|
SHEEPSKIN DECUBITIS PAD
|
Facility
|
IP
|
$222.00
|
|
| Hospital Charge Code |
2963957
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$108.78 |
| Max. Negotiated Rate |
$204.24 |
| Rate for Payer: Aetna Commercial |
$199.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.92
|
| 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
|
|
|
SHEEPSKIN DECUBITIS PAD
|
Facility
|
OP
|
$222.00
|
|
| Hospital Charge Code |
2963957
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$62.16 |
| Max. Negotiated Rate |
$888.00 |
| 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: The Alliance Commercial |
$888.00
|
| Rate for Payer: WEA Trust Commercial |
$122.10
|
| Rate for Payer: WPS Commercial |
$164.44
|
|
|
SHEET BILATERAL EXTREMITY 89291
|
Facility
|
IP
|
$277.00
|
|
| Hospital Charge Code |
2963192
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$135.73 |
| Max. Negotiated Rate |
$254.84 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$166.20
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
SHEET BILATERAL EXTREMITY 89291
|
Facility
|
OP
|
$277.00
|
|
| Hospital Charge Code |
2963192
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$77.56 |
| Max. Negotiated Rate |
$1,108.00 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Aetna Managed Medicare |
$77.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$180.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$138.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.01
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$207.75
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$180.05
|
| Rate for Payer: Quartz Medicare Advantage |
$166.20
|
| Rate for Payer: The Alliance Commercial |
$1,108.00
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
SHEET EXTREMITY LOWER 88 x 131 89276
|
Facility
|
IP
|
$214.00
|
|
| Hospital Charge Code |
2963253
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$104.86 |
| Max. Negotiated Rate |
$196.88 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$128.40
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
SHEET EXTREMITY LOWER 88 x 131 89276
|
Facility
|
OP
|
$214.00
|
|
| Hospital Charge Code |
2963253
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.92 |
| Max. Negotiated Rate |
$856.00 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Aetna Managed Medicare |
$59.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$139.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$107.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.75
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$160.50
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$139.10
|
| Rate for Payer: Quartz Medicare Advantage |
$128.40
|
| Rate for Payer: The Alliance Commercial |
$856.00
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
SHEETING PHARMELAST SILICONE #20-05
|
Facility
|
OP
|
$1,211.00
|
|
| Hospital Charge Code |
2967368
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$339.08 |
| Max. Negotiated Rate |
$4,844.00 |
| Rate for Payer: Aetna Commercial |
$1,089.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,041.46
|
| Rate for Payer: Aetna Managed Medicare |
$339.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$787.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$605.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$581.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$641.83
|
| Rate for Payer: Cash Price |
$363.30
|
| Rate for Payer: Cigna Commercial |
$1,114.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$677.68
|
| Rate for Payer: Health EOS Commercial |
$1,077.79
|
| Rate for Payer: HFN Commercial |
$1,114.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$908.25
|
| Rate for Payer: Multiplan Commercial |
$968.80
|
| Rate for Payer: NAPHCARE Commercial |
$726.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,114.12
|
| Rate for Payer: Quartz Beloit One Network |
$593.39
|
| Rate for Payer: Quartz Commercial |
$787.15
|
| Rate for Payer: Quartz Medicare Advantage |
$726.60
|
| Rate for Payer: The Alliance Commercial |
$4,844.00
|
| Rate for Payer: WEA Trust Commercial |
$666.05
|
| Rate for Payer: WPS Commercial |
$896.99
|
|
|
SHEETING PHARMELAST SILICONE #20-05
|
Facility
|
IP
|
$1,211.00
|
|
| Hospital Charge Code |
2967368
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$593.39 |
| Max. Negotiated Rate |
$1,114.12 |
| Rate for Payer: Aetna Commercial |
$1,089.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,041.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$641.83
|
| Rate for Payer: Cash Price |
