|
Application Skin Substitute Graft 15275
|
Professional
|
$1,055.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
2572824
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.54 |
| Max. Negotiated Rate |
$1,002.25 |
| Rate for Payer: Aetna Commercial |
$1,002.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$907.30
|
| Rate for Payer: Aetna Managed Medicare |
$87.54
|
| Rate for Payer: Anthem Medicare Advantage |
$87.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$87.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$87.54
|
| Rate for Payer: Cash Price |
$316.50
|
| Rate for Payer: Cash Price |
$316.50
|
| Rate for Payer: Cigna Commercial |
$1,002.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$527.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.54
|
| Rate for Payer: Health EOS Commercial |
$960.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$315.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$315.86
|
| Rate for Payer: Independent Care Health Plan Medicare |
$87.54
|
| Rate for Payer: Multiplan Commercial |
$844.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,002.25
|
| Rate for Payer: Quartz Beloit One Network |
$464.20
|
| Rate for Payer: Quartz Commercial |
$601.35
|
| Rate for Payer: Quartz Medicare Advantage |
$87.54
|
| Rate for Payer: The Alliance Commercial |
$372.04
|
| Rate for Payer: United Healthcare Medicaid |
$116.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.54
|
| Rate for Payer: WEA Trust Commercial |
$580.25
|
| Rate for Payer: WPS Commercial |
$393.93
|
|
|
Application Skin Substitute Graft, ea add'l 25sq cm 15276
|
Professional
|
$100.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
2572825
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.16 |
| Max. Negotiated Rate |
$104.22 |
| Rate for Payer: Aetna Commercial |
$95.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Aetna Managed Medicare |
$23.16
|
| Rate for Payer: Anthem Medicare Advantage |
$23.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23.16
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.16
|
| Rate for Payer: Health EOS Commercial |
$91.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23.16
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: Preferred Network Access Commercial |
$95.00
|
| Rate for Payer: Quartz Beloit One Network |
$44.00
|
| Rate for Payer: Quartz Commercial |
$57.00
|
| Rate for Payer: Quartz Medicare Advantage |
$23.16
|
| Rate for Payer: The Alliance Commercial |
$98.43
|
| Rate for Payer: United Healthcare Medicaid |
$25.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.16
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$104.22
|
|
|
Application Skin Substitute Trunk 15271
|
Professional
|
$370.00
|
|
|
Service Code
|
CPT 15271
|
| Hospital Charge Code |
3451586
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$77.32 |
| Max. Negotiated Rate |
$351.50 |
| Rate for Payer: Aetna Commercial |
$351.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Aetna Managed Medicare |
$77.32
|
| Rate for Payer: Anthem Medicare Advantage |
$77.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$77.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$77.32
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$351.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$185.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.32
|
| Rate for Payer: Health EOS Commercial |
$336.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$277.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$77.32
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: Preferred Network Access Commercial |
$351.50
|
| Rate for Payer: Quartz Beloit One Network |
$162.80
|
| Rate for Payer: Quartz Commercial |
$210.90
|
| Rate for Payer: Quartz Medicare Advantage |
$77.32
|
| Rate for Payer: The Alliance Commercial |
$328.61
|
| Rate for Payer: United Healthcare Medicaid |
$108.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$77.32
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$347.94
|
|
|
APPLICATOR ASSEMBLY 10CC 1:1 RATIO SA-3310
|
Facility
OP
|
$820.00
|
|
| Hospital Charge Code |
6234192
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$229.60 |
| Max. Negotiated Rate |
$3,280.00 |
| Rate for Payer: Aetna Commercial |
$738.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$705.20
|
| Rate for Payer: Aetna Managed Medicare |
$229.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$533.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$410.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$393.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$434.60
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$754.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$458.87
|
| Rate for Payer: Health EOS Commercial |
$729.80
|
| Rate for Payer: HFN Commercial |
