|
WRIST BONE GRAFTING
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2959868
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,125.03 |
| Max. Negotiated Rate |
$3,989.86 |
| Rate for Payer: Aetna Commercial |
$3,903.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,729.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.50
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,989.86
|
| Rate for Payer: Health EOS Commercial |
$3,859.75
|
| Rate for Payer: HFN Commercial |
$3,989.86
|
| Rate for Payer: Multiplan Commercial |
$3,469.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.03
|
| Rate for Payer: Quartz Commercial |
$2,602.08
|
| Rate for Payer: WEA Trust Commercial |
$2,385.24
|
| Rate for Payer: WPS Commercial |
$3,212.15
|
|
|
WRIST BONE GRAFTING
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2959868
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,214.30 |
| Max. Negotiated Rate |
$3,989.86 |
| Rate for Payer: Aetna Commercial |
$3,903.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,729.65
|
| Rate for Payer: Aetna Managed Medicare |
$1,214.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,818.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,168.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,081.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.50
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,989.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,426.94
|
| Rate for Payer: Health EOS Commercial |
$3,859.75
|
| Rate for Payer: HFN Commercial |
$3,989.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,252.60
|
| Rate for Payer: Multiplan Commercial |
$3,469.44
|
| Rate for Payer: NAPHCARE Commercial |
$2,602.08
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.03
|
| Rate for Payer: Quartz Commercial |
$2,818.92
|
| Rate for Payer: Quartz Medicare Advantage |
$2,602.08
|
| Rate for Payer: The Alliance Commercial |
$2,168.40
|
| Rate for Payer: WEA Trust Commercial |
$2,385.24
|
| Rate for Payer: WPS Commercial |
$3,212.15
|
|
|
WRIST BRACE AMBIDEXTROUS XL 55984004
|
Facility
|
OP
|
$332.00
|
|
| Hospital Charge Code |
2970944
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$96.68 |
| Max. Negotiated Rate |
$317.66 |
| Rate for Payer: Aetna Commercial |
$310.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Aetna Managed Medicare |
$96.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$224.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$172.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$165.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$183.00
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$317.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.22
|
| Rate for Payer: Health EOS Commercial |
$307.30
|
| Rate for Payer: HFN Commercial |
$317.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$258.96
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: NAPHCARE Commercial |
$207.17
|
| Rate for Payer: Preferred Network Access Commercial |
$317.66
|
| Rate for Payer: Quartz Beloit One Network |
$169.19
|
| Rate for Payer: Quartz Commercial |
$224.43
|
| Rate for Payer: Quartz Medicare Advantage |
$207.17
|
| Rate for Payer: The Alliance Commercial |
$172.64
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: WPS Commercial |
$255.74
|
|
|
WRIST BRACE AMBIDEXTROUS XL 55984004
|
Facility
|
IP
|
$332.00
|
|
| Hospital Charge Code |
2970944
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$169.19 |
| Max. Negotiated Rate |
$317.66 |
| Rate for Payer: Aetna Commercial |
$310.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$183.00
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$317.66
|
| Rate for Payer: Health EOS Commercial |
$307.30
|
| Rate for Payer: HFN Commercial |
$317.66
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: Preferred Network Access Commercial |
$317.66
|
| Rate for Payer: Quartz Beloit One Network |
$169.19
|
| Rate for Payer: Quartz Commercial |
$207.17
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: WPS Commercial |
$255.74
|
|
|
WRIST BRACE RIGHT TITAN 450-RT #5547-67-02
|
Facility
|
IP
|
$360.00
|
|
| Hospital Charge Code |
2969685
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$183.46 |
| Max. Negotiated Rate |
$344.45 |
| Rate for Payer: Aetna Commercial |
$336.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.43
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: Health EOS Commercial |
$333.22
|
| Rate for Payer: HFN Commercial |
$344.45
|
| Rate for Payer: Multiplan Commercial |
$299.52
|
| Rate for Payer: Preferred Network Access Commercial |
$344.45
|
| Rate for Payer: Quartz Beloit One Network |
$183.46
|
| Rate for Payer: Quartz Commercial |
$224.64
|
| Rate for Payer: WEA Trust Commercial |
$205.92
|
| Rate for Payer: WPS Commercial |
$277.31
|
|
|
WRIST BRACE RIGHT TITAN 450-RT #5547-67-02
|
Facility
|
OP
|
$360.00
|
|
| Hospital Charge Code |
2969685
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$104.83 |
| Max. Negotiated Rate |
$344.45 |
