|
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 |
$36.23 |
| Max. Negotiated Rate |
$202.54 |
| Rate for Payer: Aetna Commercial |
$202.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Aetna Managed Medicare |
$36.23
|
| Rate for Payer: Anthem Medicare Advantage |
$36.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.23
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$202.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.23
|
| Rate for Payer: Health EOS Commercial |
$194.01
|
| Rate for Payer: HFN Commercial |
$202.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$151.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.23
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: NAPHCARE Commercial |
$54.35
|
| Rate for Payer: Preferred Network Access Commercial |
$202.54
|
| Rate for Payer: Quartz Beloit One Network |
$93.81
|
| Rate for Payer: Quartz Commercial |
$121.52
|
| Rate for Payer: Quartz Medicare Advantage |
$36.23
|
| Rate for Payer: The Alliance Commercial |
$153.99
|
| Rate for Payer: United Healthcare Medicaid |
$55.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.23
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$163.05
|
|
|
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 |
$13.98 |
| Max. Negotiated Rate |
$82.00 |
| Rate for Payer: Aetna Commercial |
$82.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Aetna Managed Medicare |
$13.98
|
| Rate for Payer: Anthem Medicare Advantage |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.98
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$82.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.98
|
| Rate for Payer: Health EOS Commercial |
$78.55
|
| Rate for Payer: HFN Commercial |
$82.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$58.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.98
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: NAPHCARE Commercial |
$20.97
|
| Rate for Payer: Preferred Network Access Commercial |
$82.00
|
| Rate for Payer: Quartz Beloit One Network |
$37.98
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: Quartz Medicare Advantage |
$13.98
|
| Rate for Payer: The Alliance Commercial |
$59.40
|
| Rate for Payer: United Healthcare Medicaid |
$21.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.98
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$62.90
|
|
|
Apraclinidine 1% Ophth Solution [Med]
|
Facility
|
OP
|
$173.00
|
|
| Hospital Charge Code |
2974950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.38 |
| Max. Negotiated Rate |
$165.53 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Aetna Managed Medicare |
$50.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$116.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$89.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$86.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.36
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.69
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$134.94
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: NAPHCARE Commercial |
$107.95
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$116.95
|
| Rate for Payer: Quartz Medicare Advantage |
$107.95
|
| Rate for Payer: The Alliance Commercial |
$89.96
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Apraclinidine 1% Ophth Solution [Med]
|
Facility
|
IP
|
$173.00
|
|
| Hospital Charge Code |
2974950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.16 |
| Max. Negotiated Rate |
$165.53 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.36
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$107.95
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Apraclonidine 0.5% Ophth Soluntion 5ml [Med]
|
Facility
|
IP
|
$538.00
|
|
| Hospital Charge Code |
2974951
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$274.16 |
| Max. Negotiated Rate |
$514.76 |
| Rate for Payer: Aetna Commercial |
$503.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$481.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$296.55
|
| Rate for Payer: Cash Price |
$161.40
|
| Rate for Payer: Cigna Commercial |
$514.76
|
| Rate for Payer: Health EOS Commercial |
$497.97
|
| Rate for Payer: HFN Commercial |
$514.76
|
| Rate for Payer: Multiplan Commercial |
$447.62
|
| Rate for Payer: Preferred Network Access Commercial |
$514.76
|
| Rate for Payer: Quartz Beloit One Network |
$274.16
|
| Rate for Payer: Quartz Commercial |
$335.71
|
| Rate for Payer: WEA Trust Commercial |
$307.74
|
| Rate for Payer: WPS Commercial |
$414.42
|
|
|
Apraclonidine 0.5% Ophth Soluntion 5ml [Med]
|
Facility
|
OP
|
$538.00
|
|
| Hospital Charge Code |
2974951
