|
Matrix Metalloproteinase-9 (MMP-9)
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5242625
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$228.16 |
| Rate for Payer: Aetna Commercial |
$223.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Aetna Managed Medicare |
$17.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.67
|
| Rate for Payer: Anthem Medicaid |
$17.85
|
| Rate for Payer: Anthem Medicare Advantage |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.27
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$228.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$138.78
|
| Rate for Payer: Dean Health Medicaid |
$17.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.27
|
| Rate for Payer: Health EOS Commercial |
$220.72
|
| Rate for Payer: HFN Commercial |
$228.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.27
|
| Rate for Payer: Managed Health Services Medicaid |
$18.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.27
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: NAPHCARE Commercial |
$25.90
|
| Rate for Payer: Preferred Network Access Commercial |
$228.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.85
|
| Rate for Payer: Quartz Beloit One Network |
$121.52
|
| Rate for Payer: Quartz Commercial |
$161.20
|
| Rate for Payer: Quartz Medicare Advantage |
$17.27
|
| Rate for Payer: The Alliance Commercial |
$69.08
|
| Rate for Payer: United Healthcare Medicaid |
$17.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.27
|
| Rate for Payer: United Healthcare PPO |
$186.00
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: Wellcare Medicare |
$17.27
|
| Rate for Payer: WMAP Medicaid |
$17.85
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
MATRIX OASIS R ULTRA TRI-LAYER 3X3.5CM PAD (10.5 SQ CM) 8213-0000-16
|
Facility
|
OP
|
$2,098.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5240619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.86 |
| Max. Negotiated Rate |
$8,392.00 |
| Rate for Payer: Aetna Commercial |
$1,888.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,804.28
|
| Rate for Payer: Aetna Managed Medicare |
$587.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,363.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,049.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,007.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,111.94
|
| Rate for Payer: Cash Price |
$629.40
|
| Rate for Payer: Cash Price |
$629.40
|
| Rate for Payer: Cigna Commercial |
$1,930.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.86
|
| Rate for Payer: Health EOS Commercial |
$1,867.22
|
| Rate for Payer: HFN Commercial |
$1,930.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,573.50
|
| Rate for Payer: Multiplan Commercial |
$1,678.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,258.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,930.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,028.02
|
| Rate for Payer: Quartz Commercial |
$1,363.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,258.80
|
| Rate for Payer: The Alliance Commercial |
$8,392.00
|
| Rate for Payer: WEA Trust Commercial |
$1,153.90
|
| Rate for Payer: WPS Commercial |
$22.42
|
|
|
MATRIX OASIS R ULTRA TRI-LAYER 3X3.5CM PAD (10.5 SQ CM) 8213-0000-16
|
Facility
|
IP
|
$2,098.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5240619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,028.02 |
| Max. Negotiated Rate |
$1,930.16 |
| Rate for Payer: Aetna Commercial |
$1,888.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,804.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,111.94
|
| Rate for Payer: Cash Price |
$629.40
|
| Rate for Payer: Cigna Commercial |
$1,930.16
|
| Rate for Payer: Health EOS Commercial |
$1,867.22
|
| Rate for Payer: HFN Commercial |
$1,930.16
|
| Rate for Payer: Multiplan Commercial |
$1,678.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,258.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,930.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,028.02
|
| Rate for Payer: Quartz Commercial |
$1,258.80
|
| Rate for Payer: WEA Trust Commercial |
$1,153.90
|
| Rate for Payer: WPS Commercial |
$1,553.99
|
|
|
MATRIX OASIS R ULTRA TRI-LAYER 3X7CM (21 SQ CM) PAD 8213-0000-18
|
Facility
|
OP
|
$3,016.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5240620
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.86 |
| Max. Negotiated Rate |
$12,064.00 |
| Rate for Payer: Aetna Commercial |
$2,714.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,593.76
|
| Rate for Payer: Aetna Managed Medicare |
$844.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,960.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,508.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,447.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,598.48
