|
Avastin .25 mg J9035
|
Facility
OP
|
$73.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
6195203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.04 |
| Max. Negotiated Rate |
$1,571.88 |
| Rate for Payer: Aetna Commercial |
$65.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.78
|
| Rate for Payer: Aetna Managed Medicare |
$74.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.04
|
| Rate for Payer: Anthem Medicare Advantage |
$74.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$74.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$74.07
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$67.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$74.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$98.11
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$74.07
|
| Rate for Payer: Health EOS Commercial |
$64.97
|
| Rate for Payer: HFN Commercial |
$67.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$275.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$74.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$74.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$74.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$74.07
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: NAPHCARE Commercial |
$111.11
|
| Rate for Payer: Preferred Network Access Commercial |
$67.16
|
| Rate for Payer: Quartz Beloit One Network |
$35.77
|
| Rate for Payer: Quartz Commercial |
$47.45
|
| Rate for Payer: Quartz Medicare Advantage |
$74.07
|
| Rate for Payer: The Alliance Commercial |
$1,571.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.07
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: Wellcare Medicare |
$74.07
|
| Rate for Payer: WPS Commercial |
$185.39
|
|
|
Avastin .25 mg J9035
|
Professional
|
$73.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
6195203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.12 |
| Max. Negotiated Rate |
$202.34 |
| Rate for Payer: Aetna Commercial |
$69.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.78
|
| Rate for Payer: Aetna Managed Medicare |
$73.58
|
| Rate for Payer: Anthem Medicare Advantage |
$73.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$73.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$73.58
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$69.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.16
|
| Rate for Payer: Health EOS Commercial |
$66.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$105.86
|
| Rate for Payer: Independent Care Health Plan Medicare |
$73.58
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: Preferred Network Access Commercial |
$69.35
|
| Rate for Payer: Quartz Beloit One Network |
$32.12
|
| Rate for Payer: Quartz Commercial |
$41.61
|
| Rate for Payer: Quartz Medicare Advantage |
$73.58
|
| Rate for Payer: The Alliance Commercial |
$202.34
|
| Rate for Payer: United Healthcare Medicaid |
$74.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$73.58
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: WPS Commercial |
$185.39
|
|
|
Avastin .25 mg J9035
|
Facility
IP
|
$73.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
6195203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.77 |
| Max. Negotiated Rate |
$67.16 |
| Rate for Payer: Aetna Commercial |
$65.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.69
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$67.16
|
| Rate for Payer: Health EOS Commercial |
$64.97
|
| Rate for Payer: HFN Commercial |
$67.16
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: NAPHCARE Commercial |
$43.80
|
| Rate for Payer: Preferred Network Access Commercial |
$67.16
|
| Rate for Payer: Quartz Beloit One Network |
$35.77
|
| Rate for Payer: Quartz Commercial |
$43.80
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: WPS Commercial |
$54.07
|
|
|
Aviator 4mm x 2cm
|
Professional
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Aviator 4mm x 2cm
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Aviator 4mm x 2cm
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Aviator 5mm x 2cm
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Aviator 5mm x 2cm
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Aviator 5mm x 2cm
|
Professional
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Aviator 6mm x 2cm
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546816
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Aviator 6mm x 2cm
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546816
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Aviator 6mm x 2cm
|
Professional
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546816
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Aviator 7mm x 2cm
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546818
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Aviator 7mm x 2cm
|
Professional
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546818
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Aviator 7mm x 2cm
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546818
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Avitene 70mm x 35mm [Med]
|
Facility
IP
|
$1,086.00
|
|
|
Service Code
|
HCPCS A6023
|
| Hospital Charge Code |
2974909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$532.14 |
| Max. Negotiated Rate |
$999.12 |
| Rate for Payer: Aetna Commercial |
$977.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$575.58
|
