|
POUCH HOLLISTER 2 PC W/FILTER 1.75 18192"
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
4494222
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.53
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.86
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$23.09
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$25.01
|
| Rate for Payer: Quartz Medicare Advantage |
$23.09
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
POUCH INSTRUMENT 7 X 11 1018
|
Facility
|
OP
|
$104.00
|
|
| Hospital Charge Code |
2963874
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.28 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Aetna Managed Medicare |
$30.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.53
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.12
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: NAPHCARE Commercial |
$64.90
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$70.30
|
| Rate for Payer: Quartz Medicare Advantage |
$64.90
|
| Rate for Payer: The Alliance Commercial |
$54.08
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
POUCH INSTRUMENT 7 X 11 1018
|
Facility
|
IP
|
$104.00
|
|
| Hospital Charge Code |
2963874
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.00 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
POUCH INSTRUMENT LONG 25CM X 40CM 3 INSTRUMENT DYNJSD1018L
|
Facility
|
OP
|
$86.00
|
|
| Hospital Charge Code |
5415127
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.04 |
| Max. Negotiated Rate |
$82.28 |
| Rate for Payer: Aetna Commercial |
$80.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.92
|
| Rate for Payer: Aetna Managed Medicare |
$25.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.40
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$82.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.05
|
| Rate for Payer: Health EOS Commercial |
$79.60
|
| Rate for Payer: HFN Commercial |
$82.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.08
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
| Rate for Payer: NAPHCARE Commercial |
$53.66
|
| Rate for Payer: Preferred Network Access Commercial |
$82.28
|
| Rate for Payer: Quartz Beloit One Network |
$43.83
|
| Rate for Payer: Quartz Commercial |
$58.14
|
| Rate for Payer: Quartz Medicare Advantage |
$53.66
|
| Rate for Payer: The Alliance Commercial |
$44.72
|
| Rate for Payer: WEA Trust Commercial |
$49.19
|
| Rate for Payer: WPS Commercial |
$66.25
|
|
|
POUCH INSTRUMENT LONG 25CM X 40CM 3 INSTRUMENT DYNJSD1018L
|
Facility
|
IP
|
$86.00
|
|
| Hospital Charge Code |
5415127
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.83 |
| Max. Negotiated Rate |
$82.28 |
| Rate for Payer: Aetna Commercial |
$80.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.40
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$82.28
|
| Rate for Payer: Health EOS Commercial |
$79.60
|
| Rate for Payer: HFN Commercial |
$82.28
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
| Rate for Payer: Preferred Network Access Commercial |
$82.28
|
| Rate for Payer: Quartz Beloit One Network |
$43.83
|
| Rate for Payer: Quartz Commercial |
$53.66
|
| Rate for Payer: WEA Trust Commercial |
$49.19
|
| Rate for Payer: WPS Commercial |
$66.25
|
|
|
POUCH MINI DRNBL 2-3.25 FLANGE BEIGE 18204"
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS A5063
|
| Hospital Charge Code |
4008550
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.06 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Aetna Managed Medicare |
$50.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$118.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$87.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.85
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.50
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$118.30
|
| Rate for Payer: Quartz Medicare Advantage |
$109.20
|
| Rate for Payer: The Alliance Commercial |
$16.06
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.80
|
|
|
POUCH MINI DRNBL 2-3.25 FLANGE BEIGE 18204"
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS A5063
|
| Hospital Charge Code |
4008550
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.18 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.80
|
|
|
POUCH NEW IMAGE CLEAR 2-1/4 DRAINABLE 18003
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2974283
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$25.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Aetna Managed Medicare |
$7.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.71
|
| Rate for Payer: Health EOS Commercial |
$24.99
|
| Rate for Payer: HFN Commercial |
$25.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.06
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: NAPHCARE Commercial |
$16.85
|
| Rate for Payer: Preferred Network Access Commercial |
$25.83
|
| Rate for Payer: Quartz Beloit One Network |
$13.76
|
| Rate for Payer: Quartz Commercial |
$18.25
|
| Rate for Payer: Quartz Medicare Advantage |
$16.85
|
| Rate for Payer: The Alliance Commercial |
$14.04
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$20.80
|
|
|
POUCH NEW IMAGE CLEAR 2-1/4 DRAINABLE 18003
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2974283