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$156.67 |
| Max. Negotiated Rate |
$514.76 |
| Rate for Payer: Aetna Commercial |
$503.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$481.19
|
| Rate for Payer: Aetna Managed Medicare |
$156.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$363.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$279.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$268.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$296.55
|
| Rate for Payer: Cash Price |
$161.40
|
| Rate for Payer: Cigna Commercial |
$514.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$313.12
|
| Rate for Payer: Health EOS Commercial |
$497.97
|
| Rate for Payer: HFN Commercial |
$514.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$419.64
|
| Rate for Payer: Multiplan Commercial |
$447.62
|
| Rate for Payer: NAPHCARE Commercial |
$335.71
|
| Rate for Payer: Preferred Network Access Commercial |
$514.76
|
| Rate for Payer: Quartz Beloit One Network |
$274.16
|
| Rate for Payer: Quartz Commercial |
$363.69
|
| Rate for Payer: Quartz Medicare Advantage |
$335.71
|
| Rate for Payer: The Alliance Commercial |
$279.76
|
| Rate for Payer: WEA Trust Commercial |
$307.74
|
| Rate for Payer: WPS Commercial |
$414.42
|
|
|
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 |
$9.03 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$9.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.04
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.18
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$19.34
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$20.96
|
| Rate for Payer: Quartz Medicare Advantage |
$19.34
|
| Rate for Payer: The Alliance Commercial |
$31.28
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$23.88
|
|
|
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 |
$15.80 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$19.34
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$23.88
|
|
|
AQUACEL ADHESIVE 5 X 5
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS A6212
|
| Hospital Charge Code |
2963597
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.69 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna Commercial |
$117.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$112.69
|
| Rate for Payer: Aetna Managed Medicare |
$36.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$85.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$65.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$62.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$69.45
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$120.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$73.33
|
| Rate for Payer: Health EOS Commercial |
$116.63
|
| Rate for Payer: HFN Commercial |
$120.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$98.28
|
| Rate for Payer: Multiplan Commercial |
$104.83
|
| Rate for Payer: NAPHCARE Commercial |
$78.62
|
| Rate for Payer: Preferred Network Access Commercial |
$120.56
|
| Rate for Payer: Quartz Beloit One Network |
$64.21
|
| Rate for Payer: Quartz Commercial |
$85.18
|
| Rate for Payer: Quartz Medicare Advantage |
$78.62
|
| Rate for Payer: The Alliance Commercial |
$57.57
|
| Rate for Payer: WEA Trust Commercial |
$72.07
|
| Rate for Payer: WPS Commercial |
$97.06
|
|
|
AQUACEL ADHESIVE 5 X 5
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS A6212
|
| Hospital Charge Code |
2963597
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$64.21 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna Commercial |
$117.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$112.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$69.45
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$120.56
|
| Rate for Payer: Health EOS Commercial |
$116.63
|
| Rate for Payer: HFN Commercial |
$120.56
|
| Rate for Payer: Multiplan Commercial |
$104.83
|
| Rate for Payer: Preferred Network Access Commercial |
$120.56
|
| Rate for Payer: Quartz Beloit One Network |
$64.21
|
| Rate for Payer: Quartz Commercial |
$78.62
|
| Rate for Payer: WEA Trust Commercial |
$72.07
|
| Rate for Payer: WPS Commercial |
$97.06
|
|
|
AQUACEL AG ADVANTAGE 1X45CM 422301
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS A6199
|
| Hospital Charge Code |
2963871
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$9.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.04
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.18
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$19.34
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$20.96
|
| Rate for Payer: Quartz Medicare Advantage |
$19.34
|
| Rate for Payer: The Alliance Commercial |
