|
Aviator 4mm x 2cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Aviator 4mm x 2cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Aviator 5mm x 2cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Aviator 5mm x 2cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Aviator 5mm x 2cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Aviator 6mm x 2cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546816
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Aviator 6mm x 2cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546816
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Aviator 6mm x 2cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546816
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Aviator 7mm x 2cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546818
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Aviator 7mm x 2cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546818
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Aviator 7mm x 2cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546818
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
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 |
$553.43 |
| Max. Negotiated Rate |
$1,039.08 |
| Rate for Payer: Aetna Commercial |
$1,016.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$971.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.60
|
| Rate for Payer: Cash Price |
$325.80
|
| Rate for Payer: Cigna Commercial |
$1,039.08
|
| Rate for Payer: Health EOS Commercial |
$1,005.20
|
| Rate for Payer: HFN Commercial |
$1,039.08
|
| Rate for Payer: Multiplan Commercial |
$903.55
|
| Rate for Payer: Preferred Network Access Commercial |
$1,039.08
|
| Rate for Payer: Quartz Beloit One Network |
$553.43
|
| Rate for Payer: Quartz Commercial |
$677.66
|
| Rate for Payer: WEA Trust Commercial |
$621.19
|
| Rate for Payer: WPS Commercial |
$836.55
|
|
|
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 |
$316.24 |
| Max. Negotiated Rate |
$1,128.28 |
| Rate for Payer: Aetna Commercial |
$1,016.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$971.32
|
| Rate for Payer: Aetna Managed Medicare |
$316.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$734.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$564.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$542.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.60
|
| Rate for Payer: Cash Price |
$325.80
|
| Rate for Payer: Cash Price |
$325.80
|
| Rate for Payer: Cigna Commercial |
$1,039.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$632.05
|
| Rate for Payer: Health EOS Commercial |
$1,005.20
|
| Rate for Payer: HFN Commercial |
$1,039.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$847.08
|
| Rate for Payer: Multiplan Commercial |
$903.55
|
| Rate for Payer: NAPHCARE Commercial |
$677.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,039.08
|
| Rate for Payer: Quartz Beloit One Network |
$553.43
|
| Rate for Payer: Quartz Commercial |
$734.14
|
| Rate for Payer: Quartz Medicare Advantage |
$677.66
|
| Rate for Payer: The Alliance Commercial |
$1,128.28
|
| Rate for Payer: WEA Trust Commercial |
$621.19
|
| Rate for Payer: WPS Commercial |
$836.55
|
|
|
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 |
$927.47 |
| Max. Negotiated Rate |
$1,741.38 |
| Rate for Payer: Aetna Commercial |
$1,703.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,627.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,003.18
|
| Rate for Payer: Cash Price |
$546.00
|
| Rate for Payer: Cigna Commercial |
$1,741.38
|
| Rate for Payer: Health EOS Commercial |
$1,684.59
|
| Rate for Payer: HFN Commercial |
$1,741.38
|
| Rate for Payer: Multiplan Commercial |
$1,514.24
|
| Rate for Payer: Preferred Network Access Commercial |
$1,741.38
|
| Rate for Payer: Quartz Beloit One Network |
$927.47
|
| Rate for Payer: Quartz Commercial |
$1,135.68
|
| Rate for Payer: WEA Trust Commercial |
$1,041.04
|
| Rate for Payer: WPS Commercial |
$1,401.95
|
|
|
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 |
$124.68 |
| Max. Negotiated Rate |
$1,741.38 |
| Rate for Payer: Aetna Commercial |
$1,703.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,627.81
|
| Rate for Payer: Aetna Managed Medicare |
$529.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,230.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$946.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$908.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,003.18
|
| Rate for Payer: Cash Price |
$546.00
|
| Rate for Payer: Cash Price |
$546.00
|
| Rate for Payer: Cigna Commercial |
$1,741.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,059.24
|
| Rate for Payer: Health EOS Commercial |
$1,684.59
|
| Rate for Payer: HFN Commercial |
$1,741.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,419.60
|
| Rate for Payer: Multiplan Commercial |
$1,514.24
|
| Rate for Payer: NAPHCARE Commercial |
$1,135.68
|
| Rate for Payer: Preferred Network Access Commercial |
$1,741.38
