|
WRIST SUPPORT ADULT ARTERIAL 29980
|
Facility
|
IP
|
$194.00
|
|
| Hospital Charge Code |
2965834
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$98.86 |
| Max. Negotiated Rate |
$185.62 |
| Rate for Payer: Aetna Commercial |
$181.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.93
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Health EOS Commercial |
$179.57
|
| Rate for Payer: HFN Commercial |
$185.62
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: Preferred Network Access Commercial |
$185.62
|
| Rate for Payer: Quartz Beloit One Network |
$98.86
|
| Rate for Payer: Quartz Commercial |
$121.06
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$149.44
|
|
|
WRIST SUPPORT ADULT ARTERIAL 29980
|
Facility
|
OP
|
$194.00
|
|
| Hospital Charge Code |
2965834
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$56.49 |
| Max. Negotiated Rate |
$185.62 |
| Rate for Payer: Aetna Commercial |
$181.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Aetna Managed Medicare |
$56.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.93
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.91
|
| Rate for Payer: Health EOS Commercial |
$179.57
|
| Rate for Payer: HFN Commercial |
$185.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.32
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: NAPHCARE Commercial |
$121.06
|
| Rate for Payer: Preferred Network Access Commercial |
$185.62
|
| Rate for Payer: Quartz Beloit One Network |
$98.86
|
| Rate for Payer: Quartz Commercial |
$131.14
|
| Rate for Payer: Quartz Medicare Advantage |
$121.06
|
| Rate for Payer: The Alliance Commercial |
$100.88
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$149.44
|
|
|
WRIST, TENDON & NERVE REPAIR
|
Facility
|
IP
|
$4,492.00
|
|
| Hospital Charge Code |
2960426
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,289.12 |
| Max. Negotiated Rate |
$4,297.95 |
| Rate for Payer: Aetna Commercial |
$4,204.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,017.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,475.99
|
| Rate for Payer: Cash Price |
$1,347.60
|
| Rate for Payer: Cigna Commercial |
$4,297.95
|
| Rate for Payer: Health EOS Commercial |
$4,157.80
|
| Rate for Payer: HFN Commercial |
$4,297.95
|
| Rate for Payer: Multiplan Commercial |
$3,737.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,297.95
|
| Rate for Payer: Quartz Beloit One Network |
$2,289.12
|
| Rate for Payer: Quartz Commercial |
$2,803.01
|
| Rate for Payer: WEA Trust Commercial |
$2,569.42
|
| Rate for Payer: WPS Commercial |
$3,460.19
|
|
|
WRIST, TENDON & NERVE REPAIR
|
Facility
|
OP
|
$4,492.00
|
|
| Hospital Charge Code |
2960426
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,308.07 |
| Max. Negotiated Rate |
$4,297.95 |
| Rate for Payer: Aetna Commercial |
$4,204.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,017.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,308.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,036.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,335.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,242.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,475.99
|
| Rate for Payer: Cash Price |
$1,347.60
|
| Rate for Payer: Cigna Commercial |
$4,297.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,614.34
|
| Rate for Payer: Health EOS Commercial |
$4,157.80
|
| Rate for Payer: HFN Commercial |
$4,297.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,503.76
|
| Rate for Payer: Multiplan Commercial |
$3,737.34
|
| Rate for Payer: NAPHCARE Commercial |
$2,803.01
|
| Rate for Payer: Preferred Network Access Commercial |
$4,297.95
|
| Rate for Payer: Quartz Beloit One Network |
$2,289.12
|
| Rate for Payer: Quartz Commercial |
$3,036.59
|
| Rate for Payer: Quartz Medicare Advantage |
$2,803.01
|
| Rate for Payer: The Alliance Commercial |
$2,335.84
|
| Rate for Payer: WEA Trust Commercial |
$2,569.42
|
| Rate for Payer: WPS Commercial |
$3,460.19
|
|
|
WRIST WRAP UNIVERSAL NEOPRENE #7807-01
|
Facility
|
IP
|
$144.00
|
|
| Hospital Charge Code |
2969684
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$73.38 |
| Max. Negotiated Rate |
$137.78 |
| Rate for Payer: Aetna Commercial |