$363.30
|
| Rate for Payer: Cigna Commercial |
$1,114.12
|
| Rate for Payer: Health EOS Commercial |
$1,077.79
|
| Rate for Payer: HFN Commercial |
$1,114.12
|
| Rate for Payer: Multiplan Commercial |
$968.80
|
| Rate for Payer: NAPHCARE Commercial |
$726.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,114.12
|
| Rate for Payer: Quartz Beloit One Network |
$593.39
|
| Rate for Payer: Quartz Commercial |
$726.60
|
| Rate for Payer: WEA Trust Commercial |
$666.05
|
| Rate for Payer: WPS Commercial |
$896.99
|
|
|
SHEETING PHARMELAST SILICONE #20-10
|
Facility
|
IP
|
$1,315.00
|
|
| Hospital Charge Code |
2967369
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$644.35 |
| Max. Negotiated Rate |
$1,209.80 |
| Rate for Payer: Aetna Commercial |
$1,183.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,130.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$696.95
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$1,209.80
|
| Rate for Payer: Health EOS Commercial |
$1,170.35
|
| Rate for Payer: HFN Commercial |
$1,209.80
|
| Rate for Payer: Multiplan Commercial |
$1,052.00
|
| Rate for Payer: NAPHCARE Commercial |
$789.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,209.80
|
| Rate for Payer: Quartz Beloit One Network |
$644.35
|
| Rate for Payer: Quartz Commercial |
$789.00
|
| Rate for Payer: WEA Trust Commercial |
$723.25
|
| Rate for Payer: WPS Commercial |
$974.02
|
|
|
SHEETING PHARMELAST SILICONE #20-10
|
Facility
|
OP
|
$1,315.00
|
|
| Hospital Charge Code |
2967369
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$368.20 |
| Max. Negotiated Rate |
$5,260.00 |
| Rate for Payer: Aetna Commercial |
$1,183.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,130.90
|
| Rate for Payer: Aetna Managed Medicare |
$368.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$854.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$657.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$631.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$696.95
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$1,209.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$735.87
|
| Rate for Payer: Health EOS Commercial |
$1,170.35
|
| Rate for Payer: HFN Commercial |
$1,209.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$986.25
|
| Rate for Payer: Multiplan Commercial |
$1,052.00
|
| Rate for Payer: NAPHCARE Commercial |
$789.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,209.80
|
| Rate for Payer: Quartz Beloit One Network |
$644.35
|
| Rate for Payer: Quartz Commercial |
$854.75
|
| Rate for Payer: Quartz Medicare Advantage |
$789.00
|
| Rate for Payer: The Alliance Commercial |
$5,260.00
|
| Rate for Payer: WEA Trust Commercial |
$723.25
|
| Rate for Payer: WPS Commercial |
$974.02
|
|
|
SHEETING PHARMELAST SILICONE #20-20
|
Facility
|
IP
|
$1,440.00
|
|
| Hospital Charge Code |
2967370
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$705.60 |
| Max. Negotiated Rate |
$1,324.80 |
| Rate for Payer: Aetna Commercial |
$1,296.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,238.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$763.20
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$1,324.80
|
| Rate for Payer: Health EOS Commercial |
$1,281.60
|
| Rate for Payer: HFN Commercial |
$1,324.80
|
| Rate for Payer: Multiplan Commercial |
$1,152.00
|
| Rate for Payer: NAPHCARE Commercial |
$864.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,324.80
|
| Rate for Payer: Quartz Beloit One Network |
$705.60
|
| Rate for Payer: Quartz Commercial |
$864.00
|
| Rate for Payer: WEA Trust Commercial |
$792.00
|
| Rate for Payer: WPS Commercial |
$1,066.61
|
|
|
SHEETING PHARMELAST SILICONE #20-20
|
Facility
|
OP
|
$1,440.00
|
|
| Hospital Charge Code |
2967370
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$403.20 |
| Max. Negotiated Rate |
$5,760.00 |
| Rate for Payer: Aetna Commercial |
$1,296.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,238.40
|
| Rate for Payer: Aetna Managed Medicare |
$403.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$936.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$720.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$691.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$763.20
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$1,324.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$805.82
|
| Rate for Payer: Health EOS Commercial |
$1,281.60
|
| Rate for Payer: HFN Commercial |
$1,324.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,080.00
|
| Rate for Payer: Multiplan Commercial |