$31.28
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$23.88
|
|
|
AQUACEL AG ADVANTAGE 1X45CM 422301
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS A6199
|
| Hospital Charge Code |
2963871
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.80 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$19.34
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$23.88
|
|
|
AQUACEL DRESSING 2X2 420671
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS A6196
|
| Hospital Charge Code |
2973597
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
AQUACEL DRESSING 2X2 420671
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS A6196
|
| Hospital Charge Code |
2973597
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$43.64 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Aetna Managed Medicare |
$1.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.91
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: NAPHCARE Commercial |
$3.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3.12
|
| Rate for Payer: The Alliance Commercial |
$43.64
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
AQUACEL EXTRA 10CM X 12CM/4 IN X 5 IN HYDROFIBER 420674
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
HCPCS A6197
|
| Hospital Charge Code |
2963585
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.15 |
| Max. Negotiated Rate |
$125.34 |
| Rate for Payer: Aetna Commercial |
$122.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.17
|
| Rate for Payer: Aetna Managed Medicare |
$38.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$88.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$68.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$65.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.21
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$125.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.24
|
| Rate for Payer: Health EOS Commercial |
$121.25
|
| Rate for Payer: HFN Commercial |
$125.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.18
|
| Rate for Payer: Multiplan Commercial |
$108.99
|
| Rate for Payer: NAPHCARE Commercial |
$81.74
|
| Rate for Payer: Preferred Network Access Commercial |
$125.34
|
| Rate for Payer: Quartz Beloit One Network |
$66.76
|
| Rate for Payer: Quartz Commercial |
$88.56
|
| Rate for Payer: Quartz Medicare Advantage |
$81.74
|
| Rate for Payer: The Alliance Commercial |
$97.51
|
| Rate for Payer: WEA Trust Commercial |
$74.93
|
| Rate for Payer: WPS Commercial |
$100.91
|
|
|
AQUACEL EXTRA 10CM X 12CM/4 IN X 5 IN HYDROFIBER 420674
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
HCPCS A6197
|
| Hospital Charge Code |
2963585
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.76 |
| Max. Negotiated Rate |
$125.34 |
| Rate for Payer: Aetna Commercial |
$122.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.21
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$125.34
|
| Rate for Payer: Health EOS Commercial |
$121.25
|
| Rate for Payer: HFN Commercial |
$125.34
|
| Rate for Payer: Multiplan Commercial |
$108.99
|
| Rate for Payer: Preferred Network Access Commercial |
$125.34
|
| Rate for Payer: Quartz Beloit One Network |
$66.76
|
| Rate for Payer: Quartz Commercial |
$81.74
|
| Rate for Payer: WEA Trust Commercial |
$74.93
|
| Rate for Payer: WPS Commercial |
$100.91
|
|
|
AQUAPLAST SPLINTING #A96242104
|
Facility
|
OP
|
$874.00
|
|
| Hospital Charge Code |
2973031
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$254.51 |
| Max. Negotiated Rate |
$836.24 |
| Rate for Payer: Aetna Commercial |
$818.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$781.71
|
| Rate for Payer: Aetna Managed Medicare |
$254.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$590.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$454.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$436.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$481.75
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cigna Commercial |
$836.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$508.67
|
| Rate for Payer: Health EOS Commercial |
$808.97
|
| Rate for Payer: HFN Commercial |
$836.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$681.72
|
| Rate for Payer: Multiplan Commercial |
$727.17
|
| Rate for Payer: NAPHCARE Commercial |
$545.38
|
| Rate for Payer: Preferred Network Access Commercial |
$836.24
|
| Rate for Payer: Quartz Beloit One Network |
$445.39
|
| Rate for Payer: Quartz Commercial |
$590.82
|
| Rate for Payer: Quartz Medicare Advantage |
$545.38
|
| Rate for Payer: The Alliance Commercial |
$454.48
|
| Rate for Payer: WEA Trust Commercial |
$499.93
|
| Rate for Payer: WPS Commercial |