| Rate for Payer: Cash Price |
$325.80
|
| Rate for Payer: Cigna Commercial |
$999.12
|
| Rate for Payer: Health EOS Commercial |
$966.54
|
| Rate for Payer: HFN Commercial |
$999.12
|
| Rate for Payer: Multiplan Commercial |
$868.80
|
| Rate for Payer: NAPHCARE Commercial |
$651.60
|
| Rate for Payer: Preferred Network Access Commercial |
$999.12
|
| Rate for Payer: Quartz Beloit One Network |
$532.14
|
| Rate for Payer: Quartz Commercial |
$651.60
|
| Rate for Payer: WEA Trust Commercial |
$597.30
|
| Rate for Payer: WPS Commercial |
$804.40
|
|
|
Avitene 70mm x 35mm [Med]
|
Facility
OP
|
$1,086.00
|
|
|
Service Code
|
HCPCS A6023
|
| Hospital Charge Code |
2974909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$304.08 |
| Max. Negotiated Rate |
$999.12 |
| Rate for Payer: Aetna Commercial |
$977.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$933.96
|
| Rate for Payer: Aetna Managed Medicare |
$304.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$705.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$543.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$521.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$575.58
|
| Rate for Payer: Cash Price |
$325.80
|
| Rate for Payer: Cigna Commercial |
$999.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$607.73
|
| Rate for Payer: Health EOS Commercial |
$966.54
|
| Rate for Payer: HFN Commercial |
$999.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$814.50
|
| Rate for Payer: Multiplan Commercial |
$868.80
|
| Rate for Payer: NAPHCARE Commercial |
$651.60
|
| Rate for Payer: Preferred Network Access Commercial |
$999.12
|
| Rate for Payer: Quartz Beloit One Network |
$532.14
|
| Rate for Payer: Quartz Commercial |
$705.90
|
| Rate for Payer: Quartz Medicare Advantage |
$651.60
|
| Rate for Payer: WEA Trust Commercial |
$597.30
|
| Rate for Payer: WPS Commercial |
$804.40
|
|
|
AVITENE MICROFIBRILLAR COLLAGEN HEMOSTAT 1010090 (MED)
|
Facility
OP
|
$1,820.00
|
|
|
Service Code
|
HCPCS A6021
|
| Hospital Charge Code |
3737496
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$509.60 |
| Max. Negotiated Rate |
$1,674.40 |
| Rate for Payer: Aetna Commercial |
$1,638.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,565.20
|
| Rate for Payer: Aetna Managed Medicare |
$509.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,183.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$910.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$873.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$964.60
|
| Rate for Payer: Cash Price |
$546.00
|
| Rate for Payer: Cigna Commercial |
$1,674.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,018.47
|
| Rate for Payer: Health EOS Commercial |
$1,619.80
|
| Rate for Payer: HFN Commercial |
$1,674.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.00
|
| Rate for Payer: Multiplan Commercial |
$1,456.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,092.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,674.40
|
| Rate for Payer: Quartz Beloit One Network |
$891.80
|
| Rate for Payer: Quartz Commercial |
$1,183.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,092.00
|
| Rate for Payer: WEA Trust Commercial |
$1,001.00
|
| Rate for Payer: WPS Commercial |
$1,348.07
|
|
|
AVITENE MICROFIBRILLAR COLLAGEN HEMOSTAT 1010090 (MED)
|
Facility
IP
|
$1,820.00
|
|
|
Service Code
|
HCPCS A6021
|
| Hospital Charge Code |
3737496
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$891.80 |
| Max. Negotiated Rate |
$1,674.40 |
| Rate for Payer: Aetna Commercial |
$1,638.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$964.60
|
| Rate for Payer: Cash Price |
$546.00
|
| Rate for Payer: Cigna Commercial |
$1,674.40
|
| Rate for Payer: Health EOS Commercial |
$1,619.80
|
| Rate for Payer: HFN Commercial |
$1,674.40
|
| Rate for Payer: Multiplan Commercial |
$1,456.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,092.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,674.40
|
| Rate for Payer: Quartz Beloit One Network |
$891.80
|
| Rate for Payer: Quartz Commercial |
$1,092.00
|
| Rate for Payer: WEA Trust Commercial |
$1,001.00
|
| Rate for Payer: WPS Commercial |
$1,348.07
|
|
|
AVITENE ULTRAFOAM SPONGE 2CM X 6.25CM X 7MM (12.5SQ CM) 1050020
|
Facility
OP
|
$222.00
|
|
|
Service Code
|
HCPCS A6021
|
| Hospital Charge Code |
5190732
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.16 |
| Max. Negotiated Rate |
$204.24 |
| Rate for Payer: Aetna Commercial |
$199.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.92
|
| Rate for Payer: Aetna Managed Medicare |
$62.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$144.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.66
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$204.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.23
|
| Rate for Payer: Health EOS Commercial |
$197.58
|
| Rate for Payer: HFN Commercial |
$204.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.50
|
| Rate for Payer: Multiplan Commercial |
$177.60
|
| Rate for Payer: NAPHCARE Commercial |
$133.20
|
| Rate for Payer: Preferred Network Access Commercial |
$204.24
|
| Rate for Payer: Quartz Beloit One Network |
$108.78
|
| Rate for Payer: Quartz Commercial |
$144.30
|
| Rate for Payer: Quartz Medicare Advantage |
$133.20
|
| Rate for Payer: WEA Trust Commercial |
$122.10
|
| Rate for Payer: WPS Commercial |
$164.44
|
|
|
AVITENE ULTRAFOAM SPONGE 2CM X 6.25CM X 7MM (12.5SQ CM) 1050020