|
| Rate for Payer: Cash Price |
$904.80
|
| Rate for Payer: Cash Price |
$904.80
|
| Rate for Payer: Cigna Commercial |
$2,774.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.86
|
| Rate for Payer: Health EOS Commercial |
$2,684.24
|
| Rate for Payer: HFN Commercial |
$2,774.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,262.00
|
| Rate for Payer: Multiplan Commercial |
$2,412.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,809.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,774.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,477.84
|
| Rate for Payer: Quartz Commercial |
$1,960.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,809.60
|
| Rate for Payer: The Alliance Commercial |
$12,064.00
|
| Rate for Payer: WEA Trust Commercial |
$1,658.80
|
| Rate for Payer: WPS Commercial |
$22.42
|
|
|
MATRIX OASIS R ULTRA TRI-LAYER 3X7CM (21 SQ CM) PAD 8213-0000-18
|
Facility
|
IP
|
$3,016.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5240620
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,477.84 |
| Max. Negotiated Rate |
$2,774.72 |
| Rate for Payer: Aetna Commercial |
$2,714.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,593.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,598.48
|
| Rate for Payer: Cash Price |
$904.80
|
| Rate for Payer: Cigna Commercial |
$2,774.72
|
| Rate for Payer: Health EOS Commercial |
$2,684.24
|
| Rate for Payer: HFN Commercial |
$2,774.72
|
| Rate for Payer: Multiplan Commercial |
$2,412.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,809.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,774.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,477.84
|
| Rate for Payer: Quartz Commercial |
$1,809.60
|
| Rate for Payer: WEA Trust Commercial |
$1,658.80
|
| Rate for Payer: WPS Commercial |
$2,233.95
|
|
|
MATRIX OASIS R ULTRA TRI-LAYER 5X7CM PAD (35 SQ CM) 8213-0000-13
|
Facility
|
IP
|
$3,189.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5240621
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,562.61 |
| Max. Negotiated Rate |
$2,933.88 |
| Rate for Payer: Aetna Commercial |
$2,870.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,742.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,690.17
|
| Rate for Payer: Cash Price |
$956.70
|
| Rate for Payer: Cigna Commercial |
$2,933.88
|
| Rate for Payer: Health EOS Commercial |
$2,838.21
|
| Rate for Payer: HFN Commercial |
$2,933.88
|
| Rate for Payer: Multiplan Commercial |
$2,551.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,913.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,933.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,562.61
|
| Rate for Payer: Quartz Commercial |
$1,913.40
|
| Rate for Payer: WEA Trust Commercial |
$1,753.95
|
| Rate for Payer: WPS Commercial |
$2,362.09
|
|
|
MATRIX OASIS R ULTRA TRI-LAYER 5X7CM PAD (35 SQ CM) 8213-0000-13
|
Facility
|
OP
|
$3,189.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5240621
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.86 |
| Max. Negotiated Rate |
$12,756.00 |
| Rate for Payer: Aetna Commercial |
$2,870.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,742.54
|
| Rate for Payer: Aetna Managed Medicare |
$892.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,072.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,594.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,530.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,690.17
|
| Rate for Payer: Cash Price |
$956.70
|
| Rate for Payer: Cash Price |
$956.70
|
| Rate for Payer: Cigna Commercial |
$2,933.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.86
|
| Rate for Payer: Health EOS Commercial |
$2,838.21
|
| Rate for Payer: HFN Commercial |
$2,933.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,391.75
|
| Rate for Payer: Multiplan Commercial |
$2,551.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,913.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,933.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,562.61
|
| Rate for Payer: Quartz Commercial |
$2,072.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,913.40
|
| Rate for Payer: The Alliance Commercial |
$12,756.00
|
| Rate for Payer: WEA Trust Commercial |
$1,753.95
|
| Rate for Payer: WPS Commercial |
$22.42
|
|
|
MATRIX OASIS R ULTRA TRI-LAYER 7X10CM PAD (70 SQ CM) 8213-0000-09
|
Facility
|
OP
|
$6,378.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5240622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.86 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Aetna Commercial |
