|
Wound Drainage Management
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005549
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$145.75 |
| Max. Negotiated Rate |
$273.64 |
| Rate for Payer: Aetna Commercial |
$267.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.64
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$273.64
|
| Rate for Payer: Health EOS Commercial |
$264.72
|
| Rate for Payer: HFN Commercial |
$273.64
|
| Rate for Payer: Multiplan Commercial |
$237.95
|
| Rate for Payer: Preferred Network Access Commercial |
$273.64
|
| Rate for Payer: Quartz Beloit One Network |
$145.75
|
| Rate for Payer: Quartz Commercial |
$178.46
|
| Rate for Payer: WEA Trust Commercial |
$163.59
|
| Rate for Payer: WPS Commercial |
$220.31
|
|
|
WOUND MATRIX INTEGRA BILAYER 4 IN X 5 IN (10CM X 12.5CM = 125SQ CM) BMW4051
|
Facility
|
IP
|
$231.46
|
|
|
Service Code
|
HCPCS Q4104
|
| Hospital Charge Code |
6246270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$117.95 |
| Max. Negotiated Rate |
$221.46 |
| Rate for Payer: Aetna Commercial |
$216.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.58
|
| Rate for Payer: Cash Price |
$69.44
|
| Rate for Payer: Cigna Commercial |
$221.46
|
| Rate for Payer: Health EOS Commercial |
$214.24
|
| Rate for Payer: HFN Commercial |
$221.46
|
| Rate for Payer: Multiplan Commercial |
$192.57
|
| Rate for Payer: Preferred Network Access Commercial |
$221.46
|
| Rate for Payer: Quartz Beloit One Network |
$117.95
|
| Rate for Payer: Quartz Commercial |
$144.43
|
| Rate for Payer: WEA Trust Commercial |
$132.40
|
| Rate for Payer: WPS Commercial |
$178.29
|
|
|
WOUND MATRIX INTEGRA BILAYER 4 IN X 5 IN (10CM X 12.5CM = 125SQ CM) BMW4051
|
Facility
|
OP
|
$231.46
|
|
|
Service Code
|
HCPCS Q4104
|
| Hospital Charge Code |
6246270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.25 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$216.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.02
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$156.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$120.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$115.54
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$69.44
|
| Rate for Payer: Cash Price |
$69.44
|
| Rate for Payer: Cigna Commercial |
$221.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$214.24
|
| Rate for Payer: HFN Commercial |
$221.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$192.57
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$221.46
|
| Rate for Payer: Quartz Beloit One Network |
$117.95
|
| Rate for Payer: Quartz Commercial |
$156.47
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$132.40
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$127.08
|
|
|
WOUND MATRIX INTEGRA MESHED BILAYER 2 X 2 (5CM X 5CM=25SQ CM) MWM2021
|
Facility
|
IP
|
$622.50
|
|
|
Service Code
|
HCPCS Q4104
|
| Hospital Charge Code |
6171711
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.23 |
| Max. Negotiated Rate |
$595.61 |
| Rate for Payer: Aetna Commercial |
$582.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$556.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$343.12
|
| Rate for Payer: Cash Price |
$186.75
|
| Rate for Payer: Cigna Commercial |
$595.61
|
| Rate for Payer: Health EOS Commercial |
$576.19
|
| Rate for Payer: HFN Commercial |
$595.61
|
| Rate for Payer: Multiplan Commercial |
$517.92
|
| Rate for Payer: Preferred Network Access Commercial |
$595.61
|
| Rate for Payer: Quartz Beloit One Network |
$317.23
|
| Rate for Payer: Quartz Commercial |
$388.44
|
| Rate for Payer: WEA Trust Commercial |
$356.07
|
| Rate for Payer: WPS Commercial |
$479.51
|
|
|
WOUND MATRIX INTEGRA MESHED BILAYER 2 X 2 (5CM X 5CM=25SQ CM) MWM2021
|
Facility
|
OP
|
$622.50
|
|
|
Service Code
|
HCPCS Q4104
|
| Hospital Charge Code |
6171711
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.25 |
| Max. Negotiated Rate |
$595.61 |
| Rate for Payer: Aetna Commercial |
$582.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$556.76
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$420.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$323.70
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$310.75
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$343.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$186.75