$754.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$615.00
|
| Rate for Payer: Multiplan Commercial |
$656.00
|
| Rate for Payer: NAPHCARE Commercial |
$492.00
|
| Rate for Payer: Preferred Network Access Commercial |
$754.40
|
| Rate for Payer: Quartz Beloit One Network |
$401.80
|
| Rate for Payer: Quartz Commercial |
$533.00
|
| Rate for Payer: Quartz Medicare Advantage |
$492.00
|
| Rate for Payer: The Alliance Commercial |
$3,280.00
|
| Rate for Payer: WEA Trust Commercial |
$451.00
|
| Rate for Payer: WPS Commercial |
$607.37
|
|
|
APPLICATOR ASSEMBLY 10CC 1:1 RATIO SA-3310
|
Facility
IP
|
$820.00
|
|
| Hospital Charge Code |
6234192
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$401.80 |
| Max. Negotiated Rate |
$754.40 |
| Rate for Payer: Aetna Commercial |
$738.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$434.60
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$754.40
|
| Rate for Payer: Health EOS Commercial |
$729.80
|
| Rate for Payer: HFN Commercial |
$754.40
|
| Rate for Payer: Multiplan Commercial |
$656.00
|
| Rate for Payer: NAPHCARE Commercial |
$492.00
|
| Rate for Payer: Preferred Network Access Commercial |
$754.40
|
| Rate for Payer: Quartz Beloit One Network |
$401.80
|
| Rate for Payer: Quartz Commercial |
$492.00
|
| Rate for Payer: WEA Trust Commercial |
$451.00
|
| Rate for Payer: WPS Commercial |
$607.37
|
|
|
APPLICATOR FLEXITIP SHORT ARISTA AH AM0004
|
Facility
OP
|
$556.00
|
|
| Hospital Charge Code |
4595217
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$155.68 |
| Max. Negotiated Rate |
$2,224.00 |
| Rate for Payer: Aetna Commercial |
$500.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.16
|
| Rate for Payer: Aetna Managed Medicare |
$155.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$361.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$278.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.68
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$511.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$311.14
|
| Rate for Payer: Health EOS Commercial |
$494.84
|
| Rate for Payer: HFN Commercial |
$511.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$417.00
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: NAPHCARE Commercial |
$333.60
|
| Rate for Payer: Preferred Network Access Commercial |
$511.52
|
| Rate for Payer: Quartz Beloit One Network |
$272.44
|
| Rate for Payer: Quartz Commercial |
$361.40
|
| Rate for Payer: Quartz Medicare Advantage |
$333.60
|
| Rate for Payer: The Alliance Commercial |
$2,224.00
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$411.83
|
|
|
APPLICATOR FLEXITIP SHORT ARISTA AH AM0004
|
Facility
IP
|
$556.00
|
|
| Hospital Charge Code |
4595217
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$272.44 |
| Max. Negotiated Rate |
$511.52 |
| Rate for Payer: Aetna Commercial |
$500.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.68
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$511.52
|
| Rate for Payer: Health EOS Commercial |
$494.84
|
| Rate for Payer: HFN Commercial |
$511.52
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: NAPHCARE Commercial |
$333.60
|
| Rate for Payer: Preferred Network Access Commercial |
$511.52
|
| Rate for Payer: Quartz Beloit One Network |
$272.44
|
| Rate for Payer: Quartz Commercial |
$333.60
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$411.83
|
|
|
APPLICATOR FLEXITIP XL ARISTA AH AM0005
|
Facility
IP
|
$368.00
|
|
| Hospital Charge Code |
4594722
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$180.32 |
| Max. Negotiated Rate |
$338.56 |
| Rate for Payer: Aetna Commercial |
$331.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.04
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$338.56
|
| Rate for Payer: Health EOS Commercial |
$327.52
|
| Rate for Payer: HFN Commercial |
$338.56
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: NAPHCARE Commercial |
$220.80
|
| Rate for Payer: Preferred Network Access Commercial |
$338.56
|
| Rate for Payer: Quartz Beloit One Network |
$180.32
|
| Rate for Payer: Quartz Commercial |
$220.80
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$272.58
|
|
|
APPLICATOR FLEXITIP XL ARISTA AH AM0005
|
Facility
OP
|
$368.00
|
|
| Hospital Charge Code |
4594722
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$103.04 |
| Max. Negotiated Rate |
$1,472.00 |
| Rate for Payer: Aetna Commercial |
$331.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.48
|
| Rate for Payer: Aetna Managed Medicare |
$103.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.04
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$338.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$205.93
|
| Rate for Payer: Health EOS Commercial |
$327.52
|
| Rate for Payer: HFN Commercial |
$338.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.00
