
$75.24
|
| Rate for Payer: Quartz Commercial |
$97.47
|
| Rate for Payer: The Alliance Commercial |
$85.50
|
| Rate for Payer: WEA Trust Commercial |
$94.05
|
| Rate for Payer: WPS Commercial |
$126.66
|
|
|
Fentanyl, Qualitative, Serum
|
Facility
|
OP
|
$171.00
|
|
|
Service Code
|
CPT 80354
|
| Hospital Charge Code |
5605738
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.88 |
| Max. Negotiated Rate |
$684.00 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.06
|
| Rate for Payer: Aetna Managed Medicare |
$47.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$85.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.63
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$157.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.69
|
| Rate for Payer: Health EOS Commercial |
$152.19
|
| Rate for Payer: HFN Commercial |
$157.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.25
|
| Rate for Payer: Multiplan Commercial |
$136.80
|
| Rate for Payer: NAPHCARE Commercial |
$102.60
|
| Rate for Payer: Preferred Network Access Commercial |
$157.32
|
| Rate for Payer: Quartz Beloit One Network |
$83.79
|
| Rate for Payer: Quartz Commercial |
$111.15
|
| Rate for Payer: Quartz Medicare Advantage |
$102.60
|
| Rate for Payer: The Alliance Commercial |
$684.00
|
| Rate for Payer: United Healthcare PPO |
$128.25
|
| Rate for Payer: WEA Trust Commercial |
$94.05
|
| Rate for Payer: WPS Commercial |
$126.66
|
|
|
Fentanyl, Qualitative, Serum
|
Facility
|
IP
|
$171.00
|
|
|
Service Code
|
CPT 80354
|
| Hospital Charge Code |
5605738
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.79 |
| Max. Negotiated Rate |
$157.32 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.63
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$157.32
|
| Rate for Payer: Health EOS Commercial |
$152.19
|
| Rate for Payer: HFN Commercial |
$157.32
|
| Rate for Payer: Multiplan Commercial |
$136.80
|
| Rate for Payer: NAPHCARE Commercial |
$102.60
|
| Rate for Payer: Preferred Network Access Commercial |
$157.32
|
| Rate for Payer: Quartz Beloit One Network |
$83.79
|
| Rate for Payer: Quartz Commercial |
$102.60
|
| Rate for Payer: WEA Trust Commercial |
$94.05
|
| Rate for Payer: WPS Commercial |
$126.66
|
|
|
Fentanyl, Quantitative Urine
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
CPT 80354
|
| Hospital Charge Code |
5208634
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.80 |
| Max. Negotiated Rate |
$137.75 |
| Rate for Payer: Aetna Commercial |
$137.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.70
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$137.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.00
|
| Rate for Payer: Health EOS Commercial |
$131.95
|
| Rate for Payer: HFN Commercial |
$137.75
|
| 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 |
$116.00
|
| Rate for Payer: Preferred Network Access Commercial |
$137.75
|
| Rate for Payer: Quartz Beloit One Network |
$63.80
|
| Rate for Payer: Quartz Commercial |
$82.65
|
| Rate for Payer: The Alliance Commercial |
$72.50
|
| Rate for Payer: WEA Trust Commercial |
$79.75
|
| Rate for Payer: WPS Commercial |
$107.40
|
|
|
Fentanyl, Quantitative Urine
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
CPT 80354
|
| Hospital Charge Code |
5208634
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$71.05 |
| Max. Negotiated Rate |
$133.40 |
| Rate for Payer: Aetna Commercial |
$130.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.85
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$133.40
|
| Rate for Payer: Health EOS Commercial |
$129.05
|
| Rate for Payer: HFN Commercial |
$133.40
|
| Rate for Payer: Multiplan Commercial |
$116.00
|
| Rate for Payer: NAPHCARE Commercial |
$87.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.40
|
| Rate for Payer: Quartz Beloit One Network |
$71.05
|
| Rate for Payer: Quartz Commercial |
$87.00
|
| Rate for Payer: WEA Trust Commercial |
$79.75
|
| Rate for Payer: WPS Commercial |
$107.40
|
|
|
Fentanyl, Quantitative Urine
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
CPT 80354
|
| Hospital Charge Code |
5208634
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$580.00 |
| Rate for Payer: Aetna Commercial |
$130.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.70
|
| Rate for Payer: Aetna Managed Medicare |
$40.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.85
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$133.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.14
|
| Rate for Payer: Health EOS Commercial |
$129.05
|
| Rate for Payer: HFN Commercial |
$133.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.75
|
| Rate for Payer: Multiplan Commercial |
$116.00
|
| Rate for Payer: NAPHCARE Commercial |
$87.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.40
|
| Rate for Payer: Quartz Beloit One Network |
$71.05
|
| Rate for Payer: Quartz Commercial |
$94.25
|
| Rate for Payer: Quartz Medicare Advantage |
$87.00
|
| Rate for Payer: The Alliance Commercial |
$580.00
|
| Rate for Payer: United Healthcare PPO |
$108.75
|
| Rate for Payer: WEA Trust Commercial |
$79.75
|
| Rate for Payer: WPS Commercial |
$107.40
|
|
|
Ferritin
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
633726
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$120.05 |
| Max. Negotiated Rate |
$225.40 |
| Rate for Payer: Aetna Commercial |
$220.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.85
