|
POUCH DRAINAGE UNILATERAL
|
Facility
|
OP
|
$370.00
|
|
| Hospital Charge Code |
2963642
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$1,480.00 |
| Rate for Payer: Aetna Commercial |
$333.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Aetna Managed Medicare |
$103.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$240.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.60
|
| 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: Dean Health DHI/DHP/ASO |
$207.05
|
| Rate for Payer: Health EOS Commercial |
$329.30
|
| Rate for Payer: HFN Commercial |
$340.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.50
|
| 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 |
$240.50
|
| Rate for Payer: Quartz Medicare Advantage |
$222.00
|
| Rate for Payer: The Alliance Commercial |
$1,480.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
POUCH DRNABLE CTF ONE PIECE 8588
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS A5057
|
| Hospital Charge Code |
4640617
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
POUCH DRNABLE CTF ONE PIECE 8588
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS A5057
|
| Hospital Charge Code |
4640617
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Aetna Managed Medicare |
$21.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.65
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.50
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$50.70
|
| Rate for Payer: Quartz Medicare Advantage |
$46.80
|
| Rate for Payer: The Alliance Commercial |
$312.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
POUCH ENDO POUCH/ENDOCATCH GOLD 10MM
|
Facility
|
IP
|
$1,280.00
|
|
| Hospital Charge Code |
3633523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$627.20 |
| Max. Negotiated Rate |
$1,177.60 |
| Rate for Payer: Aetna Commercial |
$1,152.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,100.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$678.40
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$1,177.60
|
| Rate for Payer: Health EOS Commercial |
$1,139.20
|
| Rate for Payer: HFN Commercial |
$1,177.60
|
| Rate for Payer: Multiplan Commercial |
$1,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$768.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,177.60
|
| Rate for Payer: Quartz Beloit One Network |
$627.20
|
| Rate for Payer: Quartz Commercial |
$768.00
|
| Rate for Payer: WEA Trust Commercial |
$704.00
|
| Rate for Payer: WPS Commercial |
$948.10
|
|
|
POUCH ENDO POUCH/ENDOCATCH GOLD 10MM
|
Facility
|
OP
|
$1,280.00
|
|
| Hospital Charge Code |
3633523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$358.40 |
| Max. Negotiated Rate |
$5,120.00 |
| Rate for Payer: Aetna Commercial |
$1,152.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,100.80
|
| Rate for Payer: Aetna Managed Medicare |
$358.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$832.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$640.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$614.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$678.40
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$1,177.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$716.29
|
| Rate for Payer: Health EOS Commercial |
$1,139.20
|
| Rate for Payer: HFN Commercial |
$1,177.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$960.00
|
| Rate for Payer: Multiplan Commercial |
$1,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$768.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,177.60
|
| Rate for Payer: Quartz Beloit One Network |
$627.20
|
| Rate for Payer: Quartz Commercial |
$832.00
|
| Rate for Payer: Quartz Medicare Advantage |
$768.00
|
| Rate for Payer: The Alliance Commercial |
$5,120.00
|
| Rate for Payer: WEA Trust Commercial |
$704.00
|
| Rate for Payer: WPS Commercial |
$948.10
|
|
|
POUCH HIGH OUTPUT 2.25 18013
|
Facility
|
IP
|
$104.00
|
|
| Hospital Charge Code |
2964054
|
|
Hospital Revenue Code
|
271
|
| 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 HIGH OUTPUT 2.25 18013
|
Facility
|
OP
|
$104.00
|
|
| Hospital Charge Code |
2964054
|
|
Hospital Revenue Code
|
271
|
| 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 HOLLISTER 2 PC W/FILTER 1.75 18192"
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
4494222
|
|
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 HOLLISTER 2 PC W/FILTER 1.75 18192"
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
4494222
|
|
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 INSTRUMENT 7 X 11 1018
|
Facility
|
IP
|
$104.00
|
|
| Hospital Charge Code |
2963874
|
|
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 INSTRUMENT 7 X 11 1018
|
Facility
|
OP
|
$104.00
|
|
| Hospital Charge Code |
2963874
|
|
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 INSTRUMENT LONG 25CM X 40CM 3 INSTRUMENT DYNJSD1018L
|
Facility
|
IP
|
$86.00
|
|
| Hospital Charge Code |
5415127
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.14 |
| Max. Negotiated Rate |
$79.12 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$51.60
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
POUCH INSTRUMENT LONG 25CM X 40CM 3 INSTRUMENT DYNJSD1018L
|
Facility
|
OP
|
$86.00
|
|
| Hospital Charge Code |
5415127
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$344.00 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Aetna Managed Medicare |
$24.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.13
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.50
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$55.90
|
| Rate for Payer: Quartz Medicare Advantage |
$51.60
|
| Rate for Payer: The Alliance Commercial |
$344.00
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
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 |
$49.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Aetna Managed Medicare |
$49.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$113.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$87.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$84.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$161.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.93
|
| Rate for Payer: Health EOS Commercial |