|
| Rate for Payer: Quartz Beloit One Network |
$927.47
|
| Rate for Payer: Quartz Commercial |
$1,230.32
|
| Rate for Payer: Quartz Medicare Advantage |
$1,135.68
|
| Rate for Payer: The Alliance Commercial |
$124.68
|
| Rate for Payer: WEA Trust Commercial |
$1,041.04
|
| Rate for Payer: WPS Commercial |
$1,401.95
|
|
|
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 |
$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: 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 |
$124.68
|
| Rate for Payer: WEA Trust Commercial |
$126.98
|
| Rate for Payer: WPS Commercial |
$171.01
|
|
|
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 |
$113.13 |
| Max. Negotiated Rate |
$212.41 |
| Rate for Payer: Aetna Commercial |
$207.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$198.56
|
| 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: Health EOS Commercial |
$205.48
|
| Rate for Payer: HFN Commercial |
$212.41
|
| Rate for Payer: Multiplan Commercial |
$184.70
|
| Rate for Payer: Preferred Network Access Commercial |
$212.41
|
| Rate for Payer: Quartz Beloit One Network |
$113.13
|
| Rate for Payer: Quartz Commercial |
$138.53
|
| Rate for Payer: WEA Trust Commercial |
$126.98
|
| Rate for Payer: WPS Commercial |
$171.01
|
|
|
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 |
$164.09 |
| Max. Negotiated Rate |
$308.09 |
| Rate for Payer: Aetna Commercial |
$301.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$288.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.49
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$308.09
|
| Rate for Payer: Health EOS Commercial |
$298.04
|
| Rate for Payer: HFN Commercial |
$308.09
|
| Rate for Payer: Multiplan Commercial |
$267.90
|
| Rate for Payer: Preferred Network Access Commercial |
$308.09
|
| Rate for Payer: Quartz Beloit One Network |
$164.09
|
| Rate for Payer: Quartz Commercial |
$200.93
|
| Rate for Payer: WEA Trust Commercial |
$184.18
|
| Rate for Payer: WPS Commercial |
$248.04
|
|
|
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 |
$93.77 |
| Max. Negotiated Rate |
$1,128.28 |
| Rate for Payer: Aetna Commercial |
$301.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$288.00
|
| Rate for Payer: Aetna Managed Medicare |
$93.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.49
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$308.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$187.40
|
| Rate for Payer: Health EOS Commercial |
$298.04
|
| Rate for Payer: HFN Commercial |
$308.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$251.16
|
| Rate for Payer: Multiplan Commercial |
$267.90
|
| Rate for Payer: NAPHCARE Commercial |
$200.93
|
| Rate for Payer: Preferred Network Access Commercial |
$308.09
|
| Rate for Payer: Quartz Beloit One Network |
$164.09
|
| Rate for Payer: Quartz Commercial |
$217.67
|
| Rate for Payer: Quartz Medicare Advantage |
$200.93
|
| Rate for Payer: The Alliance Commercial |
$1,128.28
|
| Rate for Payer: WEA Trust Commercial |
$184.18
|
| Rate for Payer: WPS Commercial |
$248.04
|
|
|
Avulsion of Nail Plate 11730
|
Professional
|
Both
|
$342.00
|
|
|
Service Code
|
CPT 11730
|
| Hospital Charge Code |
2572799
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$337.90 |
| Rate for Payer: Aetna Commercial |
$337.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$305.88
|
| Rate for Payer: Aetna Managed Medicare |
$48.27
|
| Rate for Payer: Anthem Medicare Advantage |
$48.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$48.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$48.27
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$337.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.27
|
| Rate for Payer: Health EOS Commercial |
$323.67
|
| Rate for Payer: HFN Commercial |
$337.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$189.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$48.27
|
| Rate for Payer: Multiplan Commercial |
$284.54
|
| Rate for Payer: NAPHCARE Commercial |
$72.40
|
| Rate for Payer: Preferred Network Access Commercial |
$337.90
|
| Rate for Payer: Quartz Beloit One Network |
$156.50
|
| Rate for Payer: Quartz Commercial |
$202.74
|
| Rate for Payer: Quartz Medicare Advantage |
$48.27
|
| Rate for Payer: The Alliance Commercial |
$205.13
|
| Rate for Payer: United Healthcare Medicaid |
$43.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.27
|
| Rate for Payer: WEA Trust Commercial |
$195.62
|
| Rate for Payer: WPS Commercial |
$217.20
|
|
|
Avulsion of Nail Plate, Additional 11732
|
Professional
|
Both
|
$156.00
|
|
|
Service Code
|
CPT 11732
|
| Hospital Charge Code |
2572800
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$154.13 |
| Rate for Payer: Aetna Commercial |
$154.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Aetna Managed Medicare |
$14.84
|
| Rate for Payer: Anthem Medicare Advantage |
$14.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.84
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$154.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.84