$673.24
|
|
|
AQUAPLAST SPLINTING #A96242104
|
Facility
|
IP
|
$874.00
|
|
| Hospital Charge Code |
2973031
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$445.39 |
| Max. Negotiated Rate |
$836.24 |
| Rate for Payer: Aetna Commercial |
$818.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$781.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$481.75
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cigna Commercial |
$836.24
|
| Rate for Payer: Health EOS Commercial |
$808.97
|
| Rate for Payer: HFN Commercial |
$836.24
|
| Rate for Payer: Multiplan Commercial |
$727.17
|
| Rate for Payer: Preferred Network Access Commercial |
$836.24
|
| Rate for Payer: Quartz Beloit One Network |
$445.39
|
| Rate for Payer: Quartz Commercial |
$545.38
|
| Rate for Payer: WEA Trust Commercial |
$499.93
|
| Rate for Payer: WPS Commercial |
$673.24
|
|
|
AQUAPLAST-T WHT A-MICR #551237
|
Facility
|
OP
|
$1,143.00
|
|
| Hospital Charge Code |
2973225
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$332.84 |
| Max. Negotiated Rate |
$1,093.62 |
| Rate for Payer: Aetna Commercial |
$1,069.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,022.30
|
| Rate for Payer: Aetna Managed Medicare |
$332.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$772.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$594.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$570.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$630.02
|
| Rate for Payer: Cash Price |
$342.90
|
| Rate for Payer: Cigna Commercial |
$1,093.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$665.23
|
| Rate for Payer: Health EOS Commercial |
$1,057.96
|
| Rate for Payer: HFN Commercial |
$1,093.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$891.54
|
| Rate for Payer: Multiplan Commercial |
$950.98
|
| Rate for Payer: NAPHCARE Commercial |
$713.23
|
| Rate for Payer: Preferred Network Access Commercial |
$1,093.62
|
| Rate for Payer: Quartz Beloit One Network |
$582.47
|
| Rate for Payer: Quartz Commercial |
$772.67
|
| Rate for Payer: Quartz Medicare Advantage |
$713.23
|
| Rate for Payer: The Alliance Commercial |
$594.36
|
| Rate for Payer: WEA Trust Commercial |
$653.80
|
| Rate for Payer: WPS Commercial |
$880.45
|
|
|
AQUAPLAST-T WHT A-MICR #551237
|
Facility
|
IP
|
$1,143.00
|
|
| Hospital Charge Code |
2973225
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$582.47 |
| Max. Negotiated Rate |
$1,093.62 |
| Rate for Payer: Aetna Commercial |
$1,069.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,022.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$630.02
|
| Rate for Payer: Cash Price |
$342.90
|
| Rate for Payer: Cigna Commercial |
$1,093.62
|
| Rate for Payer: Health EOS Commercial |
$1,057.96
|
| Rate for Payer: HFN Commercial |
$1,093.62
|
| Rate for Payer: Multiplan Commercial |
$950.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,093.62
|
| Rate for Payer: Quartz Beloit One Network |
$582.47
|
| Rate for Payer: Quartz Commercial |
$713.23
|
| Rate for Payer: WEA Trust Commercial |
$653.80
|
| Rate for Payer: WPS Commercial |
$880.45
|
|
|
AQUEOUS SHUNT EXTRAOC EQUAT PLATE RSVR W/GRAFT 66180
|
Professional
|
Both
|
$6,579.00
|
|
|
Service Code
|
CPT 66180
|
| Hospital Charge Code |
6180261
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$956.11 |
| Max. Negotiated Rate |
$6,500.05 |
| Rate for Payer: Aetna Commercial |
$6,500.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,884.26
|
| Rate for Payer: Aetna Managed Medicare |
$961.99
|
| Rate for Payer: Anthem Medicare Advantage |
$961.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$961.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$961.99
|
| Rate for Payer: Cash Price |
$1,973.70
|
| Rate for Payer: Cash Price |
$1,973.70
|
| Rate for Payer: Cash Price |
$1,973.70
|
| Rate for Payer: Cigna Commercial |
$6,500.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$956.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$961.99
|
| Rate for Payer: Health EOS Commercial |
$6,226.37
|
| Rate for Payer: HFN Commercial |
$6,500.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,986.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,986.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$961.99
|
| Rate for Payer: Multiplan Commercial |
$5,473.73
|
| Rate for Payer: NAPHCARE Commercial |
$1,442.98
|
| Rate for Payer: Preferred Network Access Commercial |
$6,500.05
|
| Rate for Payer: Quartz Beloit One Network |
$3,010.55
|
| Rate for Payer: Quartz Commercial |
$3,900.03
|
| Rate for Payer: Quartz Medicare Advantage |
$961.99
|
| Rate for Payer: The Alliance Commercial |
$4,088.46
|