|
Facility
IP
|
$222.00
|
|
|
Service Code
|
HCPCS A6021
|
| Hospital Charge Code |
5190732
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$108.78 |
| Max. Negotiated Rate |
$204.24 |
| Rate for Payer: Aetna Commercial |
$199.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.66
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$204.24
|
| Rate for Payer: Health EOS Commercial |
$197.58
|
| Rate for Payer: HFN Commercial |
$204.24
|
| Rate for Payer: Multiplan Commercial |
$177.60
|
| Rate for Payer: NAPHCARE Commercial |
$133.20
|
| Rate for Payer: Preferred Network Access Commercial |
$204.24
|
| Rate for Payer: Quartz Beloit One Network |
$108.78
|
| Rate for Payer: Quartz Commercial |
$133.20
|
| Rate for Payer: WEA Trust Commercial |
$122.10
|
| Rate for Payer: WPS Commercial |
$164.44
|
|
|
AVITENE ULTRAFOAM SPONGE 8CM X 6.25CM X 1MM (50SQ CM) 1050030
|
Facility
IP
|
$322.00
|
|
|
Service Code
|
HCPCS A6023
|
| Hospital Charge Code |
5190733
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.78 |
| Max. Negotiated Rate |
$296.24 |
| Rate for Payer: Aetna Commercial |
$289.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.66
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$296.24
|
| Rate for Payer: Health EOS Commercial |
$286.58
|
| Rate for Payer: HFN Commercial |
$296.24
|
| Rate for Payer: Multiplan Commercial |
$257.60
|
| Rate for Payer: NAPHCARE Commercial |
$193.20
|
| Rate for Payer: Preferred Network Access Commercial |
$296.24
|
| Rate for Payer: Quartz Beloit One Network |
$157.78
|
| Rate for Payer: Quartz Commercial |
$193.20
|
| Rate for Payer: WEA Trust Commercial |
$177.10
|
| Rate for Payer: WPS Commercial |
$238.51
|
|
|
AVITENE ULTRAFOAM SPONGE 8CM X 6.25CM X 1MM (50SQ CM) 1050030
|
Facility
OP
|
$322.00
|
|
|
Service Code
|
HCPCS A6023
|
| Hospital Charge Code |
5190733
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$296.24 |
| Rate for Payer: Aetna Commercial |
$289.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.92
|
| Rate for Payer: Aetna Managed Medicare |
$90.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$209.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$161.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.66
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$296.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$180.19
|
| Rate for Payer: Health EOS Commercial |
$286.58
|
| Rate for Payer: HFN Commercial |
$296.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$241.50
|
| Rate for Payer: Multiplan Commercial |
$257.60
|
| Rate for Payer: NAPHCARE Commercial |
$193.20
|
| Rate for Payer: Preferred Network Access Commercial |
$296.24
|
| Rate for Payer: Quartz Beloit One Network |
$157.78
|
| Rate for Payer: Quartz Commercial |
$209.30
|
| Rate for Payer: Quartz Medicare Advantage |
$193.20
|
| Rate for Payer: WEA Trust Commercial |
$177.10
|
| Rate for Payer: WPS Commercial |
$238.51
|
|
|
Avulsion of Nail Plate 11730
|
Professional
|
$342.00
|
|
|
Service Code
|
CPT 11730
|
| Hospital Charge Code |
2572799
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Aetna Commercial |
$324.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$294.12
|
| Rate for Payer: Aetna Managed Medicare |
$50.81
|
| Rate for Payer: Anthem Medicare Advantage |
$50.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$50.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$50.81
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$324.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$171.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.81
|
| Rate for Payer: Health EOS Commercial |
$311.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$182.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$50.81
|
| Rate for Payer: Multiplan Commercial |
$273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$324.90
|
| Rate for Payer: Quartz Beloit One Network |
$150.48
|
| Rate for Payer: Quartz Commercial |
$194.94
|
| Rate for Payer: Quartz Medicare Advantage |
$50.81
|
| Rate for Payer: The Alliance Commercial |
$215.94
|
| Rate for Payer: United Healthcare Medicaid |
$42.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.81
|
| Rate for Payer: WEA Trust Commercial |
$188.10
|
| Rate for Payer: WPS Commercial |
$228.64
|
|
|
Avulsion of Nail Plate, Additional 11732
|
Professional
|
$156.00
|
|
|
Service Code
|
CPT 11732
|
| Hospital Charge Code |
2572800
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$16.20 |
| Max. Negotiated Rate |
$148.20 |
| Rate for Payer: Aetna Commercial |
$148.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Aetna Managed Medicare |
$16.20
|
| Rate for Payer: Anthem Medicare Advantage |
$16.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.20
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$148.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.20
|
| Rate for Payer: Health EOS Commercial |
$141.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$58.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.20
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$148.20
|
| Rate for Payer: Quartz Beloit One Network |
$68.64
|
| Rate for Payer: Quartz Commercial |
$88.92
|
| Rate for Payer: Quartz Medicare Advantage |
$16.20
|
| Rate for Payer: The Alliance Commercial |
$68.85
|
| Rate for Payer: United Healthcare Medicaid |
$20.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$72.90
|
|
