|
Matrix Metalloproteinase-9 (MMP-9)
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5242625
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$237.29 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$167.65
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$193.44
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
|
Matrix Metalloproteinase-9 (MMP-9)
|
Professional
|
Both
|
$248.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5242625
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$245.02 |
| Rate for Payer: Aetna Commercial |
$245.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$245.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$128.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$234.71
|
| Rate for Payer: HFN Commercial |
$245.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$245.02
|
| Rate for Payer: Quartz Beloit One Network |
$113.48
|
| Rate for Payer: Quartz Commercial |
$147.01
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
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 |
$12.34 |
| Max. Negotiated Rate |
$2,007.37 |
| Rate for Payer: Aetna Commercial |
$1,963.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,876.45
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,418.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,090.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,047.32
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,156.42
|
| 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 |
$629.40
|
| Rate for Payer: Cash Price |
$629.40
|
| Rate for Payer: Cigna Commercial |
$2,007.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$1,941.91
|
| Rate for Payer: HFN Commercial |
$2,007.37
|
| 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 |
$1,745.54
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$2,007.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,069.14
|
| Rate for Payer: Quartz Commercial |
$1,418.25
|
| 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 |
$1,200.06
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$23.32
|
|
|
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 |
$1,069.14 |
| Max. Negotiated Rate |
$2,007.37 |
| Rate for Payer: Aetna Commercial |
$1,963.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,876.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,156.42
|
| Rate for Payer: Cash Price |
$629.40
|
| Rate for Payer: Cigna Commercial |
$2,007.37
|
| Rate for Payer: Health EOS Commercial |
$1,941.91
|
| Rate for Payer: HFN Commercial |
$2,007.37
|
| Rate for Payer: Multiplan Commercial |
$1,745.54
|
| Rate for Payer: Preferred Network Access Commercial |
$2,007.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,069.14
|
| Rate for Payer: Quartz Commercial |
$1,309.15
|
| Rate for Payer: WEA Trust Commercial |
$1,200.06
|
| Rate for Payer: WPS Commercial |
$1,616.09
|
|
|
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 |
$1,536.95 |
| Max. Negotiated Rate |
$2,885.71 |
| Rate for Payer: Aetna Commercial |
$2,822.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,697.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,662.42
|
| Rate for Payer: Cash Price |
$904.80
|
| Rate for Payer: Cigna Commercial |
$2,885.71
|
| Rate for Payer: Health EOS Commercial |
$2,791.61
|
| Rate for Payer: HFN Commercial |
$2,885.71
|
| Rate for Payer: Multiplan Commercial |
$2,509.31
|
| Rate for Payer: Preferred Network Access Commercial |
$2,885.71
|
| Rate for Payer: Quartz Beloit One Network |
$1,536.95
|
| Rate for Payer: Quartz Commercial |
$1,881.98
|
| Rate for Payer: WEA Trust Commercial |
$1,725.15
|
| Rate for Payer: WPS Commercial |
$2,323.22
|
|
|
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 |
$12.34 |
| Max. Negotiated Rate |
$2,885.71 |
| Rate for Payer: Aetna Commercial |
$2,822.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,697.51
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,038.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,568.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,505.59
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,662.42
|
| 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 |
$904.80
|
| Rate for Payer: Cash Price |
$904.80
|
| Rate for Payer: Cigna Commercial |
$2,885.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$2,791.61
|
| Rate for Payer: HFN Commercial |
$2,885.71
|
| 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 |
$2,509.31
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$2,885.71
|
| Rate for Payer: Quartz Beloit One Network |
$1,536.95
|
| Rate for Payer: Quartz Commercial |
$2,038.82
|
| 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 |
$1,725.15
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$23.32
|
|
|
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 |
$1,625.11 |
| Max. Negotiated Rate |
$3,051.24 |
| Rate for Payer: Aetna Commercial |
$2,984.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,852.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,757.78
|
| Rate for Payer: Cash Price |
$956.70
|
| Rate for Payer: Cigna Commercial |
$3,051.24
|
| Rate for Payer: Health EOS Commercial |
$2,951.74
|
| Rate for Payer: HFN Commercial |
$3,051.24
|
| Rate for Payer: Multiplan Commercial |
$2,653.25
|
| Rate for Payer: Preferred Network Access Commercial |
$3,051.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,625.11
|
| Rate for Payer: Quartz Commercial |
$1,989.94
|
| Rate for Payer: WEA Trust Commercial |
$1,824.11
|
| Rate for Payer: WPS Commercial |
$2,456.49
|
|
|
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 |
$12.34 |
| Max. Negotiated Rate |
$3,051.24 |
