|
POUCH 18403 UROSTOMY 2-1/4
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2969619
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
POUCH 18403 UROSTOMY 2-1/4
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2969619
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
POUCH 1 PC CTF 2 1/8 85711"
|
Facility
|
IP
|
$85.00
|
|
| Hospital Charge Code |
6167947
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$78.20 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.05
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: Health EOS Commercial |
$75.65
|
| Rate for Payer: HFN Commercial |
$78.20
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: NAPHCARE Commercial |
$51.00
|
| Rate for Payer: Preferred Network Access Commercial |
$78.20
|
| Rate for Payer: Quartz Beloit One Network |
$41.65
|
| Rate for Payer: Quartz Commercial |
$51.00
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: WPS Commercial |
$62.96
|
|
|
POUCH 1 PC CTF 2 1/8 85711"
|
Facility
|
OP
|
$85.00
|
|
| Hospital Charge Code |
6167947
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.10
|
| Rate for Payer: Aetna Managed Medicare |
$23.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.05
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.57
|
| Rate for Payer: Health EOS Commercial |
$75.65
|
| Rate for Payer: HFN Commercial |
$78.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.75
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: NAPHCARE Commercial |
$51.00
|
| Rate for Payer: Preferred Network Access Commercial |
$78.20
|
| Rate for Payer: Quartz Beloit One Network |
$41.65
|
| Rate for Payer: Quartz Commercial |
$55.25
|
| Rate for Payer: Quartz Medicare Advantage |
$51.00
|
| Rate for Payer: The Alliance Commercial |
$340.00
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: WPS Commercial |
$62.96
|
|
|
POUCH 2PC DRAINABLE W/FILTER 18194
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
5074921
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$34.04 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$22.20
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
POUCH 2PC DRAINABLE W/FILTER 18194
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
5074921
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Aetna Managed Medicare |
$10.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.71
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$24.05
|
| Rate for Payer: Quartz Medicare Advantage |
$22.20
|
| Rate for Payer: The Alliance Commercial |
$148.00
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
POUCH 4 1/3 PREMIER 80110
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
2963364
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Aetna Managed Medicare |
$25.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.36
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.50
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$58.50
|
| Rate for Payer: Quartz Medicare Advantage |
$54.00
|
| Rate for Payer: The Alliance Commercial |
$360.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
POUCH 4 1/3 PREMIER 80110
|
Facility
|
IP
|
$90.00
|
|
| Hospital Charge Code |
2963364
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
POUCH 70MM CONVEX SENSURA 11487
|
Facility
|
OP
|
$106.00
|
|
| Hospital Charge Code |
5547236
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.68 |
| Max. Negotiated Rate |
$424.00 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Aetna Managed Medicare |
$29.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.32
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.50
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$68.90
|
| Rate for Payer: Quartz Medicare Advantage |
$63.60
|
| Rate for Payer: The Alliance Commercial |
$424.00
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
POUCH 70MM CONVEX SENSURA 11487
|
Facility
|
IP
|
$106.00
|
|
| Hospital Charge Code |
5547236
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.94 |
| Max. Negotiated Rate |
$97.52 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$63.60
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
POUCH COLOSTOMY 2.25 18103
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
2969227
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$128.00 |
| Rate for Payer: Aetna Commercial |
$28.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.52
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$29.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.91
|
| Rate for Payer: Health EOS Commercial |
$28.48
|
| Rate for Payer: HFN Commercial |
$29.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.00
|
| Rate for Payer: Multiplan Commercial |
$25.60
|
| Rate for Payer: NAPHCARE Commercial |
$19.20
|
| Rate for Payer: Preferred Network Access Commercial |
$29.44
|
| Rate for Payer: Quartz Beloit One Network |
$15.68
|
| Rate for Payer: Quartz Commercial |
$20.80
|
| Rate for Payer: Quartz Medicare Advantage |
$19.20
|
| Rate for Payer: The Alliance Commercial |
$128.00
|
| Rate for Payer: WEA Trust Commercial |
$17.60
|
| Rate for Payer: WPS Commercial |
$23.70
|
|
|
POUCH COLOSTOMY 2.25 18103
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