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: NAPHCARE Commercial |
$220.80
|
| Rate for Payer: Preferred Network Access Commercial |
$338.56
|
| Rate for Payer: Quartz Beloit One Network |
$180.32
|
| Rate for Payer: Quartz Commercial |
$239.20
|
| Rate for Payer: Quartz Medicare Advantage |
$220.80
|
| Rate for Payer: The Alliance Commercial |
$1,472.00
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$272.58
|
|
|
APPLICATOR FLEXITIP XL-R 38CM (15 IN) ARISTA AH AM0010
|
Facility
IP
|
$1,330.00
|
|
| Hospital Charge Code |
5563555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$651.70 |
| Max. Negotiated Rate |
$1,223.60 |
| Rate for Payer: Aetna Commercial |
$1,197.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$704.90
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Cigna Commercial |
$1,223.60
|
| Rate for Payer: Health EOS Commercial |
$1,183.70
|
| Rate for Payer: HFN Commercial |
$1,223.60
|
| Rate for Payer: Multiplan Commercial |
$1,064.00
|
| Rate for Payer: NAPHCARE Commercial |
$798.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,223.60
|
| Rate for Payer: Quartz Beloit One Network |
$651.70
|
| Rate for Payer: Quartz Commercial |
$798.00
|
| Rate for Payer: WEA Trust Commercial |
$731.50
|
| Rate for Payer: WPS Commercial |
$985.13
|
|
|
APPLICATOR FLEXITIP XL-R 38CM (15 IN) ARISTA AH AM0010
|
Facility
OP
|
$1,330.00
|
|
| Hospital Charge Code |
5563555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$372.40 |
| Max. Negotiated Rate |
$5,320.00 |
| Rate for Payer: Aetna Commercial |
$1,197.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,143.80
|
| Rate for Payer: Aetna Managed Medicare |
$372.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$864.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$665.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$638.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$704.90
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Cigna Commercial |
$1,223.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$744.27
|
| Rate for Payer: Health EOS Commercial |
$1,183.70
|
| Rate for Payer: HFN Commercial |
$1,223.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$997.50
|
| Rate for Payer: Multiplan Commercial |
$1,064.00
|
| Rate for Payer: NAPHCARE Commercial |
$798.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,223.60
|
| Rate for Payer: Quartz Beloit One Network |
$651.70
|
| Rate for Payer: Quartz Commercial |
$864.50
|
| Rate for Payer: Quartz Medicare Advantage |
$798.00
|
| Rate for Payer: The Alliance Commercial |
$5,320.00
|
| Rate for Payer: WEA Trust Commercial |
$731.50
|
| Rate for Payer: WPS Commercial |
$985.13
|
|
|
APPLICATOR MINI COTTON TIPPED
|
Facility
IP
|
$5.00
|
|
| Hospital Charge Code |
2970890
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
APPLICATOR MINI COTTON TIPPED
|
Facility
OP
|
$5.00
|
|
| Hospital Charge Code |
2970890
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
APPLICATOR MYCROMIST INTEGRA 14CM 205000DS
|
Facility
OP
|
$2,176.15
|
|
| Hospital Charge Code |
6246151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$609.32 |
| Max. Negotiated Rate |
$8,704.60 |
| Rate for Payer: Aetna Commercial |
$1,958.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,871.49
|
| Rate for Payer: Aetna Managed Medicare |
$609.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,414.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,088.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,044.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,153.36
|
| Rate for Payer: Cash Price |
$652.84
|
| Rate for Payer: Cigna Commercial |
$2,002.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,217.77
|
| Rate for Payer: Health EOS Commercial |
$1,936.77
|
| Rate for Payer: HFN Commercial |
$2,002.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,632.11
|
| Rate for Payer: Multiplan Commercial |
$1,740.92
|
| Rate for Payer: NAPHCARE Commercial |
$1,305.69
|
| Rate for Payer: Preferred Network Access Commercial |
$2,002.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,066.31
|
| Rate for Payer: Quartz Commercial |
$1,414.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,305.69
|
| Rate for Payer: The Alliance Commercial |
$8,704.60
|
| Rate for Payer: WEA Trust Commercial |
$1,196.88
|
| Rate for Payer: WPS Commercial |
$1,611.87
|
|
|
APPLICATOR MYCROMIST INTEGRA 14CM 205000DS
|
Facility
IP
|
$2,176.15
|
|
| Hospital Charge Code |
6246151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,066.31 |
| Max. Negotiated Rate |
$2,002.06 |
| Rate for Payer: Aetna Commercial |
$1,958.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,153.36
|
| Rate for Payer: Cash Price |
$652.84
|
| Rate for Payer: Cigna Commercial |
$2,002.06
|
| Rate for Payer: Health EOS Commercial |
$1,936.77
|
| Rate for Payer: HFN Commercial |
$2,002.06
|