|
| Rate for Payer: Cash Price |
$186.75
|
| Rate for Payer: Cigna Commercial |
$595.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$576.19
|
| Rate for Payer: HFN Commercial |
$595.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$517.92
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$595.61
|
| Rate for Payer: Quartz Beloit One Network |
$317.23
|
| Rate for Payer: Quartz Commercial |
$420.81
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$356.07
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$127.08
|
|
|
WOUND MATRIX INTEGRA MESHED BILAYER 4 IN X 5 IN (10CM X 12.5CM = 125SQ CM) MWM4051
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
HCPCS Q4104
|
| Hospital Charge Code |
6166229
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.25 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.29
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$176.44
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$127.08
|
|
|
WOUND MATRIX INTEGRA MESHED BILAYER 4 IN X 5 IN (10CM X 12.5CM = 125SQ CM) MWM4051
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
HCPCS Q4104
|
| Hospital Charge Code |
6166229
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.01 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$162.86
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
WOUND REPAIR
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960512
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
WOUND REPAIR
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960512
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
WRENCH SPANNER 5MM HOFFMANN LIMB 4933-9-205
|
Facility
|
OP
|
$3,846.00
|
|
| Hospital Charge Code |
6167872
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,119.96 |
| Max. Negotiated Rate |
$3,679.85 |
| Rate for Payer: Aetna Commercial |
$3,599.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,439.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,119.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,599.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,999.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,919.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,119.92
|
| Rate for Payer: Cash Price |
$1,153.80
|
| Rate for Payer: Cigna Commercial |
$3,679.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,238.37
|
| Rate for Payer: Health EOS Commercial |
$3,559.86
|
| Rate for Payer: HFN Commercial |
$3,679.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,999.88
|
| Rate for Payer: Multiplan Commercial |
$3,199.87
|
| Rate for Payer: NAPHCARE Commercial |
$2,399.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,679.85
|
| Rate for Payer: Quartz Beloit One Network |
$1,959.92
|
| Rate for Payer: Quartz Commercial |
$2,599.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,399.90
|
| Rate for Payer: The Alliance Commercial |
$1,999.92
|
| Rate for Payer: WEA Trust Commercial |
$2,199.91
|
| Rate for Payer: WPS Commercial |
$2,962.57
|
|
|
WRENCH SPANNER 5MM HOFFMANN LIMB 4933-9-205
|
Facility
|
IP
|
$3,846.00
|
|
| Hospital Charge Code |
6167872
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,959.92 |
| Max. Negotiated Rate |
$3,679.85 |
| Rate for Payer: Aetna Commercial |
$3,599.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,439.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,119.92
|
| Rate for Payer: Cash Price |
$1,153.80
|
| Rate for Payer: Cigna Commercial |
$3,679.85
|
| Rate for Payer: Health EOS Commercial |
$3,559.86
|
| Rate for Payer: HFN Commercial |
$3,679.85
|
| Rate for Payer: Multiplan Commercial |
$3,199.87
|
| Rate for Payer: Preferred Network Access Commercial |
$3,679.85
|
| Rate for Payer: Quartz Beloit One Network |
$1,959.92
|
| Rate for Payer: Quartz Commercial |
$2,399.90
|
| Rate for Payer: WEA Trust Commercial |
$2,199.91
|
| Rate for Payer: WPS Commercial |
$2,962.57
|
|
|
WRENCH SPANNER 7/10MM HOFFMANN LIMB 4933-9-204
|
Facility
|
IP
|
$1,385.00
|
|
| Hospital Charge Code |
5599711
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$705.80 |
| Max. Negotiated Rate |
$1,325.17 |
| Rate for Payer: Aetna Commercial |
$1,296.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,238.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$763.41