| Rate for Payer: Aetna Commercial |
$2,984.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,852.24
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,155.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,658.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,591.95
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,757.78
|
| 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 |
$956.70
|
| Rate for Payer: Cash Price |
$956.70
|
| Rate for Payer: Cigna Commercial |
$3,051.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$2,951.74
|
| Rate for Payer: HFN Commercial |
$3,051.24
|
| 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 |
$2,653.25
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$3,051.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,625.11
|
| Rate for Payer: Quartz Commercial |
$2,155.76
|
| 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 |
$1,824.11
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$23.32
|
|
|
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 |
$12.34 |
| Max. Negotiated Rate |
$6,102.47 |
| Rate for Payer: Aetna Commercial |
$5,969.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,704.48
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,311.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,316.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,183.90
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,515.55
|
| 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 |
$1,913.40
|
| Rate for Payer: Cash Price |
$1,913.40
|
| Rate for Payer: Cigna Commercial |
$6,102.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$5,903.48
|
| Rate for Payer: HFN Commercial |
$6,102.47
|
| 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 |
$5,306.50
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$6,102.47
|
| Rate for Payer: Quartz Beloit One Network |
$3,250.23
|
| Rate for Payer: Quartz Commercial |
$4,311.53
|
| 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 |
$3,648.22
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$23.32
|
|
|
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 |
$3,250.23 |
| Max. Negotiated Rate |
$6,102.47 |
| Rate for Payer: Aetna Commercial |
$5,969.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,704.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,515.55
|
| Rate for Payer: Cash Price |
$1,913.40
|
| Rate for Payer: Cigna Commercial |
$6,102.47
|
| Rate for Payer: Health EOS Commercial |
$5,903.48
|
| Rate for Payer: HFN Commercial |
$6,102.47
|
| Rate for Payer: Multiplan Commercial |
$5,306.50
|
| Rate for Payer: Preferred Network Access Commercial |
$6,102.47
|
| Rate for Payer: Quartz Beloit One Network |
$3,250.23
|
| Rate for Payer: Quartz Commercial |
$3,979.87
|
| Rate for Payer: WEA Trust Commercial |
$3,648.22
|
| Rate for Payer: WPS Commercial |
$4,912.97
|
|
|
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 |
$4,643.48 |
| Max. Negotiated Rate |
$8,718.36 |
| Rate for Payer: Aetna Commercial |
$8,528.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,149.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,022.53
|
| Rate for Payer: Cash Price |
$2,733.60
|
| Rate for Payer: Cigna Commercial |
$8,718.36
|
| Rate for Payer: Health EOS Commercial |
$8,434.07
|
| Rate for Payer: HFN Commercial |
$8,718.36
|
| Rate for Payer: Multiplan Commercial |
$7,581.18
|
| Rate for Payer: Preferred Network Access Commercial |
$8,718.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,643.48
|
| Rate for Payer: Quartz Commercial |
$5,685.89
|
| Rate for Payer: WEA Trust Commercial |
$5,212.06
|
| Rate for Payer: WPS Commercial |
$7,018.97
|
|
|
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 |
$12.34 |
| Max. Negotiated Rate |
$8,718.36 |
| Rate for Payer: Aetna Commercial |
$8,528.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,149.77
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,159.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,738.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,548.71
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,022.53
|
| 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 |
$2,733.60
|
| Rate for Payer: Cash Price |
$2,733.60
|
| Rate for Payer: Cigna Commercial |
$8,718.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$8,434.07
|
| Rate for Payer: HFN Commercial |
$8,718.36
|
| 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 |
$7,581.18
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$8,718.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,643.48
|
| Rate for Payer: Quartz Commercial |
$6,159.71
|
| 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 |
$5,212.06
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$23.32
|
|
|
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 |
$33.85 |
| Max. Negotiated Rate |
$1,022.82 |
| Rate for Payer: Aetna Commercial |
$1,000.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$956.11
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$722.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$555.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$533.64
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$589.23
|
| 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 |
$320.70
|
| Rate for Payer: Cash Price |
$320.70
|
| Rate for Payer: Cigna Commercial |
$1,022.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$989.47
|
| Rate for Payer: HFN Commercial |
$1,022.82
|
| 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 |
$889.41
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$1,022.82
|
| Rate for Payer: Quartz Beloit One Network |
$544.76