| Rate for Payer: Aetna Commercial |
$336.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.98
|
| Rate for Payer: Aetna Managed Medicare |
$104.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$243.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$187.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$179.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.43
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$209.52
|
| Rate for Payer: Health EOS Commercial |
$333.22
|
| Rate for Payer: HFN Commercial |
$344.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$280.80
|
| Rate for Payer: Multiplan Commercial |
$299.52
|
| Rate for Payer: NAPHCARE Commercial |
$224.64
|
| Rate for Payer: Preferred Network Access Commercial |
$344.45
|
| Rate for Payer: Quartz Beloit One Network |
$183.46
|
| Rate for Payer: Quartz Commercial |
$243.36
|
| Rate for Payer: Quartz Medicare Advantage |
$224.64
|
| Rate for Payer: The Alliance Commercial |
$187.20
|
| Rate for Payer: WEA Trust Commercial |
$205.92
|
| Rate for Payer: WPS Commercial |
$277.31
|
|
|
WRIST, EXTERNAL FIXATOR
|
Facility
|
OP
|
$5,453.00
|
|
| Hospital Charge Code |
2960041
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,587.91 |
| Max. Negotiated Rate |
$5,217.43 |
| Rate for Payer: Aetna Commercial |
$5,104.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,877.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,587.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,686.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,835.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,722.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,005.69
|
| Rate for Payer: Cash Price |
$1,635.90
|
| Rate for Payer: Cigna Commercial |
$5,217.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,173.65
|
| Rate for Payer: Health EOS Commercial |
$5,047.30
|
| Rate for Payer: HFN Commercial |
$5,217.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,253.34
|
| Rate for Payer: Multiplan Commercial |
$4,536.90
|
| Rate for Payer: NAPHCARE Commercial |
$3,402.67
|
| Rate for Payer: Preferred Network Access Commercial |
$5,217.43
|
| Rate for Payer: Quartz Beloit One Network |
$2,778.85
|
| Rate for Payer: Quartz Commercial |
$3,686.23
|
| Rate for Payer: Quartz Medicare Advantage |
$3,402.67
|
| Rate for Payer: The Alliance Commercial |
$2,835.56
|
| Rate for Payer: WEA Trust Commercial |
$3,119.12
|
| Rate for Payer: WPS Commercial |
$4,200.45
|
|
|
WRIST, EXTERNAL FIXATOR
|
Facility
|
IP
|
$5,453.00
|
|
| Hospital Charge Code |
2960041
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,778.85 |
| Max. Negotiated Rate |
$5,217.43 |
| Rate for Payer: Aetna Commercial |
$5,104.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,877.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,005.69
|
| Rate for Payer: Cash Price |
$1,635.90
|
| Rate for Payer: Cigna Commercial |
$5,217.43
|
| Rate for Payer: Health EOS Commercial |
$5,047.30
|
| Rate for Payer: HFN Commercial |
$5,217.43
|
| Rate for Payer: Multiplan Commercial |
$4,536.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,217.43
|
| Rate for Payer: Quartz Beloit One Network |
$2,778.85
|
| Rate for Payer: Quartz Commercial |
$3,402.67
|
| Rate for Payer: WEA Trust Commercial |
$3,119.12
|
| Rate for Payer: WPS Commercial |
$4,200.45
|
|
|
WRIST KIT MONOTUBE TRIAX 5150-9-960
|
Facility
|
IP
|
$8,101.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519002
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,128.27 |
| Max. Negotiated Rate |
$7,751.04 |
| Rate for Payer: Aetna Commercial |
$7,582.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,245.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,465.27
|
| Rate for Payer: Cash Price |
$2,430.30
|
| Rate for Payer: Cigna Commercial |
$7,751.04
|
| Rate for Payer: Health EOS Commercial |
$7,498.29
|
| Rate for Payer: HFN Commercial |
$7,751.04
|
| Rate for Payer: Multiplan Commercial |
$6,740.03
|
| Rate for Payer: Preferred Network Access Commercial |
$7,751.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,128.27
|
| Rate for Payer: Quartz Commercial |
$5,055.02
|
| Rate for Payer: WEA Trust Commercial |
$4,633.77
|
| Rate for Payer: WPS Commercial |
$6,240.20
|
|
|
WRIST KIT MONOTUBE TRIAX 5150-9-960
|
Facility
|
OP
|
$8,101.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519002
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.01 |
| Max. Negotiated Rate |
$7,751.04 |
| Rate for Payer: Aetna Commercial |
$7,582.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,245.53
|
| Rate for Payer: Aetna Managed Medicare |
$2,359.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,476.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,212.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,044.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,465.27
|
| Rate for Payer: Cash Price |
$2,430.30
|
| Rate for Payer: Cigna Commercial |
$7,751.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,714.78
|
| Rate for Payer: Health EOS Commercial |
$7,498.29