| Rate for Payer: United Healthcare Medicaid |
$956.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$961.99
|
| Rate for Payer: WEA Trust Commercial |
$3,763.19
|
| Rate for Payer: WPS Commercial |
$4,328.95
|
|
|
AQUINOX DISPOSABLE #26-P50000
|
Facility
|
OP
|
$642.00
|
|
| Hospital Charge Code |
2973418
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$186.95 |
| Max. Negotiated Rate |
$614.27 |
| Rate for Payer: Aetna Commercial |
$600.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.20
|
| Rate for Payer: Aetna Managed Medicare |
$186.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$433.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$333.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$320.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$353.87
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$614.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$373.64
|
| Rate for Payer: Health EOS Commercial |
$594.24
|
| Rate for Payer: HFN Commercial |
$614.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$500.76
|
| Rate for Payer: Multiplan Commercial |
$534.14
|
| Rate for Payer: NAPHCARE Commercial |
$400.61
|
| Rate for Payer: Preferred Network Access Commercial |
$614.27
|
| Rate for Payer: Quartz Beloit One Network |
$327.16
|
| Rate for Payer: Quartz Commercial |
$433.99
|
| Rate for Payer: Quartz Medicare Advantage |
$400.61
|
| Rate for Payer: The Alliance Commercial |
$333.84
|
| Rate for Payer: WEA Trust Commercial |
$367.22
|
| Rate for Payer: WPS Commercial |
$494.53
|
|
|
AQUINOX DISPOSABLE #26-P50000
|
Facility
|
IP
|
$642.00
|
|
| Hospital Charge Code |
2973418
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$327.16 |
| Max. Negotiated Rate |
$614.27 |
| Rate for Payer: Aetna Commercial |
$600.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$353.87
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$614.27
|
| Rate for Payer: Health EOS Commercial |
$594.24
|
| Rate for Payer: HFN Commercial |
$614.27
|
| Rate for Payer: Multiplan Commercial |
$534.14
|
| Rate for Payer: Preferred Network Access Commercial |
$614.27
|
| Rate for Payer: Quartz Beloit One Network |
$327.16
|
| Rate for Payer: Quartz Commercial |
$400.61
|
| Rate for Payer: WEA Trust Commercial |
$367.22
|
| Rate for Payer: WPS Commercial |
$494.53
|
|
|
Aranesp Administration 100mcg (Dialysis)
|
Facility
|
IP
|
$3,071.00
|
|
|
Service Code
|
HCPCS J0882 JA
|
| Hospital Charge Code |
3005566
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,564.98 |
| Max. Negotiated Rate |
$2,938.33 |
| Rate for Payer: Aetna Commercial |
$2,874.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,746.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,692.74
|
| Rate for Payer: Cash Price |
$921.30
|
| Rate for Payer: Cigna Commercial |
$2,938.33
|
| Rate for Payer: Health EOS Commercial |
$2,842.52
|
| Rate for Payer: HFN Commercial |
$2,938.33
|
| Rate for Payer: Multiplan Commercial |
$2,555.07
|
| Rate for Payer: Preferred Network Access Commercial |
$2,938.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,564.98
|
| Rate for Payer: Quartz Commercial |
$1,916.30
|
| Rate for Payer: WEA Trust Commercial |
$1,756.61
|
| Rate for Payer: WPS Commercial |
$2,365.59
|
|
|
Aranesp Administration 100mcg (Dialysis)
|
Facility
|
OP
|
$3,071.00
|
|
|
Service Code
|
HCPCS J0882 JA
|
| Hospital Charge Code |
3005566
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$2,938.33 |
| Rate for Payer: Aetna Commercial |
$2,874.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,746.70
|
| Rate for Payer: Aetna Managed Medicare |
$894.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,076.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,596.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,533.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,692.74
|
| Rate for Payer: Cash Price |
$921.30
|
| Rate for Payer: Cash Price |
$921.30
|
| Rate for Payer: Cigna Commercial |
$2,938.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.99
|
| Rate for Payer: Health EOS Commercial |
$2,842.52
|
| Rate for Payer: HFN Commercial |
$2,938.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,395.38
|
| Rate for Payer: Multiplan Commercial |
$2,555.07
|
| Rate for Payer: NAPHCARE Commercial |
$1,916.30
|
| Rate for Payer: Preferred Network Access Commercial |
$2,938.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,564.98
|
| Rate for Payer: Quartz Commercial |
$2,076.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,916.30
|
| Rate for Payer: The Alliance Commercial |
$1,596.92
|
| Rate for Payer: WEA Trust Commercial |
$1,756.61
|
| Rate for Payer: WPS Commercial |
$7.54
|
|