| Rate for Payer: Multiplan Commercial |
$1,740.92
|
| Rate for Payer: NAPHCARE Commercial |
$1,305.69
|
| Rate for Payer: Preferred Network Access Commercial |
$2,002.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,066.31
|
| Rate for Payer: Quartz Commercial |
$1,305.69
|
| Rate for Payer: WEA Trust Commercial |
$1,196.88
|
| Rate for Payer: WPS Commercial |
$1,611.87
|
|
|
APPLIER LIGACLIP MULTI CLIP LARGE DISP MCL20
|
Facility
OP
|
$940.00
|
|
| Hospital Charge Code |
4519328
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$263.20 |
| Max. Negotiated Rate |
$3,760.00 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.40
|
| Rate for Payer: Aetna Managed Medicare |
$263.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.02
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.00
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$611.00
|
| Rate for Payer: Quartz Medicare Advantage |
$564.00
|
| Rate for Payer: The Alliance Commercial |
$3,760.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
APPLIER LIGACLIP MULTI CLIP LARGE DISP MCL20
|
Facility
IP
|
$940.00
|
|
| Hospital Charge Code |
4519328
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$460.60 |
| Max. Negotiated Rate |
$864.80 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$564.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
APPLIER LIGACLIP MULTI CLIP MED DISP MCM20/MCM30
|
Facility
IP
|
$940.00
|
|
| Hospital Charge Code |
3591514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$460.60 |
| Max. Negotiated Rate |
$864.80 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$564.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
APPLIER LIGACLIP MULTI CLIP MED DISP MCM20/MCM30
|
Facility
OP
|
$940.00
|
|
| Hospital Charge Code |
3591514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$263.20 |
| Max. Negotiated Rate |
$3,760.00 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.40
|
| Rate for Payer: Aetna Managed Medicare |
$263.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.02
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.00
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$611.00
|
| Rate for Payer: Quartz Medicare Advantage |
$564.00
|
| Rate for Payer: The Alliance Commercial |
$3,760.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
APPLIER LIGACLIP MULTI CLIP SMALL DISP MCS20
|
Facility
OP
|
$899.00
|
|
| Hospital Charge Code |
5240776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.72 |
| Max. Negotiated Rate |
$3,596.00 |
| Rate for Payer: Aetna Commercial |
$809.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$773.14
|
| Rate for Payer: Aetna Managed Medicare |
$251.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$584.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$449.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$431.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$476.47
|
| Rate for Payer: Cash Price |
$269.70
|
| Rate for Payer: Cigna Commercial |
$827.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$503.08
|
| Rate for Payer: Health EOS Commercial |
$800.11
|
| Rate for Payer: HFN Commercial |
$827.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$674.25
|
| Rate for Payer: Multiplan Commercial |
$719.20
|
| Rate for Payer: NAPHCARE Commercial |
$539.40
|
| Rate for Payer: Preferred Network Access Commercial |
$827.08
|
| Rate for Payer: Quartz Beloit One Network |
$440.51
|
| Rate for Payer: Quartz Commercial |
$584.35
|
| Rate for Payer: Quartz Medicare Advantage |
$539.40
|
| Rate for Payer: The Alliance Commercial |
$3,596.00
|
| Rate for Payer: WEA Trust Commercial |
$494.45
|
| Rate for Payer: WPS Commercial |
$665.89
|
|
|
APPLIER LIGACLIP MULTI CLIP SMALL DISP MCS20
|
Facility
IP
|
$899.00
|
|
| Hospital Charge Code |
5240776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$440.51 |
| Max. Negotiated Rate |
$827.08 |
| Rate for Payer: Aetna Commercial |
$809.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$476.47
|
| Rate for Payer: Cash Price |
$269.70
|
| Rate for Payer: Cigna Commercial |
$827.08
|
| Rate for Payer: Health EOS Commercial |
$800.11
|
| Rate for Payer: HFN Commercial |
$827.08
|
| Rate for Payer: Multiplan Commercial |
$719.20
|
| Rate for Payer: NAPHCARE Commercial |
$539.40
|
| Rate for Payer: Preferred Network Access Commercial |
$827.08
|
| Rate for Payer: Quartz Beloit One Network |
$440.51
|
| Rate for Payer: Quartz Commercial |
$539.40
|
| Rate for Payer: WEA Trust Commercial |
$494.45
|
| Rate for Payer: WPS Commercial |
$665.89
|
|
|
APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION 96377
|
Professional
|
$118.00
|
|
|
Service Code
|
CPT 96377
|
| Hospital Charge Code |
6182584
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$17.78 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.48
|
| Rate for Payer: Aetna Managed Medicare |
$17.78
|