$5,740.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,485.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,785.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,145.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,189.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,061.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,380.34
|
| Rate for Payer: Cash Price |
$1,913.40
|
| Rate for Payer: Cash Price |
$1,913.40
|
| Rate for Payer: Cigna Commercial |
$5,867.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.86
|
| Rate for Payer: Health EOS Commercial |
$5,676.42
|
| Rate for Payer: HFN Commercial |
$5,867.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,783.50
|
| Rate for Payer: Multiplan Commercial |
$5,102.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,826.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,867.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,125.22
|
| Rate for Payer: Quartz Commercial |
$4,145.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,826.80
|
| Rate for Payer: The Alliance Commercial |
$25,512.00
|
| Rate for Payer: WEA Trust Commercial |
$3,507.90
|
| Rate for Payer: WPS Commercial |
$22.42
|
|
|
MATRIX OASIS R ULTRA TRI-LAYER 7X10CM PAD (70 SQ CM) 8213-0000-09
|
Facility
|
IP
|
$6,378.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5240622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,125.22 |
| Max. Negotiated Rate |
$5,867.76 |
| Rate for Payer: Aetna Commercial |
$5,740.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,485.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,380.34
|
| Rate for Payer: Cash Price |
$1,913.40
|
| Rate for Payer: Cigna Commercial |
$5,867.76
|
| Rate for Payer: Health EOS Commercial |
$5,676.42
|
| Rate for Payer: HFN Commercial |
$5,867.76
|
| Rate for Payer: Multiplan Commercial |
$5,102.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,826.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,867.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,125.22
|
| Rate for Payer: Quartz Commercial |
$3,826.80
|
| Rate for Payer: WEA Trust Commercial |
$3,507.90
|
| Rate for Payer: WPS Commercial |
$4,724.18
|
|
|
MATRIX OASIS R ULTRA TRI-LAYER 7X20CM PAD (140 SQ CM) 8213-0000-11
|
Facility
|
OP
|
$9,112.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5240623
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.86 |
| Max. Negotiated Rate |
$36,448.00 |
| Rate for Payer: Aetna Commercial |
$8,200.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,836.32
|
| Rate for Payer: Aetna Managed Medicare |
$2,551.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,922.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,556.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,373.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,829.36
|
| Rate for Payer: Cash Price |
$2,733.60
|
| Rate for Payer: Cash Price |
$2,733.60
|
| Rate for Payer: Cigna Commercial |
$8,383.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.86
|
| Rate for Payer: Health EOS Commercial |
$8,109.68
|
| Rate for Payer: HFN Commercial |
$8,383.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,834.00
|
| Rate for Payer: Multiplan Commercial |
$7,289.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,467.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,383.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,464.88
|
| Rate for Payer: Quartz Commercial |
$5,922.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,467.20
|
| Rate for Payer: The Alliance Commercial |
$36,448.00
|
| Rate for Payer: WEA Trust Commercial |
$5,011.60
|
| Rate for Payer: WPS Commercial |
$22.42
|
|
|
MATRIX OASIS R ULTRA TRI-LAYER 7X20CM PAD (140 SQ CM) 8213-0000-11
|
Facility
|
IP
|
$9,112.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5240623
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,464.88 |
| Max. Negotiated Rate |
$8,383.04 |
| Rate for Payer: Aetna Commercial |
$8,200.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,836.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,829.36
|
| Rate for Payer: Cash Price |
$2,733.60
|
| Rate for Payer: Cigna Commercial |
$8,383.04
|
| Rate for Payer: Health EOS Commercial |
$8,109.68
|
| Rate for Payer: HFN Commercial |
$8,383.04
|
| Rate for Payer: Multiplan Commercial |
$7,289.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,467.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,383.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,464.88
|
| Rate for Payer: Quartz Commercial |
$5,467.20
|
| Rate for Payer: WEA Trust Commercial |
$5,011.60
|
| Rate for Payer: WPS Commercial |
$6,749.26
|
|
|
MATRIX OMNIGRAFT DERMAL 2.5CM X 2.5CM DFU25251S
|
Facility
|
OP
|
$1,069.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5240757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$32.54 |
| Max. Negotiated Rate |
$4,276.00 |
| Rate for Payer: Aetna Commercial |