|
| Rate for Payer: Quartz Commercial |
$722.64
|
| 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 |
$611.47
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$823.45
|
|
|
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 |
$544.76 |
| Max. Negotiated Rate |
$1,022.82 |
| Rate for Payer: Aetna Commercial |
$1,000.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$956.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$589.23
|
| Rate for Payer: Cash Price |
$320.70
|
| Rate for Payer: Cigna Commercial |
$1,022.82
|
| Rate for Payer: Health EOS Commercial |
$989.47
|
| Rate for Payer: HFN Commercial |
$1,022.82
|
| Rate for Payer: Multiplan Commercial |
$889.41
|
| Rate for Payer: Preferred Network Access Commercial |
$1,022.82
|
| Rate for Payer: Quartz Beloit One Network |
$544.76
|
| Rate for Payer: Quartz Commercial |
$667.06
|
| Rate for Payer: WEA Trust Commercial |
$611.47
|
| Rate for Payer: WPS Commercial |
$823.45
|
|
|
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 |
$233.91 |
| Max. Negotiated Rate |
$439.17 |
| Rate for Payer: Aetna Commercial |
$429.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$410.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.00
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$439.17
|
| Rate for Payer: Health EOS Commercial |
$424.85
|
| Rate for Payer: HFN Commercial |
$439.17
|
| Rate for Payer: Multiplan Commercial |
$381.89
|
| Rate for Payer: Preferred Network Access Commercial |
$439.17
|
| Rate for Payer: Quartz Beloit One Network |
$233.91
|
| Rate for Payer: Quartz Commercial |
$286.42
|
| Rate for Payer: WEA Trust Commercial |
$262.55
|
| Rate for Payer: WPS Commercial |
$353.57
|
|
|
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 |
$33.85 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$429.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$410.53
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$310.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$238.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$229.13
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.00
|
| 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 |
$137.70
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$439.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$424.85
|
| Rate for Payer: HFN Commercial |
$439.17
|
| 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 |
$381.89
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$439.17
|
| Rate for Payer: Quartz Beloit One Network |
$233.91
|
| Rate for Payer: Quartz Commercial |
$310.28
|
| 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 |
$262.55
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$353.57
|
|
|
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 |
$33.85 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$280.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$268.32
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$202.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$156.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$149.76
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.36
|
| 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 |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$287.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$277.68
|
| Rate for Payer: HFN Commercial |
$287.04
|
| 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 |
$249.60
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$287.04
|
| Rate for Payer: Quartz Beloit One Network |
$152.88
|
| Rate for Payer: Quartz Commercial |
$202.80
|
| 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 |
$171.60
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$231.09
|
|
|
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 |
$152.88 |
| Max. Negotiated Rate |
$287.04 |
| Rate for Payer: Aetna Commercial |
$280.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$268.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.36
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$287.04
|
| Rate for Payer: Health EOS Commercial |
$277.68
|
| Rate for Payer: HFN Commercial |
$287.04
|
| Rate for Payer: Multiplan Commercial |
$249.60
|
| Rate for Payer: Preferred Network Access Commercial |
$287.04
|
| Rate for Payer: Quartz Beloit One Network |
$152.88
|
| Rate for Payer: Quartz Commercial |
$187.20
|
| Rate for Payer: WEA Trust Commercial |
$171.60
|
| Rate for Payer: WPS Commercial |
$231.09
|
|
|
Matrix Omnigraft Dermal Q4105
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5246741
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.85 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$301.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$288.00
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.74
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.49
|
| 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 |
$96.60
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$308.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$298.04
|
| Rate for Payer: HFN Commercial |
$308.09
|
| 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 |
$267.90
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$308.09
|
| Rate for Payer: Quartz Beloit One Network |
$164.09
|
| Rate for Payer: Quartz Commercial |
$217.67
|
| 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 |
$184.18
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$63.96
|
|
|
Matrix Omnigraft Dermal Q4105
|
Facility
|
IP
|
$322.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5246741
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$164.09 |
| Max. Negotiated Rate |
$308.09 |
