|
Surgical Dress Holder Reuse A4463
|
Professional
|
Both
|
$49.00
|
|
|
Service Code
|
HCPCS A4463
|
| Hospital Charge Code |
4954606
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$54.68 |
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.40
|
| Rate for Payer: Health EOS Commercial |
$44.59
|
| Rate for Payer: HFN Commercial |
$46.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.68
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: Preferred Network Access Commercial |
$46.55
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$27.93
|
| Rate for Payer: The Alliance Commercial |
$24.50
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$4,757.59
|
|
|
Service Code
|
CPT 15004
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$620.77 |
| Max. Negotiated Rate |
$4,757.59 |
| Rate for Payer: Aetna Managed Medicare |
$620.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$620.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$620.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$620.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$620.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$620.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,309.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$620.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$620.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$620.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$620.77
|
| Rate for Payer: NAPHCARE Commercial |
$931.16
|
| Rate for Payer: Quartz Medicare Advantage |
$620.77
|
| Rate for Payer: The Alliance Commercial |
$2,483.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$620.77
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$620.77
|
|
|
SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$7,209.92
|
|
|
Service Code
|
CPT 15002
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.48 |
| Max. Negotiated Rate |
$7,209.92 |
| Rate for Payer: Aetna Managed Medicare |
$1,802.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,802.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,802.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,802.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,705.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,802.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,802.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,802.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,802.48
|
| Rate for Payer: NAPHCARE Commercial |
$2,703.72
|
| Rate for Payer: Quartz Medicare Advantage |
$1,802.48
|
| Rate for Payer: The Alliance Commercial |
$7,209.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,802.48
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,802.48
|
|
|
SURGICAL SEALANT COSEAL 4ML 934071
|
Facility
|
IP
|
$5,240.00
|
|
| Hospital Charge Code |
5563743
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,567.60 |
| Max. Negotiated Rate |
$4,820.80 |
| Rate for Payer: Aetna Commercial |
$4,716.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,506.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,777.20
|
| Rate for Payer: Cash Price |
$1,572.00
|
| Rate for Payer: Cigna Commercial |
$4,820.80
|
| Rate for Payer: Health EOS Commercial |
$4,663.60
|
| Rate for Payer: HFN Commercial |
$4,820.80
|
| Rate for Payer: Multiplan Commercial |
$4,192.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,144.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,820.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,567.60
|
| Rate for Payer: Quartz Commercial |
$3,144.00
|
| Rate for Payer: WEA Trust Commercial |
$2,882.00
|
| Rate for Payer: WPS Commercial |
$3,881.27
|
|
|
SURGICAL SEALANT COSEAL 4ML 934071
|
Facility
|
OP
|
$5,240.00
|
|
| Hospital Charge Code |
5563743
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,467.20 |
| Max. Negotiated Rate |
$20,960.00 |
| Rate for Payer: Aetna Commercial |
$4,716.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,506.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,406.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,620.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,515.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,777.20
|
| Rate for Payer: Cash Price |
$1,572.00
|
| Rate for Payer: Cigna Commercial |
$4,820.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,932.30
|
| Rate for Payer: Health EOS Commercial |
$4,663.60
|
| Rate for Payer: HFN Commercial |
$4,820.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,930.00
|
| Rate for Payer: Multiplan Commercial |
$4,192.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,144.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,820.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,567.60
|
| Rate for Payer: Quartz Commercial |
$3,406.00
|
| Rate for Payer: Quartz Medicare Advantage |
$3,144.00
