|
SHEEPSKIN DECUBITIS PAD
|
Facility
|
OP
|
$222.00
|
|
| Hospital Charge Code |
2963957
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$64.65 |
| Max. Negotiated Rate |
$212.41 |
| Rate for Payer: Aetna Commercial |
$207.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$198.56
|
| Rate for Payer: Aetna Managed Medicare |
$64.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$110.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.37
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$212.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.20
|
| Rate for Payer: Health EOS Commercial |
$205.48
|
| Rate for Payer: HFN Commercial |
$212.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$173.16
|
| Rate for Payer: Multiplan Commercial |
$184.70
|
| Rate for Payer: NAPHCARE Commercial |
$138.53
|
| Rate for Payer: Preferred Network Access Commercial |
$212.41
|
| Rate for Payer: Quartz Beloit One Network |
$113.13
|
| Rate for Payer: Quartz Commercial |
$150.07
|
| Rate for Payer: Quartz Medicare Advantage |
$138.53
|
| Rate for Payer: The Alliance Commercial |
$115.44
|
| Rate for Payer: WEA Trust Commercial |
$126.98
|
| Rate for Payer: WPS Commercial |
$171.01
|
|
|
SHEET BILATERAL EXTREMITY 89291
|
Facility
|
OP
|
$277.00
|
|
| Hospital Charge Code |
2963192
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$80.66 |
| Max. Negotiated Rate |
$265.03 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Aetna Managed Medicare |
$80.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$187.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$144.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$138.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.21
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$216.06
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: NAPHCARE Commercial |
$172.85
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$187.25
|
| Rate for Payer: Quartz Medicare Advantage |
$172.85
|
| Rate for Payer: The Alliance Commercial |
$144.04
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
SHEET BILATERAL EXTREMITY 89291
|
Facility
|
IP
|
$277.00
|
|
| Hospital Charge Code |
2963192
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.16 |
| Max. Negotiated Rate |
$265.03 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$172.85
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
SHEET EXTREMITY LOWER 88 x 131 89276
|
Facility
|
OP
|
$214.00
|
|
| Hospital Charge Code |
2963253
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.32 |
| Max. Negotiated Rate |
$204.76 |
| Rate for Payer: Aetna Commercial |
$200.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.40
|
| Rate for Payer: Aetna Managed Medicare |
$62.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$144.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.96
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$204.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.55
|
| Rate for Payer: Health EOS Commercial |
$198.08
|
| Rate for Payer: HFN Commercial |
$204.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.92
|
| Rate for Payer: Multiplan Commercial |
$178.05
|
| Rate for Payer: NAPHCARE Commercial |
$133.54
|
| Rate for Payer: Preferred Network Access Commercial |
$204.76
|
| Rate for Payer: Quartz Beloit One Network |
$109.05
|
| Rate for Payer: Quartz Commercial |
$144.66
|
| Rate for Payer: Quartz Medicare Advantage |
$133.54
|
| Rate for Payer: The Alliance Commercial |
$111.28
|
| Rate for Payer: WEA Trust Commercial |
$122.41
|
| Rate for Payer: WPS Commercial |
$164.84
|
|
|
SHEET EXTREMITY LOWER 88 x 131 89276
|
Facility
|
IP
|
$214.00
|
|
| Hospital Charge Code |
2963253
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$109.05 |
| Max. Negotiated Rate |
$204.76 |
| Rate for Payer: Aetna Commercial |
$200.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.96
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$204.76
|
| Rate for Payer: Health EOS Commercial |
$198.08
|
| Rate for Payer: HFN Commercial |
$204.76
|
| Rate for Payer: Multiplan Commercial |
$178.05
|
| Rate for Payer: Preferred Network Access Commercial |
$204.76
|
| Rate for Payer: Quartz Beloit One Network |
$109.05
|
| Rate for Payer: Quartz Commercial |
$133.54
|
| Rate for Payer: WEA Trust Commercial |
$122.41
|
| Rate for Payer: WPS Commercial |
$164.84
|
|
|
SHEETING PHARMELAST SILICONE #20-05
|
Facility
|
IP
|
$1,211.00
|
|
| Hospital Charge Code |
2967368
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$617.13 |
| Max. Negotiated Rate |
