|
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: Aetna Gatekeeper/Not Gatekeeper |
$773.14
|
| 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
|
Both
|
$118.00
|
|
|
Service Code
|
CPT 96377
|
| Hospital Charge Code |
6182584
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.92 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.48
|
| 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 |
$70.80
|
| Rate for Payer: Health EOS Commercial |
$107.38
|
| Rate for Payer: HFN Commercial |
$112.10
|
| 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: 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: The Alliance Commercial |
$59.00
|
| Rate for Payer: WEA Trust Commercial |
$64.90
|
| Rate for Payer: WPS Commercial |
$87.40
|
|
|
APPLY FINGER CAST 29086
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
CPT 29086
|
| Hospital Charge Code |
3014292
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$194.75 |
| Rate for Payer: Aetna Commercial |
$194.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| 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 |
$25.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.00
|
| Rate for Payer: Health EOS Commercial |
$186.55
|
| Rate for Payer: HFN Commercial |
$194.75
|
| 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: 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: The Alliance Commercial |
$102.50
|
| Rate for Payer: United Healthcare Medicaid |
$25.89
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
Apply Forearm Splint, Dynamic 29126
|
Professional
|
Both
|
$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: 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 |
$22.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.40
|
| Rate for Payer: Health EOS Commercial |
$299.39
|
| Rate for Payer: HFN Commercial |
$312.55
|
| 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: 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: The Alliance Commercial |
$164.50
|
| Rate for Payer: United Healthcare Medicaid |
$22.59
|
| Rate for Payer: WEA Trust Commercial |
$180.95
|
| Rate for Payer: WPS Commercial |
$243.69
|
|
|
Apply Forearm Splint, Static 29125
|
Professional
|
Both
|
$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: 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 |
$26.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.60
|
| Rate for Payer: Health EOS Commercial |
$196.56
|
| Rate for Payer: HFN Commercial |
$205.20
|
| 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: 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: The Alliance Commercial |
$108.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.97
|
| Rate for Payer: WEA Trust Commercial |
$118.80
|
| Rate for Payer: WPS Commercial |
$159.99
|
|
|
APPLY HAND/WRIST CAST 29085
|
Professional
|
Both
|
$193.00
|
|
|
Service Code
|
CPT 29085
|
| Hospital Charge Code |
3014291
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.58 |
| Max. Negotiated Rate |
$220.52 |
| Rate for Payer: Aetna Commercial |
$183.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$183.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$48.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.80
|
| Rate for Payer: Health EOS Commercial |
$175.63
|
| Rate for Payer: HFN Commercial |
$183.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$220.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$220.52
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: Preferred Network Access Commercial |
$183.35
|
| Rate for Payer: Quartz Beloit One Network |
$84.92
|
| Rate for Payer: Quartz Commercial |
$110.01
|
| Rate for Payer: The Alliance Commercial |
$96.50
|
| Rate for Payer: United Healthcare Medicaid |
$48.58
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
APPLY LONG ARM SPLINT 29105
|
Professional
|
Both
|
$251.00
|
|
|
Service Code
|
CPT 29105
|
| Hospital Charge Code |
3014293
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.46 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Aetna Commercial |
$238.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.86
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$238.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.60
|
| Rate for Payer: Health EOS Commercial |
$228.41
|
| Rate for Payer: HFN Commercial |
$238.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$137.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.67
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: Preferred Network Access Commercial |
$238.45
|
| Rate for Payer: Quartz Beloit One Network |
$110.44
|
| Rate for Payer: Quartz Commercial |
$143.07
|
| Rate for Payer: The Alliance Commercial |
$125.50
|
| Rate for Payer: United Healthcare Medicaid |
$44.46
|
| Rate for Payer: WEA Trust Commercial |
$138.05
|
| Rate for Payer: WPS Commercial |
$185.92
|
|
|
Apply Short Leg Cast 29405PP
|
Professional
|
Both
|
$422.00
|
|
|
Service Code
|
CPT 29405
|
| Hospital Charge Code |
3925359
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.61 |