$1,152.00
|
| Rate for Payer: NAPHCARE Commercial |
$864.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,324.80
|
| Rate for Payer: Quartz Beloit One Network |
$705.60
|
| Rate for Payer: Quartz Commercial |
$936.00
|
| Rate for Payer: Quartz Medicare Advantage |
$864.00
|
| Rate for Payer: The Alliance Commercial |
$5,760.00
|
| Rate for Payer: WEA Trust Commercial |
$792.00
|
| Rate for Payer: WPS Commercial |
$1,066.61
|
|
|
SHEETING SILICONE 6X8 .040
|
Facility
|
IP
|
$2,623.00
|
|
| Hospital Charge Code |
2974002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,285.27 |
| Max. Negotiated Rate |
$2,413.16 |
| Rate for Payer: Aetna Commercial |
$2,360.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,255.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,390.19
|
| Rate for Payer: Cash Price |
$786.90
|
| Rate for Payer: Cigna Commercial |
$2,413.16
|
| Rate for Payer: Health EOS Commercial |
$2,334.47
|
| Rate for Payer: HFN Commercial |
$2,413.16
|
| Rate for Payer: Multiplan Commercial |
$2,098.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,573.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,413.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,285.27
|
| Rate for Payer: Quartz Commercial |
$1,573.80
|
| Rate for Payer: WEA Trust Commercial |
$1,442.65
|
| Rate for Payer: WPS Commercial |
$1,942.86
|
|
|
SHEETING SILICONE 6X8 .040
|
Facility
|
OP
|
$2,623.00
|
|
| Hospital Charge Code |
2974002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$734.44 |
| Max. Negotiated Rate |
$10,492.00 |
| Rate for Payer: Aetna Commercial |
$2,360.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,255.78
|
| Rate for Payer: Aetna Managed Medicare |
$734.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,704.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,311.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,259.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,390.19
|
| Rate for Payer: Cash Price |
$786.90
|
| Rate for Payer: Cigna Commercial |
$2,413.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,467.83
|
| Rate for Payer: Health EOS Commercial |
$2,334.47
|
| Rate for Payer: HFN Commercial |
$2,413.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,967.25
|
| Rate for Payer: Multiplan Commercial |
$2,098.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,573.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,413.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,285.27
|
| Rate for Payer: Quartz Commercial |
$1,704.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,573.80
|
| Rate for Payer: The Alliance Commercial |
$10,492.00
|
| Rate for Payer: WEA Trust Commercial |
$1,442.65
|
| Rate for Payer: WPS Commercial |
$1,942.86
|
|
|
SHEET SILICONE 6 X 8 .040 25-40
|
Facility
|
OP
|
$984.00
|
|
| Hospital Charge Code |
2969466
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$275.52 |
| Max. Negotiated Rate |
$3,936.00 |
| Rate for Payer: Aetna Commercial |
$885.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$846.24
|
| Rate for Payer: Aetna Managed Medicare |
$275.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$639.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$492.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$472.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$521.52
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$905.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$550.65
|
| Rate for Payer: Health EOS Commercial |
$875.76
|
| Rate for Payer: HFN Commercial |
$905.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$738.00
|
| Rate for Payer: Multiplan Commercial |
$787.20
|
| Rate for Payer: NAPHCARE Commercial |
$590.40
|
| Rate for Payer: Preferred Network Access Commercial |
$905.28
|
| Rate for Payer: Quartz Beloit One Network |
$482.16
|
| Rate for Payer: Quartz Commercial |
$639.60
|
| Rate for Payer: Quartz Medicare Advantage |
$590.40
|
| Rate for Payer: The Alliance Commercial |
$3,936.00
|
| Rate for Payer: WEA Trust Commercial |
$541.20
|
| Rate for Payer: WPS Commercial |
$728.85
|
|
|
SHEET SILICONE 6 X 8 .040 25-40
|
Facility
|
IP
|
$984.00
|
|
| Hospital Charge Code |
2969466
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$482.16 |
| Max. Negotiated Rate |
$905.28 |
| Rate for Payer: Aetna Commercial |
$885.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$846.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$521.52
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$905.28
|
| Rate for Payer: Health EOS Commercial |
$875.76