|
| Rate for Payer: Cash Price |
$415.50
|
| Rate for Payer: Cigna Commercial |
$1,325.17
|
| Rate for Payer: Health EOS Commercial |
$1,281.96
|
| Rate for Payer: HFN Commercial |
$1,325.17
|
| Rate for Payer: Multiplan Commercial |
$1,152.32
|
| Rate for Payer: Preferred Network Access Commercial |
$1,325.17
|
| Rate for Payer: Quartz Beloit One Network |
$705.80
|
| Rate for Payer: Quartz Commercial |
$864.24
|
| Rate for Payer: WEA Trust Commercial |
$792.22
|
| Rate for Payer: WPS Commercial |
$1,066.87
|
|
|
WRENCH SPANNER 7/10MM HOFFMANN LIMB 4933-9-204
|
Facility
|
OP
|
$1,385.00
|
|
| Hospital Charge Code |
5599711
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$403.31 |
| Max. Negotiated Rate |
$1,325.17 |
| Rate for Payer: Aetna Commercial |
$1,296.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,238.74
|
| Rate for Payer: Aetna Managed Medicare |
$403.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$936.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$720.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$691.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$763.41
|
| Rate for Payer: Cash Price |
$415.50
|
| Rate for Payer: Cigna Commercial |
$1,325.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$806.07
|
| Rate for Payer: Health EOS Commercial |
$1,281.96
|
| Rate for Payer: HFN Commercial |
$1,325.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,080.30
|
| Rate for Payer: Multiplan Commercial |
$1,152.32
|
| Rate for Payer: NAPHCARE Commercial |
$864.24
|
| Rate for Payer: Preferred Network Access Commercial |
$1,325.17
|
| Rate for Payer: Quartz Beloit One Network |
$705.80
|
| Rate for Payer: Quartz Commercial |
$936.26
|
| Rate for Payer: Quartz Medicare Advantage |
$864.24
|
| Rate for Payer: The Alliance Commercial |
$720.20
|
| Rate for Payer: WEA Trust Commercial |
$792.22
|
| Rate for Payer: WPS Commercial |
$1,066.87
|
|
|
WRIST ARTHRODESIS
|
Facility
|
OP
|
$4,912.00
|
|
| Hospital Charge Code |
2959824
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,430.37 |
| Max. Negotiated Rate |
$4,699.80 |
| Rate for Payer: Aetna Commercial |
$4,597.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,393.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,430.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,320.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,554.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,452.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,707.49
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,699.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,858.78
|
| Rate for Payer: Health EOS Commercial |
$4,546.55
|
| Rate for Payer: HFN Commercial |
$4,699.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,831.36
|
| Rate for Payer: Multiplan Commercial |
$4,086.78
|
| Rate for Payer: NAPHCARE Commercial |
$3,065.09
|
| Rate for Payer: Preferred Network Access Commercial |
$4,699.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,503.16
|
| Rate for Payer: Quartz Commercial |
$3,320.51
|
| Rate for Payer: Quartz Medicare Advantage |
$3,065.09
|
| Rate for Payer: The Alliance Commercial |
$2,554.24
|
| Rate for Payer: WEA Trust Commercial |
$2,809.66
|
| Rate for Payer: WPS Commercial |
$3,783.71
|
|
|
WRIST ARTHRODESIS
|
Facility
|
IP
|
$4,912.00
|
|
| Hospital Charge Code |
2959824
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,503.16 |
| Max. Negotiated Rate |
$4,699.80 |
| Rate for Payer: Aetna Commercial |
$4,597.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,393.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,707.49
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,699.80
|
| Rate for Payer: Health EOS Commercial |
$4,546.55
|
| Rate for Payer: HFN Commercial |
$4,699.80
|
| Rate for Payer: Multiplan Commercial |
$4,086.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,699.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,503.16
|
| Rate for Payer: Quartz Commercial |
$3,065.09
|
| Rate for Payer: WEA Trust Commercial |
$2,809.66
|
| Rate for Payer: WPS Commercial |
$3,783.71
|
|
|
Wrist Arthrogram XR Left
|
Facility
|
OP
|
$1,218.00
|
|
|
Service Code
|
CPT 73115
|
| Hospital Charge Code |
3072709
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$1,482.47 |