| Max. Negotiated Rate |
$400.90 |
| Rate for Payer: Aetna Commercial |
$400.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.92
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cigna Commercial |
$400.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$253.20
|
| Rate for Payer: Health EOS Commercial |
$384.02
|
| Rate for Payer: HFN Commercial |
$400.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$193.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$193.80
|
| Rate for Payer: Multiplan Commercial |
$337.60
|
| Rate for Payer: Preferred Network Access Commercial |
$400.90
|
| Rate for Payer: Quartz Beloit One Network |
$185.68
|
| Rate for Payer: Quartz Commercial |
$240.54
|
| Rate for Payer: The Alliance Commercial |
$211.00
|
| Rate for Payer: United Healthcare Medicaid |
$72.61
|
| Rate for Payer: WEA Trust Commercial |
$232.10
|
| Rate for Payer: WPS Commercial |
$312.58
|
|
|
Apply Short Leg Cast 29425PP
|
Professional
|
Both
|
$476.00
|
|
|
Service Code
|
CPT 29425
|
| Hospital Charge Code |
3263486
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$74.10 |
| Max. Negotiated Rate |
$452.20 |
| Rate for Payer: Aetna Commercial |
$452.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$409.36
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cigna Commercial |
$452.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$285.60
|
| Rate for Payer: Health EOS Commercial |
$433.16
|
| Rate for Payer: HFN Commercial |
$452.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$182.25
|
| Rate for Payer: Multiplan Commercial |
$380.80
|
| Rate for Payer: Preferred Network Access Commercial |
$452.20
|
| Rate for Payer: Quartz Beloit One Network |
$209.44
|
| Rate for Payer: Quartz Commercial |
$271.32
|
| Rate for Payer: The Alliance Commercial |
$238.00
|
| Rate for Payer: United Healthcare Medicaid |
$74.10
|
| Rate for Payer: WEA Trust Commercial |
$261.80
|
| Rate for Payer: WPS Commercial |
$352.57
|
|
|
APPLY SHORT LEG CAST 29435
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
CPT 29435
|
| Hospital Charge Code |
3014301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.21 |
| Max. Negotiated Rate |
$380.00 |
| Rate for Payer: Aetna Commercial |
$380.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$380.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$82.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.00
|
| Rate for Payer: Health EOS Commercial |
$364.00
|
| Rate for Payer: HFN Commercial |
$380.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$266.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$266.69
|
| Rate for Payer: Multiplan Commercial |
$320.00
|
| Rate for Payer: Preferred Network Access Commercial |
$380.00
|
| Rate for Payer: Quartz Beloit One Network |
$176.00
|
| Rate for Payer: Quartz Commercial |
$228.00
|
| Rate for Payer: The Alliance Commercial |
$200.00
|
| Rate for Payer: United Healthcare Medicaid |
$82.21
|
| Rate for Payer: WEA Trust Commercial |
$220.00
|
| Rate for Payer: WPS Commercial |
$296.28
|
|
|
App of Low Cost Skin Substitute T/A/L each addtl 25 sq cm C5272
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
HCPCS C5272
|
| Hospital Charge Code |
5506781
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.52 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Health EOS Commercial |
$75.53
|
| Rate for Payer: HFN Commercial |
$78.85
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: Preferred Network Access Commercial |
$78.85
|
| Rate for Payer: Quartz Beloit One Network |
$36.52
|
| Rate for Payer: Quartz Commercial |
$47.31
|
| Rate for Payer: The Alliance Commercial |
$41.50
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
App of Low Cost Skin Substitute T/A/L First 25 sq cm C5271
|
Professional
|
Both
|
$370.00
|
|
|
Service Code
|
HCPCS C5271
|
| Hospital Charge Code |
5506780
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$162.80 |
| Max. Negotiated Rate |
$351.50 |
| Rate for Payer: Aetna Commercial |
$351.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| 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 |
$222.00
|
| Rate for Payer: Health EOS Commercial |
$336.70
|
| Rate for Payer: HFN Commercial |
$351.50
|
| 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: The Alliance Commercial |
$185.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
App of multi-layer venous wound compression system, below knee 29581PP
|
Professional
|
Both
|
$209.00
|
|
|
Service Code
|
CPT 29581
|
| Hospital Charge Code |
4728606
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.06 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Aetna Commercial |
$198.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.74
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$198.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.40
|
| Rate for Payer: Health EOS Commercial |
$190.19
|
| Rate for Payer: HFN Commercial |
$198.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$95.52