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.76 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$25.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.83
|
| Rate for Payer: Health EOS Commercial |
$24.99
|
| Rate for Payer: HFN Commercial |
$25.83
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$25.83
|
| Rate for Payer: Quartz Beloit One Network |
$13.76
|
| Rate for Payer: Quartz Commercial |
$16.85
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$20.80
|
|
|
POUCH ONE PIECE CLOSED 82400
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
2974492
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.40 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna Commercial |
$39.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.15
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$40.19
|
| Rate for Payer: Health EOS Commercial |
$38.88
|
| Rate for Payer: HFN Commercial |
$40.19
|
| Rate for Payer: Multiplan Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$40.19
|
| Rate for Payer: Quartz Beloit One Network |
$21.40
|
| Rate for Payer: Quartz Commercial |
$26.21
|
| Rate for Payer: WEA Trust Commercial |
$24.02
|
| Rate for Payer: WPS Commercial |
$32.35
|
|
|
POUCH ONE PIECE CLOSED 82400
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
2974492
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.23 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna Commercial |
$39.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.56
|
| Rate for Payer: Aetna Managed Medicare |
$12.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.15
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$40.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.44
|
| Rate for Payer: Health EOS Commercial |
$38.88
|
| Rate for Payer: HFN Commercial |
$40.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.76
|
| Rate for Payer: Multiplan Commercial |
$34.94
|
| Rate for Payer: NAPHCARE Commercial |
$26.21
|
| Rate for Payer: Preferred Network Access Commercial |
$40.19
|
| Rate for Payer: Quartz Beloit One Network |
$21.40
|
| Rate for Payer: Quartz Commercial |
$28.39
|
| Rate for Payer: Quartz Medicare Advantage |
$26.21
|
| Rate for Payer: The Alliance Commercial |
$21.84
|
| Rate for Payer: WEA Trust Commercial |
$24.02
|
| Rate for Payer: WPS Commercial |
$32.35
|
|
|
POUCH OSTOMY DRAIN 1.75 18102
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
2963979
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.31 |
| Max. Negotiated Rate |
$30.62 |
| Rate for Payer: Aetna Commercial |
$29.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.64
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$30.62
|
| Rate for Payer: Health EOS Commercial |
$29.62
|
| Rate for Payer: HFN Commercial |
$30.62
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: Preferred Network Access Commercial |
$30.62
|
| Rate for Payer: Quartz Beloit One Network |
$16.31
|
| Rate for Payer: Quartz Commercial |
$19.97
|
| Rate for Payer: WEA Trust Commercial |
$18.30
|
| Rate for Payer: WPS Commercial |
$24.65
|
|
|
POUCH OSTOMY DRAIN 1.75 18102
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
2963979
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$9.32 |
| Max. Negotiated Rate |
$30.62 |
| Rate for Payer: Aetna Commercial |
$29.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.62
|
| Rate for Payer: Aetna Managed Medicare |
$9.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.64
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$30.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.62
|
| Rate for Payer: Health EOS Commercial |
$29.62
|
| Rate for Payer: HFN Commercial |
$30.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.96
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: NAPHCARE Commercial |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$30.62
|
| Rate for Payer: Quartz Beloit One Network |
$16.31
|
| Rate for Payer: Quartz Commercial |
$21.63
|
| Rate for Payer: Quartz Medicare Advantage |
$19.97
|
| Rate for Payer: The Alliance Commercial |
$16.64
|
| Rate for Payer: WEA Trust Commercial |
$18.30
|
| Rate for Payer: WPS Commercial |
$24.65
|
|
|
POUCH PREMIER DRAINABLE 2 1/2 8131"
|
Facility
|
IP
|
$51.00
|
|
| Hospital Charge Code |
2963912
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$48.80 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$31.82
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
POUCH PREMIER DRAINABLE 2 1/2 8131"
|
Facility
|
OP
|
$51.00
|
|
| Hospital Charge Code |
2963912
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$48.80 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Aetna Managed Medicare |
$14.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.68
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.78
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: NAPHCARE Commercial |
$31.82
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$34.48
|
| Rate for Payer: Quartz Medicare Advantage |
$31.82
|
| Rate for Payer: The Alliance Commercial |
$26.52
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
POUCH PREMIER FLEXTEND #8631
|
Facility
|
OP
|
$60.00
|
|