$134.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$128.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.37
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$137.78
|
| Rate for Payer: Health EOS Commercial |
$133.29
|
| Rate for Payer: HFN Commercial |
$137.78
|
| Rate for Payer: Multiplan Commercial |
$119.81
|
| Rate for Payer: Preferred Network Access Commercial |
$137.78
|
| Rate for Payer: Quartz Beloit One Network |
$73.38
|
| Rate for Payer: Quartz Commercial |
$89.86
|
| Rate for Payer: WEA Trust Commercial |
$82.37
|
| Rate for Payer: WPS Commercial |
$110.92
|
|
|
WRIST WRAP UNIVERSAL NEOPRENE #7807-01
|
Facility
|
OP
|
$144.00
|
|
| Hospital Charge Code |
2969684
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$41.93 |
| Max. Negotiated Rate |
$137.78 |
| Rate for Payer: Aetna Commercial |
$134.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$128.79
|
| Rate for Payer: Aetna Managed Medicare |
$41.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$97.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$74.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$71.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.37
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$137.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.81
|
| Rate for Payer: Health EOS Commercial |
$133.29
|
| Rate for Payer: HFN Commercial |
$137.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.32
|
| Rate for Payer: Multiplan Commercial |
$119.81
|
| Rate for Payer: NAPHCARE Commercial |
$89.86
|
| Rate for Payer: Preferred Network Access Commercial |
$137.78
|
| Rate for Payer: Quartz Beloit One Network |
$73.38
|
| Rate for Payer: Quartz Commercial |
$97.34
|
| Rate for Payer: Quartz Medicare Advantage |
$89.86
|
| Rate for Payer: The Alliance Commercial |
$74.88
|
| Rate for Payer: WEA Trust Commercial |
$82.37
|
| Rate for Payer: WPS Commercial |
$110.92
|
|
|
Xe-133 gas
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
HCPCS A9558
|
| Hospital Charge Code |
1486830
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.26 |
| Max. Negotiated Rate |
$145.43 |
| Rate for Payer: Aetna Commercial |
$142.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.95
|
| Rate for Payer: Aetna Managed Medicare |
$44.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.78
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$145.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.46
|
| Rate for Payer: Health EOS Commercial |
$140.69
|
| Rate for Payer: HFN Commercial |
$145.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$118.56
|
| Rate for Payer: Multiplan Commercial |
$126.46
|
| Rate for Payer: NAPHCARE Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$145.43
|
| Rate for Payer: Quartz Beloit One Network |
$77.46
|
| Rate for Payer: Quartz Commercial |
$102.75
|
| Rate for Payer: Quartz Medicare Advantage |
$94.85
|
| Rate for Payer: The Alliance Commercial |
$79.04
|
| Rate for Payer: WEA Trust Commercial |
$86.94
|
| Rate for Payer: WPS Commercial |
$117.09
|
|
|
Xe-133 gas
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
HCPCS A9558
|
| Hospital Charge Code |
1486830
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.46 |
| Max. Negotiated Rate |
$145.43 |
| Rate for Payer: Aetna Commercial |
$142.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.78
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$145.43
|
| Rate for Payer: Health EOS Commercial |
$140.69
|
| Rate for Payer: HFN Commercial |
$145.43
|
| Rate for Payer: Multiplan Commercial |
$126.46
|
| Rate for Payer: Preferred Network Access Commercial |
$145.43
|
| Rate for Payer: Quartz Beloit One Network |
$77.46
|
| Rate for Payer: Quartz Commercial |
$94.85
|
| Rate for Payer: WEA Trust Commercial |
$86.94
|
| Rate for Payer: WPS Commercial |
$117.09
|
|
|
Xe-133 gas
|
Professional
|
Both
|
$152.00
|
|
|
Service Code
|
HCPCS A9558
|
| Hospital Charge Code |
1486830
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.42 |
| Max. Negotiated Rate |
$382.11 |
| Rate for Payer: Aetna Commercial |
$150.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.95