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: Preferred Network Access Commercial |
$198.55
|
| Rate for Payer: Quartz Beloit One Network |
$91.96
|
| Rate for Payer: Quartz Commercial |
$119.13
|
| Rate for Payer: The Alliance Commercial |
$104.50
|
| Rate for Payer: United Healthcare Medicaid |
$72.06
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: WPS Commercial |
$154.81
|
|
|
App of skin graft to arms, legs, wound surface area >=100sq cm 15273
|
Professional
|
Both
|
$930.00
|
|
|
Service Code
|
CPT 15273
|
| Hospital Charge Code |
4596904
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.89 |
| Max. Negotiated Rate |
$883.50 |
| Rate for Payer: Aetna Commercial |
$883.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$799.80
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cigna Commercial |
$883.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$222.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$558.00
|
| Rate for Payer: Health EOS Commercial |
$846.30
|
| Rate for Payer: HFN Commercial |
$883.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$648.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$648.21
|
| Rate for Payer: Multiplan Commercial |
$744.00
|
| Rate for Payer: Preferred Network Access Commercial |
$883.50
|
| Rate for Payer: Quartz Beloit One Network |
$409.20
|
| Rate for Payer: Quartz Commercial |
$530.10
|
| Rate for Payer: The Alliance Commercial |
$465.00
|
| Rate for Payer: United Healthcare Medicaid |
$222.89
|
| Rate for Payer: WEA Trust Commercial |
$511.50
|
| Rate for Payer: WPS Commercial |
$688.85
|
|
|
App of skin graft to arms, legs, wound surface area, ea add'l 100sq cm 15274
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
CPT 15274
|
| Hospital Charge Code |
4612677
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.96 |
| Max. Negotiated Rate |
$194.75 |
| Rate for Payer: Aetna Commercial |
$194.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| 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 |
$52.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.00
|
| Rate for Payer: Health EOS Commercial |
$186.55
|
| Rate for Payer: HFN Commercial |
$194.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$146.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$146.14
|
| 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: The Alliance Commercial |
$102.50
|
| Rate for Payer: United Healthcare Medicaid |
$52.96
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
App Skn Sub Grft T/A/L Area/100 Sq 15272
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
4608615
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.67 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Health EOS Commercial |
$75.53
|
| Rate for Payer: HFN Commercial |
$78.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.41
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: Preferred Network Access Commercial |
$78.85
|
| Rate for Payer: Quartz Beloit One Network |
$36.52
|
| Rate for Payer: Quartz Commercial |
$47.31
|
| Rate for Payer: The Alliance Commercial |
$41.50
|
| Rate for Payer: United Healthcare Medicaid |
$20.67
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
Apraclinidine 1% Ophth Solution [Med]
|
Facility
|
OP
|
$173.00
|
|
| Hospital Charge Code |
2974950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.44 |
| Max. Negotiated Rate |
$692.00 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Aetna Managed Medicare |
$48.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$112.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$86.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$83.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.69
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.81
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.75
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$103.80
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$112.45
|
| Rate for Payer: Quartz Medicare Advantage |
$103.80
|
| Rate for Payer: The Alliance Commercial |
$692.00
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
|
Apraclinidine 1% Ophth Solution [Med]
|
Facility
|
IP
|
$173.00
|
|
| Hospital Charge Code |
2974950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.77 |
| Max. Negotiated Rate |
$159.16 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.69
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$103.80
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$103.80
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
|
Apraclonidine 0.5% Ophth Soluntion 5ml [Med]
|
Facility
|
IP
|
$538.00
|
|
| Hospital Charge Code |
2974951
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$263.62 |
| Max. Negotiated Rate |
$494.96 |
| Rate for Payer: Aetna Commercial |
$484.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$462.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$285.14
|
| Rate for Payer: Cash Price |
$161.40
|
| Rate for Payer: Cigna Commercial |
$494.96
|