$1,158.68 |
| Rate for Payer: Aetna Commercial |
$1,133.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,083.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$667.50
|
| Rate for Payer: Cash Price |
$363.30
|
| Rate for Payer: Cigna Commercial |
$1,158.68
|
| Rate for Payer: Health EOS Commercial |
$1,120.90
|
| Rate for Payer: HFN Commercial |
$1,158.68
|
| Rate for Payer: Multiplan Commercial |
$1,007.55
|
| Rate for Payer: Preferred Network Access Commercial |
$1,158.68
|
| Rate for Payer: Quartz Beloit One Network |
$617.13
|
| Rate for Payer: Quartz Commercial |
$755.66
|
| Rate for Payer: WEA Trust Commercial |
$692.69
|
| Rate for Payer: WPS Commercial |
$932.83
|
|
|
SHEETING PHARMELAST SILICONE #20-05
|
Facility
|
OP
|
$1,211.00
|
|
| Hospital Charge Code |
2967368
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.64 |
| Max. Negotiated Rate |
$1,158.68 |
| Rate for Payer: Aetna Commercial |
$1,133.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,083.12
|
| Rate for Payer: Aetna Managed Medicare |
$352.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$818.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$629.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$604.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$667.50
|
| Rate for Payer: Cash Price |
$363.30
|
| Rate for Payer: Cigna Commercial |
$1,158.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$704.80
|
| Rate for Payer: Health EOS Commercial |
$1,120.90
|
| Rate for Payer: HFN Commercial |
$1,158.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$944.58
|
| Rate for Payer: Multiplan Commercial |
$1,007.55
|
| Rate for Payer: NAPHCARE Commercial |
$755.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,158.68
|
| Rate for Payer: Quartz Beloit One Network |
$617.13
|
| Rate for Payer: Quartz Commercial |
$818.64
|
| Rate for Payer: Quartz Medicare Advantage |
$755.66
|
| Rate for Payer: The Alliance Commercial |
$629.72
|
| Rate for Payer: WEA Trust Commercial |
$692.69
|
| Rate for Payer: WPS Commercial |
$932.83
|
|
|
SHEETING PHARMELAST SILICONE #20-10
|
Facility
|
IP
|
$1,315.00
|
|
| Hospital Charge Code |
2967369
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$670.12 |
| Max. Negotiated Rate |
$1,258.19 |
| Rate for Payer: Aetna Commercial |
$1,230.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,176.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$724.83
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$1,258.19
|
| Rate for Payer: Health EOS Commercial |
$1,217.16
|
| Rate for Payer: HFN Commercial |
$1,258.19
|
| Rate for Payer: Multiplan Commercial |
$1,094.08
|
| Rate for Payer: Preferred Network Access Commercial |
$1,258.19
|
| Rate for Payer: Quartz Beloit One Network |
$670.12
|
| Rate for Payer: Quartz Commercial |
$820.56
|
| Rate for Payer: WEA Trust Commercial |
$752.18
|
| Rate for Payer: WPS Commercial |
$1,012.94
|
|
|
SHEETING PHARMELAST SILICONE #20-10
|
Facility
|
OP
|
$1,315.00
|
|
| Hospital Charge Code |
2967369
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$382.93 |
| Max. Negotiated Rate |
$1,258.19 |
| Rate for Payer: Aetna Commercial |
$1,230.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,176.14
|
| Rate for Payer: Aetna Managed Medicare |
$382.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$888.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$683.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$656.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$724.83
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$1,258.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$765.33
|
| Rate for Payer: Health EOS Commercial |
$1,217.16
|
| Rate for Payer: HFN Commercial |
$1,258.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,025.70
|
| Rate for Payer: Multiplan Commercial |
$1,094.08
|
| Rate for Payer: NAPHCARE Commercial |
$820.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,258.19
|
| Rate for Payer: Quartz Beloit One Network |
$670.12
|
| Rate for Payer: Quartz Commercial |
$888.94
|
| Rate for Payer: Quartz Medicare Advantage |
$820.56
|
| Rate for Payer: The Alliance Commercial |
$683.80
|
| Rate for Payer: WEA Trust Commercial |
$752.18
|
| Rate for Payer: WPS Commercial |
$1,012.94
|
|
|
SHEETING PHARMELAST SILICONE #20-20
|
Facility
|
OP
|
$1,440.00
|
|
| Hospital Charge Code |
2967370
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$419.33 |
| Max. Negotiated Rate |
$1,377.79 |
| Rate for Payer: Aetna Commercial |
$1,347.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,287.94