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$150.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.85
|
| Rate for Payer: Health EOS Commercial |
$143.85
|
| Rate for Payer: HFN Commercial |
$150.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$382.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$382.11
|
| Rate for Payer: Multiplan Commercial |
$126.46
|
| Rate for Payer: Preferred Network Access Commercial |
$150.18
|
| Rate for Payer: Quartz Beloit One Network |
$69.56
|
| Rate for Payer: Quartz Commercial |
$90.11
|
| Rate for Payer: The Alliance Commercial |
$79.04
|
| Rate for Payer: United Healthcare Medicaid |
$32.42
|
| Rate for Payer: WEA Trust Commercial |
$86.94
|
| Rate for Payer: WPS Commercial |
$117.09
|
|
|
Xiaflex 0.9mg vial J0775
|
Facility
|
IP
|
$10,805.00
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
4356598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,506.23 |
| Max. Negotiated Rate |
$10,338.22 |
| Rate for Payer: Aetna Commercial |
$10,113.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,663.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,955.72
|
| Rate for Payer: Cash Price |
$3,241.50
|
| Rate for Payer: Cigna Commercial |
$10,338.22
|
| Rate for Payer: Health EOS Commercial |
$10,001.11
|
| Rate for Payer: HFN Commercial |
$10,338.22
|
| Rate for Payer: Multiplan Commercial |
$8,989.76
|
| Rate for Payer: Preferred Network Access Commercial |
$10,338.22
|
| Rate for Payer: Quartz Beloit One Network |
$5,506.23
|
| Rate for Payer: Quartz Commercial |
$6,742.32
|
| Rate for Payer: WEA Trust Commercial |
$6,180.46
|
| Rate for Payer: WPS Commercial |
$8,323.09
|
|
|
Xiaflex 0.9mg vial J0775
|
Facility
|
OP
|
$10,805.00
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
4356598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.78 |
| Max. Negotiated Rate |
$10,338.22 |
| Rate for Payer: Aetna Commercial |
$10,113.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,663.99
|
| Rate for Payer: Aetna Managed Medicare |
$78.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,304.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,618.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,393.86
|
| Rate for Payer: Anthem Medicare Advantage |
$78.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,955.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$78.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$78.78
|
| Rate for Payer: Cash Price |
$3,241.50
|
| Rate for Payer: Cash Price |
$3,241.50
|
| Rate for Payer: Cigna Commercial |
$10,338.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$78.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$78.78
|
| Rate for Payer: Health EOS Commercial |
$10,001.11
|
| Rate for Payer: HFN Commercial |
$10,338.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$293.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$78.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$78.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$78.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$78.78
|
| Rate for Payer: Multiplan Commercial |
$8,989.76
|
| Rate for Payer: NAPHCARE Commercial |
$118.17
|
| Rate for Payer: Preferred Network Access Commercial |
$10,338.22
|
| Rate for Payer: Quartz Beloit One Network |
$5,506.23
|
| Rate for Payer: Quartz Commercial |
$7,304.18
|
| Rate for Payer: Quartz Medicare Advantage |
$78.78
|
| Rate for Payer: The Alliance Commercial |
$315.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.78
|
| Rate for Payer: WEA Trust Commercial |
$6,180.46
|
| Rate for Payer: Wellcare Medicare |
$78.78
|
| Rate for Payer: WPS Commercial |
$179.32
|
|
|
Xiaflex 0.9mg vial J0775
|
Professional
|
Both
|
$10,805.00
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
4356598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.73 |
| Max. Negotiated Rate |
$10,675.34 |
| Rate for Payer: Aetna Commercial |
$10,675.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,663.99
|
| Rate for Payer: Aetna Managed Medicare |
$78.78
|
| Rate for Payer: Anthem Medicare Advantage |
$78.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$78.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$78.78
|
| Rate for Payer: Cash Price |