| Hospital Charge Code |
2963856
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.47 |
| Max. Negotiated Rate |
$57.41 |
| Rate for Payer: Aetna Commercial |
$56.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.66
|
| Rate for Payer: Aetna Managed Medicare |
$17.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.92
|
| Rate for Payer: Health EOS Commercial |
$55.54
|
| Rate for Payer: HFN Commercial |
$57.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.80
|
| Rate for Payer: Multiplan Commercial |
$49.92
|
| Rate for Payer: NAPHCARE Commercial |
$37.44
|
| Rate for Payer: Preferred Network Access Commercial |
$57.41
|
| Rate for Payer: Quartz Beloit One Network |
$30.58
|
| Rate for Payer: Quartz Commercial |
$40.56
|
| Rate for Payer: Quartz Medicare Advantage |
$37.44
|
| Rate for Payer: The Alliance Commercial |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$34.32
|
| Rate for Payer: WPS Commercial |
$46.22
|
|
|
POUCH PREMIER FLEXTEND #8631
|
Facility
|
IP
|
$60.00
|
|
| Hospital Charge Code |
2963856
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$57.41 |
| Rate for Payer: Aetna Commercial |
$56.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.41
|
| Rate for Payer: Health EOS Commercial |
$55.54
|
| Rate for Payer: HFN Commercial |
$57.41
|
| Rate for Payer: Multiplan Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$57.41
|
| Rate for Payer: Quartz Beloit One Network |
$30.58
|
| Rate for Payer: Quartz Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$34.32
|
| Rate for Payer: WPS Commercial |
$46.22
|
|
|
POUCH SENSURA MIO 1080ML 12.5 18642"
|
Facility
|
OP
|
$10.00
|
|
| Hospital Charge Code |
6207072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Aetna Managed Medicare |
$2.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.82
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.80
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: NAPHCARE Commercial |
$6.24
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.76
|
| Rate for Payer: Quartz Medicare Advantage |
$6.24
|
| Rate for Payer: The Alliance Commercial |
$5.20
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
POUCH SENSURA MIO 1080ML 12.5 18642"
|
Facility
|
IP
|
$10.00
|
|
| Hospital Charge Code |
6207072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
POUCH UROSTOMY 1-1/8 8485
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2974519
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
POUCH UROSTOMY 1-1/8 8485
|
Facility
|
IP
|
$151.00
|
|
| Hospital Charge Code |
2974519
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
POUCH UROSTOMY 1 3/4
|
Facility
|
OP
|
$55.00
|
|
| Hospital Charge Code |
3098283
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.02 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Aetna Managed Medicare |
$16.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.01
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.90
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: NAPHCARE Commercial |
$34.32
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$37.18
|
| Rate for Payer: Quartz Medicare Advantage |
$34.32
|
| Rate for Payer: The Alliance Commercial |
$28.60
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
POUCH UROSTOMY 1 3/4
|
Facility
|
IP
|
$55.00
|
|
| Hospital Charge Code |
3098283
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.03 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$34.32
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
POUCH UROSTOMY CUT TO FIT 64MM 8460
|
Facility
|
OP
|
$116.00
|
|
| Hospital Charge Code |
2963713
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$33.78 |
| Max. Negotiated Rate |
$110.99 |
| Rate for Payer: Aetna Commercial |
$108.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Aetna Managed Medicare |
$33.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.94
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.51
|
| Rate for Payer: Health EOS Commercial |
$107.37
|
| Rate for Payer: HFN Commercial |
$110.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.48
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: NAPHCARE Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$110.99
|
| Rate for Payer: Quartz Beloit One Network |
$59.11
|
| Rate for Payer: Quartz Commercial |
$78.42
|
| Rate for Payer: Quartz Medicare Advantage |
$72.38
|
| Rate for Payer: The Alliance Commercial |
$60.32
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$89.35
|
|
|
POUCH UROSTOMY CUT TO FIT 64MM 8460
|
Facility
|
IP
|
$116.00
|
|
| Hospital Charge Code |
2963713
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$59.11 |
| Max. Negotiated Rate |
$110.99 |
| Rate for Payer: Aetna Commercial |
$108.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.94
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.99
|
| Rate for Payer: Health EOS Commercial |
$107.37
|
| Rate for Payer: HFN Commercial |
$110.99
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: Preferred Network Access Commercial |
$110.99
|
| Rate for Payer: Quartz Beloit One Network |
$59.11
|
| Rate for Payer: Quartz Commercial |
$72.38
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$89.35
|
|