| Rate for Payer: Aetna Commercial |
$1,140.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,089.38
|
| Rate for Payer: Aetna Managed Medicare |
$367.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,185.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,126.68
|
| Rate for Payer: Anthem Medicare Advantage |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$671.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$367.15
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cigna Commercial |
$1,165.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$367.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$708.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$367.15
|
| Rate for Payer: Health EOS Commercial |
$1,127.38
|
| Rate for Payer: HFN Commercial |
$1,165.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$367.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$367.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$367.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$367.15
|
| Rate for Payer: Multiplan Commercial |
$1,013.38
|
| Rate for Payer: NAPHCARE Commercial |
$550.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,165.38
|
| Rate for Payer: Quartz Beloit One Network |
$620.69
|
| Rate for Payer: Quartz Commercial |
$823.37
|
| Rate for Payer: Quartz Medicare Advantage |
$367.15
|
| Rate for Payer: The Alliance Commercial |
$1,468.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$367.15
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$696.70
|
| Rate for Payer: Wellcare Medicare |
$367.15
|
| Rate for Payer: WPS Commercial |
$938.23
|
|
|
Wrist Arthrogram XR Left
|
Facility
|
IP
|
$1,218.00
|
|
|
Service Code
|
CPT 73115
|
| Hospital Charge Code |
3072709
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$620.69 |
| Max. Negotiated Rate |
$1,165.38 |
| Rate for Payer: Aetna Commercial |
$1,140.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,089.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$671.36
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cigna Commercial |
$1,165.38
|
| Rate for Payer: Health EOS Commercial |
$1,127.38
|
| Rate for Payer: HFN Commercial |
$1,165.38
|
| Rate for Payer: Multiplan Commercial |
$1,013.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,165.38
|
| Rate for Payer: Quartz Beloit One Network |
$620.69
|
| Rate for Payer: Quartz Commercial |
$760.03
|
| Rate for Payer: WEA Trust Commercial |
$696.70
|
| Rate for Payer: WPS Commercial |
$938.23
|
|
|
Wrist Arthrogram XR Left
|
Professional
|
Both
|
$1,218.00
|
|
|
Service Code
|
CPT 73115
|
| Hospital Charge Code |
3072709
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$132.42 |
| Max. Negotiated Rate |
$1,203.38 |
| Rate for Payer: Aetna Commercial |
$1,203.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,089.38
|
| Rate for Payer: Aetna Managed Medicare |
$132.42
|
| Rate for Payer: Anthem Medicare Advantage |
$132.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$132.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$132.42
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cigna Commercial |
$1,203.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$633.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.42
|
| Rate for Payer: Health EOS Commercial |
$1,152.72
|
| Rate for Payer: HFN Commercial |
$1,203.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$483.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$483.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$132.42
|
| Rate for Payer: Multiplan Commercial |
$1,013.38
|
| Rate for Payer: NAPHCARE Commercial |
$198.63
|
| Rate for Payer: Preferred Network Access Commercial |
$1,203.38
|
| Rate for Payer: Quartz Beloit One Network |
$557.36
|
| Rate for Payer: Quartz Commercial |
$722.03
|
| Rate for Payer: Quartz Medicare Advantage |
$132.42
|
| Rate for Payer: The Alliance Commercial |
$503.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$132.42
|
| Rate for Payer: WEA Trust Commercial |
$696.70
|
| Rate for Payer: WPS Commercial |
$662.12
|
|
|
Wrist Arthrogram XR Right
|
Professional
|
Both
|
$1,218.00
|
|
|
Service Code
|
CPT 73115
|
| Hospital Charge Code |
3072710
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$132.42 |