| Rate for Payer: Health EOS Commercial |
$478.82
|
| Rate for Payer: HFN Commercial |
$494.96
|
| Rate for Payer: Multiplan Commercial |
$430.40
|
| Rate for Payer: NAPHCARE Commercial |
$322.80
|
| Rate for Payer: Preferred Network Access Commercial |
$494.96
|
| Rate for Payer: Quartz Beloit One Network |
$263.62
|
| Rate for Payer: Quartz Commercial |
$322.80
|
| Rate for Payer: WEA Trust Commercial |
$295.90
|
| Rate for Payer: WPS Commercial |
$398.50
|
|
|
Apraclonidine 0.5% Ophth Soluntion 5ml [Med]
|
Facility
|
OP
|
$538.00
|
|
| Hospital Charge Code |
2974951
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$150.64 |
| Max. Negotiated Rate |
$2,152.00 |
| Rate for Payer: Aetna Commercial |
$484.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$462.68
|
| Rate for Payer: Aetna Managed Medicare |
$150.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$258.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$285.14
|
| Rate for Payer: Cash Price |
$161.40
|
| Rate for Payer: Cigna Commercial |
$494.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$301.06
|
| Rate for Payer: Health EOS Commercial |
$478.82
|
| Rate for Payer: HFN Commercial |
$494.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$403.50
|
| Rate for Payer: Multiplan Commercial |
$430.40
|
| Rate for Payer: NAPHCARE Commercial |
$322.80
|
| Rate for Payer: Preferred Network Access Commercial |
$494.96
|
| Rate for Payer: Quartz Beloit One Network |
$263.62
|
| Rate for Payer: Quartz Commercial |
$349.70
|
| Rate for Payer: Quartz Medicare Advantage |
$322.80
|
| Rate for Payer: The Alliance Commercial |
$2,152.00
|
| Rate for Payer: WEA Trust Commercial |
$295.90
|
| Rate for Payer: WPS Commercial |
$398.50
|
|
|
AQUACEL 0086 ROPE .75X18 IN (2 X 45CM) SB1543A 403770
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS A6199
|
| Hospital Charge Code |
2969968
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.19 |
| Max. Negotiated Rate |
$28.52 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$18.60
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$22.96
|
|
|
AQUACEL 0086 ROPE .75X18 IN (2 X 45CM) SB1543A 403770
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS A6199
|
| Hospital Charge Code |
2969968
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Managed Medicare |
$8.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.35
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.25
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$20.15
|
| Rate for Payer: Quartz Medicare Advantage |
$18.60
|
| Rate for Payer: The Alliance Commercial |
$124.00
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$22.96
|
|
|
AQUACEL ADHESIVE 5 X 5
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS A6212
|
| Hospital Charge Code |
2963597
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$35.28 |
| Max. Negotiated Rate |
$504.00 |
| Rate for Payer: Aetna Commercial |
$113.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.36
|
| Rate for Payer: Aetna Managed Medicare |
$35.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.78
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$115.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.51
|
| Rate for Payer: Health EOS Commercial |
$112.14
|
| Rate for Payer: HFN Commercial |
$115.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.50
|
| Rate for Payer: Multiplan Commercial |
$100.80
|
| Rate for Payer: NAPHCARE Commercial |
$75.60
|
| Rate for Payer: Preferred Network Access Commercial |
$115.92
|
| Rate for Payer: Quartz Beloit One Network |
$61.74
|
| Rate for Payer: Quartz Commercial |
$81.90
|
| Rate for Payer: Quartz Medicare Advantage |
$75.60
|
| Rate for Payer: The Alliance Commercial |
$504.00
|
| Rate for Payer: WEA Trust Commercial |
$69.30
|
| Rate for Payer: WPS Commercial |
$93.33
|
|
|
AQUACEL ADHESIVE 5 X 5
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS A6212
|
| Hospital Charge Code |
2963597
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$61.74 |
| Max. Negotiated Rate |
$115.92 |
| Rate for Payer: Aetna Commercial |
$113.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.78
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$115.92
|
| Rate for Payer: Health EOS Commercial |
$112.14
|
| Rate for Payer: HFN Commercial |
$115.92
|
| Rate for Payer: Multiplan Commercial |
$100.80
|
| Rate for Payer: NAPHCARE Commercial |
$75.60
|
| Rate for Payer: Preferred Network Access Commercial |
$115.92
|
| Rate for Payer: Quartz Beloit One Network |
$61.74
|
| Rate for Payer: Quartz Commercial |
$75.60
|
| Rate for Payer: WEA Trust Commercial |
$69.30
|
| Rate for Payer: WPS Commercial |
$93.33
|
|
|
AQUACEL AG ADVANTAGE 1X45CM 422301
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS A6199
|
| Hospital Charge Code |
2963871
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.19 |
| Max. Negotiated Rate |
$28.52 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$18.60
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$22.96
|
|