|
| Rate for Payer: Aetna Managed Medicare |
$419.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$973.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$748.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$718.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$793.73
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$1,377.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$838.08
|
| Rate for Payer: Health EOS Commercial |
$1,332.86
|
| Rate for Payer: HFN Commercial |
$1,377.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,123.20
|
| Rate for Payer: Multiplan Commercial |
$1,198.08
|
| Rate for Payer: NAPHCARE Commercial |
$898.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,377.79
|
| Rate for Payer: Quartz Beloit One Network |
$733.82
|
| Rate for Payer: Quartz Commercial |
$973.44
|
| Rate for Payer: Quartz Medicare Advantage |
$898.56
|
| Rate for Payer: The Alliance Commercial |
$748.80
|
| Rate for Payer: WEA Trust Commercial |
$823.68
|
| Rate for Payer: WPS Commercial |
$1,109.23
|
|
|
SHEETING PHARMELAST SILICONE #20-20
|
Facility
|
IP
|
$1,440.00
|
|
| Hospital Charge Code |
2967370
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$733.82 |
| Max. Negotiated Rate |
$1,377.79 |
| Rate for Payer: Aetna Commercial |
$1,347.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,287.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$793.73
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$1,377.79
|
| Rate for Payer: Health EOS Commercial |
$1,332.86
|
| Rate for Payer: HFN Commercial |
$1,377.79
|
| Rate for Payer: Multiplan Commercial |
$1,198.08
|
| Rate for Payer: Preferred Network Access Commercial |
$1,377.79
|
| Rate for Payer: Quartz Beloit One Network |
$733.82
|
| Rate for Payer: Quartz Commercial |
$898.56
|
| Rate for Payer: WEA Trust Commercial |
$823.68
|
| Rate for Payer: WPS Commercial |
$1,109.23
|
|
|
SHEETING SILICONE 6X8 .040
|
Facility
|
IP
|
$2,623.00
|
|
| Hospital Charge Code |
2974002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,336.68 |
| Max. Negotiated Rate |
$2,509.69 |
| Rate for Payer: Aetna Commercial |
$2,455.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,346.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,445.80
|
| Rate for Payer: Cash Price |
$786.90
|
| Rate for Payer: Cigna Commercial |
$2,509.69
|
| Rate for Payer: Health EOS Commercial |
$2,427.85
|
| Rate for Payer: HFN Commercial |
$2,509.69
|
| Rate for Payer: Multiplan Commercial |
$2,182.34
|
| Rate for Payer: Preferred Network Access Commercial |
$2,509.69
|
| Rate for Payer: Quartz Beloit One Network |
$1,336.68
|
| Rate for Payer: Quartz Commercial |
$1,636.75
|
| Rate for Payer: WEA Trust Commercial |
$1,500.36
|
| Rate for Payer: WPS Commercial |
$2,020.50
|
|
|
SHEETING SILICONE 6X8 .040
|
Facility
|
OP
|
$2,623.00
|
|
| Hospital Charge Code |
2974002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$763.82 |
| Max. Negotiated Rate |
$2,509.69 |
| Rate for Payer: Aetna Commercial |
$2,455.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,346.01
|
| Rate for Payer: Aetna Managed Medicare |
$763.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,773.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,363.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,309.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,445.80
|
| Rate for Payer: Cash Price |
$786.90
|
| Rate for Payer: Cigna Commercial |
$2,509.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,526.59
|
| Rate for Payer: Health EOS Commercial |
$2,427.85
|
| Rate for Payer: HFN Commercial |
$2,509.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,045.94
|
| Rate for Payer: Multiplan Commercial |
$2,182.34
|
| Rate for Payer: NAPHCARE Commercial |
$1,636.75
|
| Rate for Payer: Preferred Network Access Commercial |
$2,509.69
|
| Rate for Payer: Quartz Beloit One Network |
$1,336.68
|
| Rate for Payer: Quartz Commercial |
$1,773.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,636.75
|
| Rate for Payer: The Alliance Commercial |
$1,363.96
|
| Rate for Payer: WEA Trust Commercial |
$1,500.36
|
| Rate for Payer: WPS Commercial |
$2,020.50
|
|
|
SHEET SILICONE 6 X 8 .040 25-40
|
Facility
|
IP
|
$984.00
|
|
| Hospital Charge Code |
2969466
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$501.45 |
| Max. Negotiated Rate |
$941.49 |
| Rate for Payer: Aetna Commercial |
$921.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$880.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$542.38