$3,241.50
|
| Rate for Payer: Cash Price |
$3,241.50
|
| Rate for Payer: Cigna Commercial |
$10,675.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.73
|
| Rate for Payer: Health EOS Commercial |
$10,225.85
|
| Rate for Payer: HFN Commercial |
$10,675.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$82.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$78.78
|
| Rate for Payer: Multiplan Commercial |
$8,989.76
|
| Rate for Payer: NAPHCARE Commercial |
$118.17
|
| Rate for Payer: Preferred Network Access Commercial |
$10,675.34
|
| Rate for Payer: Quartz Beloit One Network |
$4,944.37
|
| Rate for Payer: Quartz Commercial |
$6,405.20
|
| Rate for Payer: Quartz Medicare Advantage |
$78.78
|
| Rate for Payer: The Alliance Commercial |
$216.65
|
| Rate for Payer: United Healthcare Medicaid |
$78.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.78
|
| Rate for Payer: WEA Trust Commercial |
$6,180.46
|
| Rate for Payer: WPS Commercial |
$179.32
|
|
|
Xopenex 0.5 mg Charge
|
Facility
|
IP
|
$10.00
|
|
| Hospital Charge Code |
2958858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
Xopenex 0.5 mg Charge
|
Professional
|
Both
|
$10.00
|
|
| Hospital Charge Code |
2958858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Aetna Commercial |
$9.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.24
|
| Rate for Payer: Health EOS Commercial |
$9.46
|
| Rate for Payer: HFN Commercial |
$9.88
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: Preferred Network Access Commercial |
$9.88
|
| Rate for Payer: Quartz Beloit One Network |
$4.58
|
| Rate for Payer: Quartz Commercial |
$5.93
|
| Rate for Payer: The Alliance Commercial |
$5.20
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
Xopenex 0.5 mg Charge
|
Facility
|
OP
|
$10.00
|
|
| Hospital Charge Code |
2958858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Aetna Managed Medicare |
$2.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.82
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.80
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: NAPHCARE Commercial |
$6.24
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.76
|
| Rate for Payer: Quartz Medicare Advantage |
$6.24
|
| Rate for Payer: The Alliance Commercial |
$5.20
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
Xopenex - Additional Unit Dose Medicaiton
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
5516922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Aetna Managed Medicare |
$10.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.95
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.08
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: NAPHCARE Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$24.34
|
| Rate for Payer: Quartz Medicare Advantage |
$22.46
|
| Rate for Payer: The Alliance Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$27.73
|
|
|
Xopenex - Additional Unit Dose Medicaiton
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
5516922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$22.46
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$27.73
|
|
|
X-PLATE 8 HOLE BIOMET 73-2623
|
Facility
|
IP
|
$5,401.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4205986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,752.35 |
| Max. Negotiated Rate |
$5,167.68 |
| Rate for Payer: Aetna Commercial |
$5,055.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,830.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,977.03
|
| Rate for Payer: Cash Price |
$1,620.30
|
| Rate for Payer: Cigna Commercial |
$5,167.68
|
| Rate for Payer: Health EOS Commercial |
$4,999.17
|
| Rate for Payer: HFN Commercial |
$5,167.68
|
| Rate for Payer: Multiplan Commercial |
$4,493.63
|
| Rate for Payer: Preferred Network Access Commercial |
$5,167.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,752.35
|
| Rate for Payer: Quartz Commercial |
$3,370.22
|
| Rate for Payer: WEA Trust Commercial |
$3,089.37
|
| Rate for Payer: WPS Commercial |
$4,160.39
|
|
|
X-PLATE 8 HOLE BIOMET 73-2623
|
Facility
|
OP
|
$5,401.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4205986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,572.77 |