| Rate for Payer: Aetna Commercial |
$301.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$288.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.49
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$308.09
|
| Rate for Payer: Health EOS Commercial |
$298.04
|
| Rate for Payer: HFN Commercial |
$308.09
|
| Rate for Payer: Multiplan Commercial |
$267.90
|
| Rate for Payer: Preferred Network Access Commercial |
$308.09
|
| Rate for Payer: Quartz Beloit One Network |
$164.09
|
| Rate for Payer: Quartz Commercial |
$200.93
|
| Rate for Payer: WEA Trust Commercial |
$184.18
|
| Rate for Payer: WPS Commercial |
$248.04
|
|
|
Matrix Omnigraft Dermal Q4105
|
Professional
|
Both
|
$322.00
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
5246741
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.58 |
| Max. Negotiated Rate |
$348.66 |
| Rate for Payer: Aetna Commercial |
$318.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$288.00
|
| Rate for Payer: Aetna Managed Medicare |
$126.79
|
| Rate for Payer: Anthem Medicare Advantage |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.79
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$318.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$167.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.58
|
| Rate for Payer: Health EOS Commercial |
$304.74
|
| Rate for Payer: HFN Commercial |
$318.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$127.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$267.90
|
| Rate for Payer: NAPHCARE Commercial |
$190.18
|
| Rate for Payer: Preferred Network Access Commercial |
$318.14
|
| Rate for Payer: Quartz Beloit One Network |
$147.35
|
| Rate for Payer: Quartz Commercial |
$190.88
|
| Rate for Payer: Quartz Medicare Advantage |
$126.79
|
| Rate for Payer: The Alliance Commercial |
$348.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.79
|
| Rate for Payer: WEA Trust Commercial |
$184.18
|
| Rate for Payer: WPS Commercial |
$63.96
|
|
|
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 |
$17.08 |
| Max. Negotiated Rate |
$1,434.24 |
| Rate for Payer: Aetna Commercial |
$1,403.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.71
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,013.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$779.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$748.30
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$826.25
|
| 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 |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,434.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$1,387.47
|
| Rate for Payer: HFN Commercial |
$1,434.24
|
| 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 |
$1,247.17
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$1,434.24
|
| Rate for Payer: Quartz Beloit One Network |
$763.89
|
| Rate for Payer: Quartz Commercial |
$1,013.32
|
| 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 |
$857.43
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$32.28
|
|
|
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 |
$763.89 |
| Max. Negotiated Rate |
$1,434.24 |
| Rate for Payer: Aetna Commercial |
$1,403.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,340.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$826.25
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,434.24
|
| Rate for Payer: Health EOS Commercial |
$1,387.47
|
| Rate for Payer: HFN Commercial |
$1,434.24
|
| Rate for Payer: Multiplan Commercial |
$1,247.17
|
| Rate for Payer: Preferred Network Access Commercial |
$1,434.24
|
| Rate for Payer: Quartz Beloit One Network |
$763.89
|
| Rate for Payer: Quartz Commercial |
$935.38
|
| Rate for Payer: WEA Trust Commercial |
$857.43
|
| Rate for Payer: WPS Commercial |
$1,154.68
|
|
|
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 |
$1,220.49 |
| Max. Negotiated Rate |
$2,291.54 |
| Rate for Payer: Aetna Commercial |
$2,241.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,142.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,320.12
|
| Rate for Payer: Cash Price |
$718.50
|
| Rate for Payer: Cigna Commercial |
$2,291.54
|
| Rate for Payer: Health EOS Commercial |
$2,216.81
|
| Rate for Payer: HFN Commercial |
$2,291.54
|
| Rate for Payer: Multiplan Commercial |
$1,992.64
|
| Rate for Payer: Preferred Network Access Commercial |
$2,291.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,220.49
|
| Rate for Payer: Quartz Commercial |
$1,494.48
|
| Rate for Payer: WEA Trust Commercial |
$1,369.94
|
| Rate for Payer: WPS Commercial |
$1,844.87
|
|
|
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 |
$17.08 |
| Max. Negotiated Rate |
$2,291.54 |
| Rate for Payer: Aetna Commercial |
$2,241.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,142.09
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,619.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,245.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,195.58
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,320.12
|
| 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 |
$718.50
|
| Rate for Payer: Cash Price |
$718.50
|
| Rate for Payer: Cigna Commercial |
$2,291.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$2,216.81
|
| Rate for Payer: HFN Commercial |
$2,291.54
|
| 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 |
$1,992.64
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$2,291.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,220.49
|
| Rate for Payer: Quartz Commercial |
$1,619.02
|
| 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 |
$1,369.94
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$32.28
|
|