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$941.49
|
| Rate for Payer: Health EOS Commercial |
$910.79
|
| Rate for Payer: HFN Commercial |
$941.49
|
| Rate for Payer: Multiplan Commercial |
$818.69
|
| Rate for Payer: Preferred Network Access Commercial |
$941.49
|
| Rate for Payer: Quartz Beloit One Network |
$501.45
|
| Rate for Payer: Quartz Commercial |
$614.02
|
| Rate for Payer: WEA Trust Commercial |
$562.85
|
| Rate for Payer: WPS Commercial |
$757.98
|
|
|
SHEET SILICONE 6 X 8 .040 25-40
|
Facility
|
OP
|
$984.00
|
|
| Hospital Charge Code |
2969466
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$286.54 |
| Max. Negotiated Rate |
$941.49 |
| Rate for Payer: Aetna Commercial |
$921.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$880.09
|
| Rate for Payer: Aetna Managed Medicare |
$286.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$665.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$511.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$491.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$542.38
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$941.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$572.69
|
| Rate for Payer: Health EOS Commercial |
$910.79
|
| Rate for Payer: HFN Commercial |
$941.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$767.52
|
| Rate for Payer: Multiplan Commercial |
$818.69
|
| Rate for Payer: NAPHCARE Commercial |
$614.02
|
| Rate for Payer: Preferred Network Access Commercial |
$941.49
|
| Rate for Payer: Quartz Beloit One Network |
$501.45
|
| Rate for Payer: Quartz Commercial |
$665.18
|
| Rate for Payer: Quartz Medicare Advantage |
$614.02
|
| Rate for Payer: The Alliance Commercial |
$511.68
|
| Rate for Payer: WEA Trust Commercial |
$562.85
|
| Rate for Payer: WPS Commercial |
$757.98
|
|
|
SHEET SPLIT ARTHROSCOPY 60x70 89331
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2963306
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.67 |
| Max. Negotiated Rate |
$66.98 |
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.58
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: Health EOS Commercial |
$64.79
|
| Rate for Payer: HFN Commercial |
$66.98
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: Preferred Network Access Commercial |
$66.98
|
| Rate for Payer: Quartz Beloit One Network |
$35.67
|
| Rate for Payer: Quartz Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: WPS Commercial |
$53.92
|
|
|
SHEET SPLIT ARTHROSCOPY 60x70 89331
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2963306
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$66.98 |
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Aetna Managed Medicare |
$20.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.58
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.74
|
| Rate for Payer: Health EOS Commercial |
$64.79
|
| Rate for Payer: HFN Commercial |
$66.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.60
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: NAPHCARE Commercial |
$43.68
|
| Rate for Payer: Preferred Network Access Commercial |
$66.98
|
| Rate for Payer: Quartz Beloit One Network |
$35.67
|
| Rate for Payer: Quartz Commercial |
$47.32
|
| Rate for Payer: Quartz Medicare Advantage |
$43.68
|
| Rate for Payer: The Alliance Commercial |
$36.40
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: WPS Commercial |
$53.92
|
|
|
SHEET SPLIT WITH ADHESIVE 89301
|
Facility
|
OP
|
$164.00
|
|
| Hospital Charge Code |
2963274
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.76 |
| Max. Negotiated Rate |
$156.92 |
| Rate for Payer: Aetna Commercial |
$153.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.68
|
| Rate for Payer: Aetna Managed Medicare |
$47.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$85.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.40
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$156.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.45
|
| Rate for Payer: Health EOS Commercial |
$151.80
|
| Rate for Payer: HFN Commercial |
$156.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.92
|
| Rate for Payer: Multiplan Commercial |
$136.45
|
| Rate for Payer: NAPHCARE Commercial |
$102.34
|
| Rate for Payer: Preferred Network Access Commercial |
$156.92
|
| Rate for Payer: Quartz Beloit One Network |
$83.57
|
| Rate for Payer: Quartz Commercial |
$110.86
|
| Rate for Payer: Quartz Medicare Advantage |
$102.34
|
| Rate for Payer: The Alliance Commercial |
$85.28
|
| Rate for Payer: WEA Trust Commercial |
$93.81
|