| Max. Negotiated Rate |
$1,203.38 |
| Rate for Payer: Aetna Commercial |
$1,203.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,089.38
|
| Rate for Payer: Aetna Managed Medicare |
$132.42
|
| Rate for Payer: Anthem Medicare Advantage |
$132.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$132.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$132.42
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cigna Commercial |
$1,203.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$633.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.42
|
| Rate for Payer: Health EOS Commercial |
$1,152.72
|
| Rate for Payer: HFN Commercial |
$1,203.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$483.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$483.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$132.42
|
| Rate for Payer: Multiplan Commercial |
$1,013.38
|
| Rate for Payer: NAPHCARE Commercial |
$198.63
|
| Rate for Payer: Preferred Network Access Commercial |
$1,203.38
|
| Rate for Payer: Quartz Beloit One Network |
$557.36
|
| Rate for Payer: Quartz Commercial |
$722.03
|
| Rate for Payer: Quartz Medicare Advantage |
$132.42
|
| Rate for Payer: The Alliance Commercial |
$503.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$132.42
|
| Rate for Payer: WEA Trust Commercial |
$696.70
|
| Rate for Payer: WPS Commercial |
$662.12
|
|
|
Wrist Arthrogram XR Right
|
Facility
|
OP
|
$1,218.00
|
|
|
Service Code
|
CPT 73115
|
| Hospital Charge Code |
3072710
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$1,482.47 |
| Rate for Payer: Aetna Commercial |
$1,140.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,089.38
|
| Rate for Payer: Aetna Managed Medicare |
$367.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,185.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,126.68
|
| Rate for Payer: Anthem Medicare Advantage |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$671.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$367.15
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cigna Commercial |
$1,165.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$367.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$708.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$367.15
|
| Rate for Payer: Health EOS Commercial |
$1,127.38
|
| Rate for Payer: HFN Commercial |
$1,165.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$367.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$367.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$367.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$367.15
|
| Rate for Payer: Multiplan Commercial |
$1,013.38
|
| Rate for Payer: NAPHCARE Commercial |
$550.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,165.38
|
| Rate for Payer: Quartz Beloit One Network |
$620.69
|
| Rate for Payer: Quartz Commercial |
$823.37
|
| Rate for Payer: Quartz Medicare Advantage |
$367.15
|
| Rate for Payer: The Alliance Commercial |
$1,468.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$367.15
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$696.70
|
| Rate for Payer: Wellcare Medicare |
$367.15
|
| Rate for Payer: WPS Commercial |
$938.23
|
|
|
Wrist Arthrogram XR Right
|
Facility
|
IP
|
$1,218.00
|
|
|
Service Code
|
CPT 73115
|
| Hospital Charge Code |
3072710
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$620.69 |
| Max. Negotiated Rate |
$1,165.38 |
| Rate for Payer: Aetna Commercial |
$1,140.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,089.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$671.36
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cigna Commercial |
$1,165.38
|
| Rate for Payer: Health EOS Commercial |
$1,127.38
|
| Rate for Payer: HFN Commercial |
$1,165.38
|
| Rate for Payer: Multiplan Commercial |
$1,013.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,165.38
|
| Rate for Payer: Quartz Beloit One Network |
$620.69
|
| Rate for Payer: Quartz Commercial |
$760.03
|
| Rate for Payer: WEA Trust Commercial |
$696.70
|
| Rate for Payer: WPS Commercial |
$938.23
|
|
|
WRIST ARTHROPLASTY
|
Facility
|
OP
|
$8,012.00
|
|
| Hospital Charge Code |
2960446
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,333.09 |
| Max. Negotiated Rate |
$7,665.88 |
| Rate for Payer: Aetna Commercial |