| Rate for Payer: Anthem Medicare Advantage |
$17.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.78
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.78
|
| Rate for Payer: Health EOS Commercial |
$107.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$67.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.78
|
| Rate for Payer: Multiplan Commercial |
$94.40
|
| Rate for Payer: Preferred Network Access Commercial |
$112.10
|
| Rate for Payer: Quartz Beloit One Network |
$51.92
|
| Rate for Payer: Quartz Commercial |
$67.26
|
| Rate for Payer: Quartz Medicare Advantage |
$17.78
|
| Rate for Payer: The Alliance Commercial |
$44.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.78
|
| Rate for Payer: WEA Trust Commercial |
$64.90
|
| Rate for Payer: WPS Commercial |
$71.12
|
|
|
APPLY FINGER CAST 29086
|
Professional
|
$205.00
|
|
|
Service Code
|
CPT 29086
|
| Hospital Charge Code |
3014292
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$210.92 |
| Rate for Payer: Aetna Commercial |
$194.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Aetna Managed Medicare |
$46.87
|
| Rate for Payer: Anthem Medicare Advantage |
$46.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.87
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$194.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$102.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.87
|
| Rate for Payer: Health EOS Commercial |
$186.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$162.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$162.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.87
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: Preferred Network Access Commercial |
$194.75
|
| Rate for Payer: Quartz Beloit One Network |
$90.20
|
| Rate for Payer: Quartz Commercial |
$116.85
|
| Rate for Payer: Quartz Medicare Advantage |
$46.87
|
| Rate for Payer: The Alliance Commercial |
$199.20
|
| Rate for Payer: United Healthcare Medicaid |
$25.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.87
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$210.92
|
|
|
Apply Forearm Splint, Dynamic 29126
|
Professional
|
$329.00
|
|
|
Service Code
|
CPT 29126
|
| Hospital Charge Code |
4590636
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.59 |
| Max. Negotiated Rate |
$312.55 |
| Rate for Payer: Aetna Commercial |
$312.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$282.94
|
| Rate for Payer: Aetna Managed Medicare |
$46.32
|
| Rate for Payer: Anthem Medicare Advantage |
$46.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.32
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cigna Commercial |
$312.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$164.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.32
|
| Rate for Payer: Health EOS Commercial |
$299.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$160.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$160.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.32
|
| Rate for Payer: Multiplan Commercial |
$263.20
|
| Rate for Payer: Preferred Network Access Commercial |
$312.55
|
| Rate for Payer: Quartz Beloit One Network |
$144.76
|
| Rate for Payer: Quartz Commercial |
$187.53
|
| Rate for Payer: Quartz Medicare Advantage |
$46.32
|
| Rate for Payer: The Alliance Commercial |
$196.86
|
| Rate for Payer: United Healthcare Medicaid |
$22.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.32
|
| Rate for Payer: WEA Trust Commercial |
$180.95
|
| Rate for Payer: WPS Commercial |
$208.44
|
|
|
Apply Forearm Splint, Static 29125
|
Professional
|
$216.00
|
|
|
Service Code
|
CPT 29125
|
| Hospital Charge Code |
3014294
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.97 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.76
|
| Rate for Payer: Aetna Managed Medicare |
$37.65
|
| Rate for Payer: Anthem Medicare Advantage |
$37.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$37.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$37.65
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$205.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$108.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.65
|
| Rate for Payer: Health EOS Commercial |
$196.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$131.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$37.65
|
| Rate for Payer: Multiplan Commercial |
$172.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.20
|
| Rate for Payer: Quartz Beloit One Network |
$95.04
|
| Rate for Payer: Quartz Commercial |
$123.12
|
| Rate for Payer: Quartz Medicare Advantage |
$37.65
|
| Rate for Payer: The Alliance Commercial |
$160.01
|
| Rate for Payer: United Healthcare Medicaid |
$26.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.65
|
| Rate for Payer: WEA Trust Commercial |
$118.80
|
| Rate for Payer: WPS Commercial |
$169.42
|
|