|
| Rate for Payer: HFN Commercial |
$905.28
|
| Rate for Payer: Multiplan Commercial |
$787.20
|
| Rate for Payer: NAPHCARE Commercial |
$590.40
|
| Rate for Payer: Preferred Network Access Commercial |
$905.28
|
| Rate for Payer: Quartz Beloit One Network |
$482.16
|
| Rate for Payer: Quartz Commercial |
$590.40
|
| Rate for Payer: WEA Trust Commercial |
$541.20
|
| Rate for Payer: WPS Commercial |
$728.85
|
|
|
SHEET SPLIT ARTHROSCOPY 60x70 89331
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2963306
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
SHEET SPLIT ARTHROSCOPY 60x70 89331
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2963306
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
SHEET SPLIT WITH ADHESIVE 89301
|
Facility
|
OP
|
$164.00
|
|
| Hospital Charge Code |
2963274
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.92 |
| Max. Negotiated Rate |
$656.00 |
| Rate for Payer: Aetna Commercial |
$147.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.04
|
| Rate for Payer: Aetna Managed Medicare |
$45.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.92
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$150.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.77
|
| Rate for Payer: Health EOS Commercial |
$145.96
|
| Rate for Payer: HFN Commercial |
$150.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.00
|
| Rate for Payer: Multiplan Commercial |
$131.20
|
| Rate for Payer: NAPHCARE Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.88
|
| Rate for Payer: Quartz Beloit One Network |
$80.36
|
| Rate for Payer: Quartz Commercial |
$106.60
|
| Rate for Payer: Quartz Medicare Advantage |
$98.40
|
| Rate for Payer: The Alliance Commercial |
$656.00
|
| Rate for Payer: WEA Trust Commercial |
$90.20
|
| Rate for Payer: WPS Commercial |
$121.47
|
|
|
SHEET SPLIT WITH ADHESIVE 89301
|
Facility
|
IP
|
$164.00
|
|
| Hospital Charge Code |
2963274
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$80.36 |
| Max. Negotiated Rate |
$150.88 |
| Rate for Payer: Aetna Commercial |
$147.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.92
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$150.88
|
| Rate for Payer: Health EOS Commercial |
$145.96
|
| Rate for Payer: HFN Commercial |
$150.88
|
| Rate for Payer: Multiplan Commercial |
$131.20
|
| Rate for Payer: NAPHCARE Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.88
|
| Rate for Payer: Quartz Beloit One Network |
$80.36
|
| Rate for Payer: Quartz Commercial |
$98.40
|
| Rate for Payer: WEA Trust Commercial |
$90.20
|
| Rate for Payer: WPS Commercial |
$121.47
|
|
|
SHEET TRANSVERSE LAP 72 x 119 89281
|
Facility
|
OP
|
$194.00
|
|
| Hospital Charge Code |
2963259
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.32 |
| Max. Negotiated Rate |
$776.00 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Aetna Managed Medicare |
$54.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.56
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.50
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$126.10
|
| Rate for Payer: Quartz Medicare Advantage |
$116.40
|
| Rate for Payer: The Alliance Commercial |
$776.00
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
SHEET TRANSVERSE LAP 72 x 119 89281
|
Facility
|
IP
|
$194.00
|
|
| Hospital Charge Code |
2963259
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$95.06 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
SHEILD SPLASH STERILE ZEROWET #SS-100
|
Facility
|
OP
|
$62.00
|
|
| Hospital Charge Code |
2969559
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.36 |
| Max. Negotiated Rate |
$248.00 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Aetna Managed Medicare |
$17.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.70
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.50
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$40.30
|
| Rate for Payer: Quartz Medicare Advantage |
$37.20
|
| Rate for Payer: The Alliance Commercial |
$248.00
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
SHEILD SPLASH STERILE ZEROWET #SS-100
|
Facility
|
IP
|
$62.00
|
|
| Hospital Charge Code |
2969559
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.38 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$37.20
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
SHELL 44MM TRABEC CLUSTER 6202-44-22
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$593.88 |
| Max. Negotiated Rate |
$1,115.04 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$727.20
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