2969227
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$29.44 |
| Rate for Payer: Aetna Commercial |
$28.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$29.44
|
| Rate for Payer: Health EOS Commercial |
$28.48
|
| Rate for Payer: HFN Commercial |
$29.44
|
| Rate for Payer: Multiplan Commercial |
$25.60
|
| Rate for Payer: NAPHCARE Commercial |
$19.20
|
| Rate for Payer: Preferred Network Access Commercial |
$29.44
|
| Rate for Payer: Quartz Beloit One Network |
$15.68
|
| Rate for Payer: Quartz Commercial |
$19.20
|
| Rate for Payer: WEA Trust Commercial |
$17.60
|
| Rate for Payer: WPS Commercial |
$23.70
|
|
|
POUCH DRAINABLE
|
Facility
|
IP
|
$54.00
|
|
| Hospital Charge Code |
2970836
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
POUCH DRAINABLE
|
Facility
|
OP
|
$54.00
|
|
| Hospital Charge Code |
2970836
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$32.40
|
| Rate for Payer: The Alliance Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
POUCH DRAINABLE 1 3/4 18132
|
Facility
|
IP
|
$31.00
|
|
| Hospital Charge Code |
2974282
|
|
Hospital Revenue Code
|
271
|
| 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
|
|
|
POUCH DRAINABLE 1 3/4 18132
|
Facility
|
OP
|
$31.00
|
|
| Hospital Charge Code |
2974282
|
|
Hospital Revenue Code
|
271
|
| 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
|
|
|
POUCH DRAINABLE 2.25 18133"
|
Facility
|
IP
|
$31.00
|
|
| Hospital Charge Code |
4493953
|
|
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
|
|
|
POUCH DRAINABLE 2.25 18133"
|
Facility
|
OP
|
$31.00
|
|
| Hospital Charge Code |
4493953
|
|
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
|
|
|
POUCH DRAINABLE 2.5 88501
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
2964064
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Aetna Managed Medicare |
$13.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.42
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.75
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$31.85
|
| Rate for Payer: Quartz Medicare Advantage |
$29.40
|
| Rate for Payer: The Alliance Commercial |
$196.00
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
POUCH DRAINABLE 2.5 88501
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
2964064
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.01 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$29.40
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
POUCH DRAINABLE 2.75 18014
|
Facility
|
OP
|
$104.00
|
|
| Hospital Charge Code |
2964053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$416.00 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$29.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.00
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$62.40
|
| Rate for Payer: The Alliance Commercial |
$416.00
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
POUCH DRAINABLE 2.75 18014
|
Facility
|
IP
|
$104.00
|
|
| Hospital Charge Code |
2964053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
POUCH DRAINABLE 2.75 18104
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
2964069
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$9.52 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.24
|
| Rate for Payer: Aetna Managed Medicare |
$9.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.02
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$31.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.03
|
| Rate for Payer: Health EOS Commercial |
$30.26
|
| Rate for Payer: HFN Commercial |
$31.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.50
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31.28
|
| Rate for Payer: Quartz Beloit One Network |
$16.66
|
| Rate for Payer: Quartz Commercial |
$22.10
|
| Rate for Payer: Quartz Medicare Advantage |
$20.40
|
| Rate for Payer: The Alliance Commercial |
$136.00
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$25.18
|
|
|
POUCH DRAINABLE 2.75 18104
|
Facility
|
IP
|
$34.00
|
|
| Hospital Charge Code |
2964069
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.66 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.02
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$31.28
|
| Rate for Payer: Health EOS Commercial |
$30.26
|
| Rate for Payer: HFN Commercial |
$31.28
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31.28
|
| Rate for Payer: Quartz Beloit One Network |
$16.66
|
| Rate for Payer: Quartz Commercial |
$20.40
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$25.18
|
|
|
POUCH DRAINAGE UNILATERAL
|
Facility
|
IP
|
$370.00
|
|
| Hospital Charge Code |
2963642
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$340.40 |
| Rate for Payer: Aetna Commercial |
$333.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.10
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$340.40
|
| Rate for Payer: Health EOS Commercial |
$329.30
|
| Rate for Payer: HFN Commercial |
$340.40
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: NAPHCARE Commercial |
$222.00
|
| Rate for Payer: Preferred Network Access Commercial |
$340.40
|
| Rate for Payer: Quartz Beloit One Network |
$181.30
|
| Rate for Payer: Quartz Commercial |
$222.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