$7,499.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,165.93
|
| Rate for Payer: Aetna Managed Medicare |
$2,333.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,416.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,166.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,999.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,416.21
|
| Rate for Payer: Cash Price |
$2,403.60
|
| Rate for Payer: Cigna Commercial |
$7,665.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,662.98
|
| Rate for Payer: Health EOS Commercial |
$7,415.91
|
| Rate for Payer: HFN Commercial |
$7,665.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,249.36
|
| Rate for Payer: Multiplan Commercial |
$6,665.98
|
| Rate for Payer: NAPHCARE Commercial |
$4,999.49
|
| Rate for Payer: Preferred Network Access Commercial |
$7,665.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,082.92
|
| Rate for Payer: Quartz Commercial |
$5,416.11
|
| Rate for Payer: Quartz Medicare Advantage |
$4,999.49
|
| Rate for Payer: The Alliance Commercial |
$4,166.24
|
| Rate for Payer: WEA Trust Commercial |
$4,582.86
|
| Rate for Payer: WPS Commercial |
$6,171.64
|
|
|
WRIST ARTHROPLASTY
|
Facility
|
IP
|
$8,012.00
|
|
| Hospital Charge Code |
2960446
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,082.92 |
| Max. Negotiated Rate |
$7,665.88 |
| Rate for Payer: Aetna Commercial |
$7,499.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,165.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,416.21
|
| Rate for Payer: Cash Price |
$2,403.60
|
| Rate for Payer: Cigna Commercial |
$7,665.88
|
| Rate for Payer: Health EOS Commercial |
$7,415.91
|
| Rate for Payer: HFN Commercial |
$7,665.88
|
| Rate for Payer: Multiplan Commercial |
$6,665.98
|
| Rate for Payer: Preferred Network Access Commercial |
$7,665.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,082.92
|
| Rate for Payer: Quartz Commercial |
$4,999.49
|
| Rate for Payer: WEA Trust Commercial |
$4,582.86
|
| Rate for Payer: WPS Commercial |
$6,171.64
|
|
|
WRIST ARTHROSCOPY
|
Facility
|
OP
|
$7,950.00
|
|
| Hospital Charge Code |
2959831
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,315.04 |
| Max. Negotiated Rate |
$7,606.56 |
| Rate for Payer: Aetna Commercial |
$7,441.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,110.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,315.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,374.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,134.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,968.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,382.04
|
| Rate for Payer: Cash Price |
$2,385.00
|
| Rate for Payer: Cigna Commercial |
$7,606.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,626.90
|
| Rate for Payer: Health EOS Commercial |
$7,358.52
|
| Rate for Payer: HFN Commercial |
$7,606.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,201.00
|
| Rate for Payer: Multiplan Commercial |
$6,614.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,960.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,606.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,051.32
|
| Rate for Payer: Quartz Commercial |
$5,374.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,960.80
|
| Rate for Payer: The Alliance Commercial |
$4,134.00
|
| Rate for Payer: WEA Trust Commercial |
$4,547.40
|
| Rate for Payer: WPS Commercial |
$6,123.89
|
|
|
WRIST ARTHROSCOPY
|
Facility
|
IP
|
$7,950.00
|
|
| Hospital Charge Code |
2959831
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,051.32 |
| Max. Negotiated Rate |
$7,606.56 |
| Rate for Payer: Aetna Commercial |
$7,441.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,110.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,382.04
|
| Rate for Payer: Cash Price |
$2,385.00
|
| Rate for Payer: Cigna Commercial |
$7,606.56
|
| Rate for Payer: Health EOS Commercial |
$7,358.52
|
| Rate for Payer: HFN Commercial |
$7,606.56
|
| Rate for Payer: Multiplan Commercial |
$6,614.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,606.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,051.32
|
| Rate for Payer: Quartz Commercial |
$4,960.80
|
| Rate for Payer: WEA Trust Commercial |
$4,547.40
|
| Rate for Payer: WPS Commercial |
$6,123.89
|
|