| Max. Negotiated Rate |
$5,167.68 |
| Rate for Payer: Aetna Commercial |
$5,055.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,830.65
|
| Rate for Payer: Aetna Managed Medicare |
$1,572.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,651.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,808.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,696.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,977.03
|
| Rate for Payer: Cash Price |
$1,620.30
|
| Rate for Payer: Cigna Commercial |
$5,167.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,143.38
|
| Rate for Payer: Health EOS Commercial |
$4,999.17
|
| Rate for Payer: HFN Commercial |
$5,167.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,212.78
|
| Rate for Payer: Multiplan Commercial |
$4,493.63
|
| Rate for Payer: NAPHCARE Commercial |
$3,370.22
|
| Rate for Payer: Preferred Network Access Commercial |
$5,167.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,752.35
|
| Rate for Payer: Quartz Commercial |
$3,651.08
|
| Rate for Payer: Quartz Medicare Advantage |
$3,370.22
|
| Rate for Payer: The Alliance Commercial |
$2,808.52
|
| Rate for Payer: WEA Trust Commercial |
$3,089.37
|
| Rate for Payer: WPS Commercial |
$4,160.39
|
|
|
XPOSE FOR ENDOPROSTH, FEMORL, EXT 3481222
|
Professional
|
Both
|
$2,712.00
|
|
|
Service Code
|
CPT 34812 22
|
| Hospital Charge Code |
6173443
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$258.11 |
| Max. Negotiated Rate |
$2,679.46 |
| Rate for Payer: Aetna Commercial |
$2,679.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,425.61
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Cigna Commercial |
$2,679.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$258.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,692.29
|
| Rate for Payer: Health EOS Commercial |
$2,566.64
|
| Rate for Payer: HFN Commercial |
$2,679.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$674.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$674.80
|
| Rate for Payer: Multiplan Commercial |
$2,256.38
|
| Rate for Payer: Preferred Network Access Commercial |
$2,679.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,241.01
|
| Rate for Payer: Quartz Commercial |
$1,607.67
|
| Rate for Payer: The Alliance Commercial |
$1,410.24
|
| Rate for Payer: United Healthcare Medicaid |
$258.11
|
| Rate for Payer: WEA Trust Commercial |
$1,551.26
|
| Rate for Payer: WPS Commercial |
$2,089.05
|
|
|
XPOSE FOR ENDOPROSTH, FEMORL, EXT & BILAT 34812-2250
|
Professional
|
Both
|
$5,425.00
|
|
|
Service Code
|
CPT 34812 22,50
|
| Hospital Charge Code |
6173442
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$258.11 |
| Max. Negotiated Rate |
$5,359.90 |
| Rate for Payer: Aetna Commercial |
$5,359.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,852.12
|
| Rate for Payer: Cash Price |
$1,627.50
|
| Rate for Payer: Cash Price |
$1,627.50
|
| Rate for Payer: Cash Price |
$1,627.50
|
| Rate for Payer: Cigna Commercial |
$5,359.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$258.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,385.20
|
| Rate for Payer: Health EOS Commercial |
$5,134.22
|
| Rate for Payer: HFN Commercial |
$5,359.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$674.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$674.80
|
| Rate for Payer: Multiplan Commercial |
$4,513.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,359.90
|
| Rate for Payer: Quartz Beloit One Network |
$2,482.48
|
| Rate for Payer: Quartz Commercial |
$3,215.94
|
| Rate for Payer: The Alliance Commercial |
$2,821.00
|
| Rate for Payer: United Healthcare Medicaid |
$258.11
|
| Rate for Payer: WEA Trust Commercial |
$3,103.10
|
| Rate for Payer: WPS Commercial |
$4,178.88
|
|
|
XR Abdomen 1 View
|
Professional
|
Both
|
$531.00
|
|
|
Service Code
|
CPT 74018 TC
|
| Hospital Charge Code |
5724247
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.74 |
| Max. Negotiated Rate |
$524.63 |
| Rate for Payer: Aetna Commercial |
$524.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$474.93
|
| Rate for Payer: Aetna Managed Medicare |
$20.74
|
| Rate for Payer: Anthem Medicare Advantage |
$20.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.74