$962.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$919.34
|
| Rate for Payer: Aetna Managed Medicare |
$299.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$694.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$534.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$513.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$566.57
|
| Rate for Payer: Cash Price |
$320.70
|
| Rate for Payer: Cash Price |
$320.70
|
| Rate for Payer: Cigna Commercial |
$983.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.54
|
| Rate for Payer: Health EOS Commercial |
$951.41
|
| Rate for Payer: HFN Commercial |
$983.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$801.75
|
| Rate for Payer: Multiplan Commercial |
$855.20
|
| Rate for Payer: NAPHCARE Commercial |
$641.40
|
| Rate for Payer: Preferred Network Access Commercial |
$983.48
|
| Rate for Payer: Quartz Beloit One Network |
$523.81
|
| Rate for Payer: Quartz Commercial |
$694.85
|
| Rate for Payer: Quartz Medicare Advantage |
$641.40
|
| Rate for Payer: The Alliance Commercial |
$4,276.00
|
| Rate for Payer: WEA Trust Commercial |
$587.95
|
| Rate for Payer: WPS Commercial |
$791.81
|
|
|
MATRIX OMNIGRAFT DERMAL 2.5CM X 2.5CM DFU25251S
|
Facility
|
IP
|
$1,069.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5240757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$523.81 |
| Max. Negotiated Rate |
$983.48 |
| Rate for Payer: Aetna Commercial |
$962.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$919.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$566.57
|
| Rate for Payer: Cash Price |
$320.70
|
| Rate for Payer: Cigna Commercial |
$983.48
|
| Rate for Payer: Health EOS Commercial |
$951.41
|
| Rate for Payer: HFN Commercial |
$983.48
|
| Rate for Payer: Multiplan Commercial |
$855.20
|
| Rate for Payer: NAPHCARE Commercial |
$641.40
|
| Rate for Payer: Preferred Network Access Commercial |
$983.48
|
| Rate for Payer: Quartz Beloit One Network |
$523.81
|
| Rate for Payer: Quartz Commercial |
$641.40
|
| Rate for Payer: WEA Trust Commercial |
$587.95
|
| Rate for Payer: WPS Commercial |
$791.81
|
|
|
MATRIX OMNIGRAFT DERMAL 4CM X 4CM DFU4041S
|
Facility
|
IP
|
$459.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5240758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$224.91 |
| Max. Negotiated Rate |
$422.28 |
| Rate for Payer: Aetna Commercial |
$413.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$394.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.27
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$422.28
|
| Rate for Payer: Health EOS Commercial |
$408.51
|
| Rate for Payer: HFN Commercial |
$422.28
|
| Rate for Payer: Multiplan Commercial |
$367.20
|
| Rate for Payer: NAPHCARE Commercial |
$275.40
|
| Rate for Payer: Preferred Network Access Commercial |
$422.28
|
| Rate for Payer: Quartz Beloit One Network |
$224.91
|
| Rate for Payer: Quartz Commercial |
$275.40
|
| Rate for Payer: WEA Trust Commercial |
$252.45
|
| Rate for Payer: WPS Commercial |
$339.98
|
|
|
MATRIX OMNIGRAFT DERMAL 4CM X 4CM DFU4041S
|
Facility
|
OP
|
$459.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5240758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$32.54 |
| Max. Negotiated Rate |
$1,836.00 |
| Rate for Payer: Aetna Commercial |
$413.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$394.74
|
| Rate for Payer: Aetna Managed Medicare |
$128.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$298.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$229.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$220.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.27
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$422.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.54
|
| Rate for Payer: Health EOS Commercial |
$408.51
|
| Rate for Payer: HFN Commercial |
$422.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$344.25
|
| Rate for Payer: Multiplan Commercial |
$367.20
|
| Rate for Payer: NAPHCARE Commercial |
$275.40
|
| Rate for Payer: Preferred Network Access Commercial |
$422.28
|
| Rate for Payer: Quartz Beloit One Network |
$224.91
|
| Rate for Payer: Quartz Commercial |
$298.35
|
| Rate for Payer: Quartz Medicare Advantage |
$275.40
|
| Rate for Payer: The Alliance Commercial |
$1,836.00
|
| Rate for Payer: WEA Trust Commercial |
$252.45
|
| Rate for Payer: WPS Commercial |
$339.98
|
|
|
MATRIX OMNIGRAFT DERMAL 7CM X 7CM DFU7071S
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5240760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$32.54 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$270.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.00
|
| Rate for Payer: Aetna Managed Medicare |