|
| Rate for Payer: HFN Commercial |
$7,751.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,318.78
|
| Rate for Payer: Multiplan Commercial |
$6,740.03
|
| Rate for Payer: NAPHCARE Commercial |
$5,055.02
|
| Rate for Payer: Preferred Network Access Commercial |
$7,751.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,128.27
|
| Rate for Payer: Quartz Commercial |
$5,476.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5,055.02
|
| Rate for Payer: The Alliance Commercial |
$4,212.52
|
| Rate for Payer: WEA Trust Commercial |
$4,633.77
|
| Rate for Payer: WPS Commercial |
$6,240.20
|
|
|
WRIST SPLINT 8 XS LT **USE DMECON1081
|
Facility
|
IP
|
$253.00
|
|
| Hospital Charge Code |
2974323
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.93 |
| Max. Negotiated Rate |
$242.07 |
| Rate for Payer: Aetna Commercial |
$236.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$226.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$139.45
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$242.07
|
| Rate for Payer: Health EOS Commercial |
$234.18
|
| Rate for Payer: HFN Commercial |
$242.07
|
| Rate for Payer: Multiplan Commercial |
$210.50
|
| Rate for Payer: Preferred Network Access Commercial |
$242.07
|
| Rate for Payer: Quartz Beloit One Network |
$128.93
|
| Rate for Payer: Quartz Commercial |
$157.87
|
| Rate for Payer: WEA Trust Commercial |
$144.72
|
| Rate for Payer: WPS Commercial |
$194.89
|
|
|
WRIST SPLINT 8 XS LT **USE DMECON1081
|
Facility
|
OP
|
$253.00
|
|
| Hospital Charge Code |
2974323
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$73.67 |
| Max. Negotiated Rate |
$242.07 |
| Rate for Payer: Aetna Commercial |
$236.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$226.28
|
| Rate for Payer: Aetna Managed Medicare |
$73.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$171.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$131.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$126.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$139.45
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$242.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.25
|
| Rate for Payer: Health EOS Commercial |
$234.18
|
| Rate for Payer: HFN Commercial |
$242.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$197.34
|
| Rate for Payer: Multiplan Commercial |
$210.50
|
| Rate for Payer: NAPHCARE Commercial |
$157.87
|
| Rate for Payer: Preferred Network Access Commercial |
$242.07
|
| Rate for Payer: Quartz Beloit One Network |
$128.93
|
| Rate for Payer: Quartz Commercial |
$171.03
|
| Rate for Payer: Quartz Medicare Advantage |
$157.87
|
| Rate for Payer: The Alliance Commercial |
$131.56
|
| Rate for Payer: WEA Trust Commercial |
$144.72
|
| Rate for Payer: WPS Commercial |
$194.89
|
|
|
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
|
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, 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 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
|
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
|
|
|
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
|
|
|
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 |
$81.43 |
| 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 |
$81.43
|
| 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 |
$81.43
|
| 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 |
$81.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$81.43
|
| 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 |
$81.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$81.43
|
| 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 |
$302.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$81.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$81.43
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$81.43
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$81.43
|
| Rate for Payer: Multiplan Commercial |
$8,989.76
|
| Rate for Payer: NAPHCARE Commercial |
$122.15
|
| 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 |
$81.43
|
| Rate for Payer: The Alliance Commercial |
$325.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$81.43
|
| Rate for Payer: WEA Trust Commercial |
$6,180.46
|
| Rate for Payer: Wellcare Medicare |
$81.43
|
| 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 |
$81.43
|
| Rate for Payer: Anthem Medicare Advantage |
$81.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$81.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$81.43
|
| 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 |
$81.43
|
| Rate for Payer: Multiplan Commercial |
$8,989.76
|
| Rate for Payer: NAPHCARE Commercial |
$122.15
|
| 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 |
$81.43
|
| Rate for Payer: The Alliance Commercial |
$223.94
|
| Rate for Payer: United Healthcare Medicaid |
$78.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$81.43
|
| Rate for Payer: WEA Trust Commercial |
$6,180.46
|
| Rate for Payer: WPS Commercial |
$179.32
|
|
|
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
|
|