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$524.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$276.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.74
|
| Rate for Payer: Health EOS Commercial |
$502.54
|
| Rate for Payer: HFN Commercial |
$524.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$72.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.74
|
| Rate for Payer: Multiplan Commercial |
$441.79
|
| Rate for Payer: NAPHCARE Commercial |
$31.11
|
| Rate for Payer: Preferred Network Access Commercial |
$524.63
|
| Rate for Payer: Quartz Beloit One Network |
$242.99
|
| Rate for Payer: Quartz Commercial |
$314.78
|
| Rate for Payer: Quartz Medicare Advantage |
$20.74
|
| Rate for Payer: The Alliance Commercial |
$78.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.74
|
| Rate for Payer: WEA Trust Commercial |
$303.73
|
| Rate for Payer: WPS Commercial |
$103.69
|
|
|
XR Abdomen 1 View
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
CPT 74018 TC
|
| Hospital Charge Code |
5724247
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$270.60 |
| Max. Negotiated Rate |
$508.06 |
| Rate for Payer: Aetna Commercial |
$497.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$474.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$292.69
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$508.06
|
| Rate for Payer: Health EOS Commercial |
$491.49
|
| Rate for Payer: HFN Commercial |
$508.06
|
| Rate for Payer: Multiplan Commercial |
$441.79
|
| Rate for Payer: Preferred Network Access Commercial |
$508.06
|
| Rate for Payer: Quartz Beloit One Network |
$270.60
|
| Rate for Payer: Quartz Commercial |
$331.34
|
| Rate for Payer: WEA Trust Commercial |
$303.73
|
| Rate for Payer: WPS Commercial |
$409.03
|
|
|
XR Abdomen 1 View
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
CPT 74018 TC
|
| Hospital Charge Code |
5724247
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$82.95 |
| Max. Negotiated Rate |
$508.06 |
| Rate for Payer: Aetna Commercial |
$497.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$474.93
|
| Rate for Payer: Aetna Managed Medicare |
$154.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$292.69
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$508.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$309.04
|
| Rate for Payer: Health EOS Commercial |
$491.49
|
| Rate for Payer: HFN Commercial |
$508.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$414.18
|
| Rate for Payer: Multiplan Commercial |
$441.79
|
| Rate for Payer: NAPHCARE Commercial |
$331.34
|
| Rate for Payer: Preferred Network Access Commercial |
$508.06
|
| Rate for Payer: Quartz Beloit One Network |
$270.60
|
| Rate for Payer: Quartz Commercial |
$358.96
|
| Rate for Payer: Quartz Medicare Advantage |
$331.34
|
| Rate for Payer: The Alliance Commercial |
$82.95
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$303.73
|
| Rate for Payer: WPS Commercial |
$409.03
|
|
|
XR Abdomen 2 Views
|
Facility
|
OP
|
$530.00
|
|
|
Service Code
|
CPT 74019 TC
|
| Hospital Charge Code |
5963652
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$100.26 |
| Max. Negotiated Rate |
$507.10 |
| Rate for Payer: Aetna Commercial |
$496.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$474.03
|
| Rate for Payer: Aetna Managed Medicare |
$154.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$292.14
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cigna Commercial |
$507.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$308.46
|
| Rate for Payer: Health EOS Commercial |
$490.57
|
| Rate for Payer: HFN Commercial |
$507.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$413.40
|
| Rate for Payer: Multiplan Commercial |
$440.96
|
| Rate for Payer: NAPHCARE Commercial |
$330.72
|
| Rate for Payer: Preferred Network Access Commercial |
$507.10
|
| Rate for Payer: Quartz Beloit One Network |
$270.09
|
| Rate for Payer: Quartz Commercial |
$358.28
|
| Rate for Payer: Quartz Medicare Advantage |
$330.72
|
| Rate for Payer: The Alliance Commercial |
$100.26
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$303.16
|
| Rate for Payer: WPS Commercial |
$408.26
|
|