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$225.40
|
| Rate for Payer: Health EOS Commercial |
$218.05
|
| Rate for Payer: HFN Commercial |
$225.40
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: NAPHCARE Commercial |
$147.00
|
| Rate for Payer: Preferred Network Access Commercial |
$225.40
|
| Rate for Payer: Quartz Beloit One Network |
$120.05
|
| Rate for Payer: Quartz Commercial |
$147.00
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
Ferritin
|
Professional
|
Both
|
$245.00
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
633726
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.11 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Aetna Commercial |
$232.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.70
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$232.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$122.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.00
|
| Rate for Payer: Health EOS Commercial |
$222.95
|
| Rate for Payer: HFN Commercial |
$232.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.11
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: Preferred Network Access Commercial |
$232.75
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$139.65
|
| Rate for Payer: The Alliance Commercial |
$122.50
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
Ferritin
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
633726
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.63 |
| Max. Negotiated Rate |
$225.40 |
| Rate for Payer: Aetna Commercial |
$220.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.70
|
| Rate for Payer: Aetna Managed Medicare |
$13.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.63
|
| Rate for Payer: Anthem Medicaid |
$14.08
|
| Rate for Payer: Anthem Medicare Advantage |
$13.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.63
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$225.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.10
|
| Rate for Payer: Dean Health Medicaid |
$14.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.63
|
| Rate for Payer: Health EOS Commercial |
$218.05
|
| Rate for Payer: HFN Commercial |
$225.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.63
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.63
|
| Rate for Payer: Managed Health Services Medicaid |
$14.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.63
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: NAPHCARE Commercial |
$20.44
|
| Rate for Payer: Preferred Network Access Commercial |
$225.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.08
|
| Rate for Payer: Quartz Beloit One Network |
$120.05
|
| Rate for Payer: Quartz Commercial |
$159.25
|
| Rate for Payer: Quartz Medicare Advantage |
$13.63
|
| Rate for Payer: The Alliance Commercial |
$54.52
|
| Rate for Payer: United Healthcare Medicaid |
$14.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.63
|
| Rate for Payer: United Healthcare PPO |
$183.75
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: Wellcare Medicare |
$13.63
|
| Rate for Payer: WMAP Medicaid |
$14.08
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
Fetal Biophys Profile W/Inst 7681826
|
Professional
|
Both
|
$2,599.00
|
|
|
Service Code
|
CPT 76818 26
|
| Hospital Charge Code |
5144606
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$177.21 |
| Max. Negotiated Rate |
$2,469.05 |
| Rate for Payer: Aetna Commercial |
$2,469.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,235.14
|
| Rate for Payer: Cash Price |
$779.70
|
| Rate for Payer: Cash Price |
$779.70
|
| Rate for Payer: Cash Price |
$779.70
|
| Rate for Payer: Cigna Commercial |
$2,469.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,299.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,559.40
|
| Rate for Payer: Health EOS Commercial |
$2,365.09
|
| Rate for Payer: HFN Commercial |
$2,469.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$177.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$177.21
|
| Rate for Payer: Multiplan Commercial |
$2,079.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,469.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,143.56
|
| Rate for Payer: Quartz Commercial |
$1,481.43
|
| Rate for Payer: The Alliance Commercial |
$1,299.50
|
| Rate for Payer: WEA Trust Commercial |
$1,429.45
|
| Rate for Payer: WPS Commercial |
$1,925.08
|
|
|
Fetal Fibronectin
|
Professional
|
Both
|
$1,214.00
|
|
|
Service Code
|
CPT 82731
|
| Hospital Charge Code |
977950
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$227.37 |
| Max. Negotiated Rate |
$1,153.30 |
| Rate for Payer: Aetna Commercial |
$1,153.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,044.04
|
| Rate for Payer: Cash Price |
$364.20
|
| Rate for Payer: Cash Price |
$364.20
|
| Rate for Payer: Cigna Commercial |
$1,153.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$607.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$728.40
|
| Rate for Payer: Health EOS Commercial |
$1,104.74
|
| Rate for Payer: HFN Commercial |
$1,153.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.37
|
| Rate for Payer: Multiplan Commercial |
$971.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,153.30
|
| Rate for Payer: Quartz Beloit One Network |
$534.16
|
| Rate for Payer: Quartz Commercial |
$691.98
|
| Rate for Payer: The Alliance Commercial |
$607.00
|
| Rate for Payer: WEA Trust Commercial |
$667.70
|
| Rate for Payer: WPS Commercial |
$899.21
|
|