| Rate for Payer: WPS Commercial |
$126.33
|
|
|
SHEET SPLIT WITH ADHESIVE 89301
|
Facility
|
IP
|
$164.00
|
|
| Hospital Charge Code |
2963274
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.57 |
| Max. Negotiated Rate |
$156.92 |
| Rate for Payer: Aetna Commercial |
$153.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.40
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$156.92
|
| Rate for Payer: Health EOS Commercial |
$151.80
|
| Rate for Payer: HFN Commercial |
$156.92
|
| Rate for Payer: Multiplan Commercial |
$136.45
|
| Rate for Payer: Preferred Network Access Commercial |
$156.92
|
| Rate for Payer: Quartz Beloit One Network |
$83.57
|
| Rate for Payer: Quartz Commercial |
$102.34
|
| Rate for Payer: WEA Trust Commercial |
$93.81
|
| Rate for Payer: WPS Commercial |
$126.33
|
|
|
SHEET TRANSVERSE LAP 72 x 119 89281
|
Facility
|
OP
|
$194.00
|
|
| Hospital Charge Code |
2963259
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.49 |
| Max. Negotiated Rate |
$185.62 |
| Rate for Payer: Aetna Commercial |
$181.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Aetna Managed Medicare |
$56.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.93
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.91
|
| Rate for Payer: Health EOS Commercial |
$179.57
|
| Rate for Payer: HFN Commercial |
$185.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.32
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: NAPHCARE Commercial |
$121.06
|
| Rate for Payer: Preferred Network Access Commercial |
$185.62
|
| Rate for Payer: Quartz Beloit One Network |
$98.86
|
| Rate for Payer: Quartz Commercial |
$131.14
|
| Rate for Payer: Quartz Medicare Advantage |
$121.06
|
| Rate for Payer: The Alliance Commercial |
$100.88
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$149.44
|
|
|
SHEET TRANSVERSE LAP 72 x 119 89281
|
Facility
|
IP
|
$194.00
|
|
| Hospital Charge Code |
2963259
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.86 |
| Max. Negotiated Rate |
$185.62 |
| Rate for Payer: Aetna Commercial |
$181.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.93
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Health EOS Commercial |
$179.57
|
| Rate for Payer: HFN Commercial |
$185.62
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: Preferred Network Access Commercial |
$185.62
|
| Rate for Payer: Quartz Beloit One Network |
$98.86
|
| Rate for Payer: Quartz Commercial |
$121.06
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$149.44
|
|
|
SHEILD SPLASH STERILE ZEROWET #SS-100
|
Facility
|
IP
|
$62.00
|
|
| Hospital Charge Code |
2969559
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.60 |
| Max. Negotiated Rate |
$59.32 |
| Rate for Payer: Aetna Commercial |
$58.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.17
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$59.32
|
| Rate for Payer: Health EOS Commercial |
$57.39
|
| Rate for Payer: HFN Commercial |
$59.32
|
| Rate for Payer: Multiplan Commercial |
$51.58
|
| Rate for Payer: Preferred Network Access Commercial |
$59.32
|
| Rate for Payer: Quartz Beloit One Network |
$31.60
|
| Rate for Payer: Quartz Commercial |
$38.69
|
| Rate for Payer: WEA Trust Commercial |
$35.46
|
| Rate for Payer: WPS Commercial |
$47.76
|
|
|
SHEILD SPLASH STERILE ZEROWET #SS-100
|
Facility
|
OP
|
$62.00
|
|
| Hospital Charge Code |
2969559
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$59.32 |
| Rate for Payer: Aetna Commercial |
$58.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.45
|
| Rate for Payer: Aetna Managed Medicare |
$18.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.17
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$59.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.08
|
| Rate for Payer: Health EOS Commercial |
$57.39
|
| Rate for Payer: HFN Commercial |
$59.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.36
|
| Rate for Payer: Multiplan Commercial |
$51.58
|
| Rate for Payer: NAPHCARE Commercial |
$38.69
|
| Rate for Payer: Preferred Network Access Commercial |
$59.32
|
| Rate for Payer: Quartz Beloit One Network |
$31.60
|
| Rate for Payer: Quartz Commercial |
$41.91
|
| Rate for Payer: Quartz Medicare Advantage |
$38.69
|
| Rate for Payer: The Alliance Commercial |
$32.24
|
| Rate for Payer: WEA Trust Commercial |
$35.46
|
| Rate for Payer: WPS Commercial |
$47.76
|
|
|
SHELL 44MM TRABEC CLUSTER 6202-44-22
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
SHELL 44MM TRABEC CLUSTER 6202-44-22
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