$84.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$195.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$150.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$144.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$276.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.54
|
| Rate for Payer: Health EOS Commercial |
$267.00
|
| Rate for Payer: HFN Commercial |
$276.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$225.00
|
| Rate for Payer: Multiplan Commercial |
$240.00
|
| Rate for Payer: NAPHCARE Commercial |
$180.00
|
| Rate for Payer: Preferred Network Access Commercial |
$276.00
|
| Rate for Payer: Quartz Beloit One Network |
$147.00
|
| Rate for Payer: Quartz Commercial |
$195.00
|
| Rate for Payer: Quartz Medicare Advantage |
$180.00
|
| Rate for Payer: The Alliance Commercial |
$1,200.00
|
| Rate for Payer: WEA Trust Commercial |
$165.00
|
| Rate for Payer: WPS Commercial |
$222.21
|
|
|
MATRIX OMNIGRAFT DERMAL 7CM X 7CM DFU7071S
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5240760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$147.00 |
| Max. Negotiated Rate |
$276.00 |
| Rate for Payer: Aetna Commercial |
$270.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$276.00
|
| Rate for Payer: Health EOS Commercial |
$267.00
|
| Rate for Payer: HFN Commercial |
$276.00
|
| Rate for Payer: Multiplan Commercial |
$240.00
|
| Rate for Payer: NAPHCARE Commercial |
$180.00
|
| Rate for Payer: Preferred Network Access Commercial |
$276.00
|
| Rate for Payer: Quartz Beloit One Network |
$147.00
|
| Rate for Payer: Quartz Commercial |
$180.00
|
| Rate for Payer: WEA Trust Commercial |
$165.00
|
| Rate for Payer: WPS Commercial |
$222.21
|
|
|
Matrix Omnigraft Dermal Q4105
|
Facility
|
IP
|
$322.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5246741
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$157.78 |
| Max. Negotiated Rate |
$296.24 |
| Rate for Payer: Aetna Commercial |
$289.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.66
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$296.24
|
| Rate for Payer: Health EOS Commercial |
$286.58
|
| Rate for Payer: HFN Commercial |
$296.24
|
| Rate for Payer: Multiplan Commercial |
$257.60
|
| Rate for Payer: NAPHCARE Commercial |
$193.20
|
| Rate for Payer: Preferred Network Access Commercial |
$296.24
|
| Rate for Payer: Quartz Beloit One Network |
$157.78
|
| Rate for Payer: Quartz Commercial |
$193.20
|
| Rate for Payer: WEA Trust Commercial |
$177.10
|
| Rate for Payer: WPS Commercial |
$238.51
|
|
|
Matrix Omnigraft Dermal Q4105
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5246741
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.54 |
| Max. Negotiated Rate |
$1,288.00 |
| Rate for Payer: Aetna Commercial |
$289.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.92
|
| Rate for Payer: Aetna Managed Medicare |
$90.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$209.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$161.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.66
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$296.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.54
|
| Rate for Payer: Health EOS Commercial |
$286.58
|
| Rate for Payer: HFN Commercial |
$296.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$241.50
|
| Rate for Payer: Multiplan Commercial |
$257.60
|
| Rate for Payer: NAPHCARE Commercial |
$193.20
|
| Rate for Payer: Preferred Network Access Commercial |
$296.24
|
| Rate for Payer: Quartz Beloit One Network |
$157.78
|
| Rate for Payer: Quartz Commercial |
$209.30
|
| Rate for Payer: Quartz Medicare Advantage |
$193.20
|
| Rate for Payer: The Alliance Commercial |
$1,288.00
|
| Rate for Payer: WEA Trust Commercial |
$177.10
|
| Rate for Payer: WPS Commercial |
$61.50
|
|
|
Matrix Omnigraft Dermal Q4105
|
Professional
|
Both
|
$322.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5246741
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.60 |
| Max. Negotiated Rate |
$305.90 |
| Rate for Payer: Aetna Commercial |
$305.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.92
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$305.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$161.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.60
|
| Rate for Payer: Health EOS Commercial |
$293.02
|
| Rate for Payer: HFN Commercial |
$305.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$122.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$122.99
|
| Rate for Payer: Multiplan Commercial |
$257.60
|
| Rate for Payer: Preferred Network Access Commercial |
$305.90
|
| Rate for Payer: Quartz Beloit One Network |
$141.68
|
| Rate for Payer: Quartz Commercial |
$183.54
|
| Rate for Payer: The Alliance Commercial |
$161.00
|
| Rate for Payer: WEA Trust Commercial |
$177.10
|