$155.75
|
| Rate for Payer: HFN Commercial |
$161.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.25
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: NAPHCARE Commercial |
$105.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.00
|
| Rate for Payer: Quartz Beloit One Network |
$85.75
|
| Rate for Payer: Quartz Commercial |
$113.75
|
| Rate for Payer: Quartz Medicare Advantage |
$105.00
|
| Rate for Payer: The Alliance Commercial |
$700.00
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$129.62
|
|
|
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 |
$85.75 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$161.00
|
| Rate for Payer: Health EOS Commercial |
$155.75
|
| Rate for Payer: HFN Commercial |
$161.00
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: NAPHCARE Commercial |
$105.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.00
|
| Rate for Payer: Quartz Beloit One Network |
$85.75
|
| Rate for Payer: Quartz Commercial |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$129.62
|
|
|
POUCH NEW IMAGE CLEAR 2-1/4 DRAINABLE 18003
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2974283
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Aetna Managed Medicare |
$7.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.11
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.25
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$17.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.20
|
| Rate for Payer: The Alliance Commercial |
$108.00
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
POUCH NEW IMAGE CLEAR 2-1/4 DRAINABLE 18003
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2974283
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.23 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
POUCH ONE PIECE CLOSED 82400
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
2974492
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$168.00 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36.12
|
| Rate for Payer: Aetna Managed Medicare |
$11.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.26
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$38.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.50
|
| Rate for Payer: Health EOS Commercial |
$37.38
|
| Rate for Payer: HFN Commercial |
$38.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.20
|
| Rate for Payer: Preferred Network Access Commercial |
$38.64
|
| Rate for Payer: Quartz Beloit One Network |
$20.58
|
| Rate for Payer: Quartz Commercial |
$27.30
|
| Rate for Payer: Quartz Medicare Advantage |
$25.20
|
| Rate for Payer: The Alliance Commercial |
$168.00
|
| Rate for Payer: WEA Trust Commercial |
$23.10
|
| Rate for Payer: WPS Commercial |
$31.11
|
|
|
POUCH ONE PIECE CLOSED 82400
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
2974492
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$20.58 |
| Max. Negotiated Rate |
$38.64 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.26
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$38.64
|
| Rate for Payer: Health EOS Commercial |
$37.38
|
| Rate for Payer: HFN Commercial |
$38.64
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.20
|
| Rate for Payer: Preferred Network Access Commercial |
$38.64
|
| Rate for Payer: Quartz Beloit One Network |
$20.58
|
| Rate for Payer: Quartz Commercial |
$25.20
|
| Rate for Payer: WEA Trust Commercial |
$23.10
|
| Rate for Payer: WPS Commercial |
$31.11
|
|
|
POUCH OSTOMY DRAIN 1.75 18102
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
2963979
|
|
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 OSTOMY DRAIN 1.75 18102
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
2963979
|
|
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 PREMIER DRAINABLE 2 1/2 8131"
|
Facility
|
IP
|
$51.00
|
|
| Hospital Charge Code |
2963912
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$46.92 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$30.60
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$30.60
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
POUCH PREMIER DRAINABLE 2 1/2 8131"
|
Facility
|
OP
|
$51.00
|
|
| Hospital Charge Code |
2963912
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Aetna Managed Medicare |
$14.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.54
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.25
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$30.60
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$33.15
|
| Rate for Payer: Quartz Medicare Advantage |
$30.60
|
| Rate for Payer: The Alliance Commercial |
$204.00
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
POUCH PREMIER FLEXTEND #8631
|
Facility
|
IP
|
$60.00
|
|
| Hospital Charge Code |
2963856
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$55.20 |
| Rate for Payer: Aetna Commercial |
$54.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$55.20
|
| Rate for Payer: Health EOS Commercial |
$53.40
|
| Rate for Payer: HFN Commercial |
$55.20
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: NAPHCARE Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$55.20
|
| Rate for Payer: Quartz Beloit One Network |
$29.40
|
| Rate for Payer: Quartz Commercial |
$36.00
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$44.44
|
|
|
POUCH PREMIER FLEXTEND #8631
|
Facility
|
OP
|
$60.00
|
|
| Hospital Charge Code |
2963856
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$54.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Aetna Managed Medicare |
$16.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$55.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.58
|
| Rate for Payer: Health EOS Commercial |
$53.40
|
| Rate for Payer: HFN Commercial |
$55.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.00
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: NAPHCARE Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$55.20
|
| Rate for Payer: Quartz Beloit One Network |
$29.40
|
| Rate for Payer: Quartz Commercial |
$39.00
|
| Rate for Payer: Quartz Medicare Advantage |
$36.00
|
| Rate for Payer: The Alliance Commercial |
$240.00
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$44.44
|
|