|
| Rate for Payer: Health EOS Commercial |
$147.64
|
| Rate for Payer: HFN Commercial |
$154.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$61.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.84
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: NAPHCARE Commercial |
$22.26
|
| Rate for Payer: Preferred Network Access Commercial |
$154.13
|
| Rate for Payer: Quartz Beloit One Network |
$71.39
|
| Rate for Payer: Quartz Commercial |
$92.48
|
| Rate for Payer: Quartz Medicare Advantage |
$14.84
|
| Rate for Payer: The Alliance Commercial |
$63.07
|
| Rate for Payer: United Healthcare Medicaid |
$21.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.84
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$66.78
|
|
|
AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 11732
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$59.36 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: The Alliance Commercial |
$59.36
|
|
|
AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 11730
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$211.14 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Managed Medicare |
$211.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Anthem Medicare Advantage |
$211.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$211.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$211.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$211.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$211.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$785.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$211.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$211.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$211.14
|
| Rate for Payer: NAPHCARE Commercial |
$316.71
|
| Rate for Payer: Quartz Medicare Advantage |
$211.14
|
| Rate for Payer: The Alliance Commercial |
$844.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$211.14
|
| Rate for Payer: United Healthcare PPO |
$2,347.28
|
| Rate for Payer: Wellcare Medicare |
$211.14
|
|
|
Awake Maintenance Test(MWT)
|
Facility
|
IP
|
$3,781.00
|
|
|
Service Code
|
CPT 95805
|
| Hospital Charge Code |
3101729
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$1,926.80 |
| Max. Negotiated Rate |
$3,617.66 |
| Rate for Payer: Aetna Commercial |
$3,539.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,381.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,084.09
|
| Rate for Payer: Cash Price |
$1,134.30
|
| Rate for Payer: Cigna Commercial |
$3,617.66
|
| Rate for Payer: Health EOS Commercial |
$3,499.69
|
| Rate for Payer: HFN Commercial |
$3,617.66
|
| Rate for Payer: Multiplan Commercial |
$3,145.79
|
| Rate for Payer: Preferred Network Access Commercial |
$3,617.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,926.80
|
| Rate for Payer: Quartz Commercial |
$2,359.34
|
| Rate for Payer: WEA Trust Commercial |
$2,162.73
|
| Rate for Payer: WPS Commercial |
$2,912.50
|
|
|
Awake Maintenance Test(MWT)
|
Facility
|
OP
|
$3,781.00
|
|
|
Service Code
|
CPT 95805
|
| Hospital Charge Code |
3101729
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$903.73 |
| Max. Negotiated Rate |
$3,635.84 |
| Rate for Payer: Aetna Commercial |
$3,539.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,381.73
|
| Rate for Payer: Aetna Managed Medicare |
$903.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$903.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,084.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$903.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$903.73
|
| Rate for Payer: Cash Price |
$1,134.30
|
| Rate for Payer: Cash Price |
$1,134.30
|
| Rate for Payer: Cash Price |
$1,134.30
|
| Rate for Payer: Cigna Commercial |
$3,617.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$903.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,200.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$903.73
|
| Rate for Payer: Health EOS Commercial |
$3,499.69
|
| Rate for Payer: HFN Commercial |
$3,617.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,361.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$903.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$903.73
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$903.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$903.73
|
| Rate for Payer: Multiplan Commercial |
$3,145.79
|
| Rate for Payer: NAPHCARE Commercial |
$1,355.59
|
| Rate for Payer: Preferred Network Access Commercial |
$3,617.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,926.80
|
| Rate for Payer: Quartz Commercial |
$2,555.96
|
| Rate for Payer: Quartz Medicare Advantage |
$903.73
|
| Rate for Payer: The Alliance Commercial |
$3,614.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$903.73
|
| Rate for Payer: United Healthcare PPO |
$2,949.18
|
| Rate for Payer: WEA Trust Commercial |
$2,162.73
|
| Rate for Payer: Wellcare Medicare |
$903.73
|
| Rate for Payer: WPS Commercial |
$2,912.50
|
|