| Rate for Payer: WPS Commercial |
$61.50
|
|
|
MATRIX WOUND OASIS R FENESTRATED 3X3.5CM PAD (10.5 SQ CM) 8213-1000-33
|
Facility
|
IP
|
$1,499.00
|
|
|
Service Code
|
HCPCS Q4102
|
| Hospital Charge Code |
5240617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$734.51 |
| Max. Negotiated Rate |
$1,379.08 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$794.47
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,379.08
|
| Rate for Payer: Health EOS Commercial |
$1,334.11
|
| Rate for Payer: HFN Commercial |
$1,379.08
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: NAPHCARE Commercial |
$899.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,379.08
|
| Rate for Payer: Quartz Beloit One Network |
$734.51
|
| Rate for Payer: Quartz Commercial |
$899.40
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
MATRIX WOUND OASIS R FENESTRATED 3X3.5CM PAD (10.5 SQ CM) 8213-1000-33
|
Facility
|
OP
|
$1,499.00
|
|
|
Service Code
|
HCPCS Q4102
|
| Hospital Charge Code |
5240617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.43 |
| Max. Negotiated Rate |
$5,996.00 |
| Rate for Payer: Aetna Commercial |
$1,349.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Aetna Managed Medicare |
$419.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$974.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$749.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$719.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$794.47
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,379.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.43
|
| Rate for Payer: Health EOS Commercial |
$1,334.11
|
| Rate for Payer: HFN Commercial |
$1,379.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,124.25
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: NAPHCARE Commercial |
$899.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,379.08
|
| Rate for Payer: Quartz Beloit One Network |
$734.51
|
| Rate for Payer: Quartz Commercial |
$974.35
|
| Rate for Payer: Quartz Medicare Advantage |
$899.40
|
| Rate for Payer: The Alliance Commercial |
$5,996.00
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: WPS Commercial |
$31.04
|
|
|
MATRIX WOUND OASIS R FENESTRATED 3X7CM PAD (21 SQ CM) 8213-1000-37
|
Facility
|
IP
|
$2,395.00
|
|
|
Service Code
|
HCPCS Q4102
|
| Hospital Charge Code |
5240618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,173.55 |
| Max. Negotiated Rate |
$2,203.40 |
| Rate for Payer: Aetna Commercial |
$2,155.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,059.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,269.35
|
| Rate for Payer: Cash Price |
$718.50
|
| Rate for Payer: Cigna Commercial |
$2,203.40
|
| Rate for Payer: Health EOS Commercial |
$2,131.55
|
| Rate for Payer: HFN Commercial |
$2,203.40
|
| Rate for Payer: Multiplan Commercial |
$1,916.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,437.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,203.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.55
|
| Rate for Payer: Quartz Commercial |
$1,437.00
|
| Rate for Payer: WEA Trust Commercial |
$1,317.25
|
| Rate for Payer: WPS Commercial |
$1,773.98
|
|
|
MATRIX WOUND OASIS R FENESTRATED 3X7CM PAD (21 SQ CM) 8213-1000-37
|
Facility
|
OP
|
$2,395.00
|
|
|
Service Code
|
HCPCS Q4102
|
| Hospital Charge Code |
5240618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.43 |
| Max. Negotiated Rate |
$9,580.00 |
| Rate for Payer: Aetna Commercial |
$2,155.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,059.70
|
| Rate for Payer: Aetna Managed Medicare |
$670.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,556.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,197.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,149.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,269.35
|
| Rate for Payer: Cash Price |
$718.50
|
| Rate for Payer: Cash Price |
$718.50
|
| Rate for Payer: Cigna Commercial |
$2,203.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.43
|
| Rate for Payer: Health EOS Commercial |
$2,131.55
|
| Rate for Payer: HFN Commercial |
$2,203.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,796.25
|
| Rate for Payer: Multiplan Commercial |
$1,916.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,437.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,203.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.55
|
| Rate for Payer: Quartz Commercial |
$1,556.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,437.00
|
| Rate for Payer: The Alliance Commercial |
$9,580.00
|
| Rate for Payer: WEA Trust Commercial |
$1,317.25
|
| Rate for Payer: WPS Commercial |
$31.04
|
|
|
Maverick 2.0 mm x 15mm
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159028
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