|
| Rate for Payer: The Alliance Commercial |
$20,960.00
|
| Rate for Payer: WEA Trust Commercial |
$2,882.00
|
| Rate for Payer: WPS Commercial |
$3,881.27
|
|
|
SURGICAL SEALANT PREVELEAK 4ML ADS201808
|
Facility
|
IP
|
$5,699.00
|
|
| Hospital Charge Code |
5264699
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,792.51 |
| Max. Negotiated Rate |
$5,243.08 |
| Rate for Payer: Aetna Commercial |
$5,129.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,901.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,020.47
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,243.08
|
| Rate for Payer: Health EOS Commercial |
$5,072.11
|
| Rate for Payer: HFN Commercial |
$5,243.08
|
| Rate for Payer: Multiplan Commercial |
$4,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,419.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,243.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,792.51
|
| Rate for Payer: Quartz Commercial |
$3,419.40
|
| Rate for Payer: WEA Trust Commercial |
$3,134.45
|
| Rate for Payer: WPS Commercial |
$4,221.25
|
|
|
SURGICAL SEALANT PREVELEAK 4ML ADS201808
|
Facility
|
OP
|
$5,699.00
|
|
| Hospital Charge Code |
5264699
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,595.72 |
| Max. Negotiated Rate |
$22,796.00 |
| Rate for Payer: Aetna Commercial |
$5,129.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,901.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,595.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,704.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,849.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,735.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,020.47
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,243.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,189.16
|
| Rate for Payer: Health EOS Commercial |
$5,072.11
|
| Rate for Payer: HFN Commercial |
$5,243.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,274.25
|
| Rate for Payer: Multiplan Commercial |
$4,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,419.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,243.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,792.51
|
| Rate for Payer: Quartz Commercial |
$3,704.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,419.40
|
| Rate for Payer: The Alliance Commercial |
$22,796.00
|
| Rate for Payer: WEA Trust Commercial |
$3,134.45
|
| Rate for Payer: WPS Commercial |
$4,221.25
|
|
|
SURGICAL SEALANT PROGEL PLEURAL AIR LEAK PGPS002
|
Facility
|
IP
|
$7,350.00
|
|
|
Service Code
|
HCPCS C2615
|
| Hospital Charge Code |
3072346
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,601.50 |
| Max. Negotiated Rate |
$6,762.00 |
| Rate for Payer: Aetna Commercial |
$6,615.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,321.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,895.50
|
| Rate for Payer: Cash Price |
$2,205.00
|
| Rate for Payer: Cigna Commercial |
$6,762.00
|
| Rate for Payer: Health EOS Commercial |
$6,541.50
|
| Rate for Payer: HFN Commercial |
$6,762.00
|
| Rate for Payer: Multiplan Commercial |
$5,880.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,410.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,762.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,601.50
|
| Rate for Payer: Quartz Commercial |
$4,410.00
|
| Rate for Payer: WEA Trust Commercial |
$4,042.50
|
| Rate for Payer: WPS Commercial |
$5,444.14
|
|
|
SURGICAL SEALANT PROGEL PLEURAL AIR LEAK PGPS002
|
Facility
|
OP
|
$7,350.00
|
|
|
Service Code
|
HCPCS C2615
|
| Hospital Charge Code |
3072346
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,058.00 |
| Max. Negotiated Rate |
$29,400.00 |
| Rate for Payer: Aetna Commercial |
$6,615.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,321.00
|
| Rate for Payer: Aetna Managed Medicare |
$2,058.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,777.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,675.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,528.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,895.50
|
| Rate for Payer: Cash Price |
$2,205.00
|
| Rate for Payer: Cigna Commercial |
$6,762.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,113.06
|
| Rate for Payer: Health EOS Commercial |
$6,541.50
|
| Rate for Payer: HFN Commercial |
$6,762.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,512.50
|
| Rate for Payer: Multiplan Commercial |
$5,880.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,410.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,762.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,601.50
|
| Rate for Payer: Quartz Commercial |
$4,777.50
|
| Rate for Payer: Quartz Medicare Advantage |
$4,410.00
|
| Rate for Payer: The Alliance Commercial |
$29,400.00
|
| Rate for Payer: WEA Trust Commercial |
$4,042.50
|
| Rate for Payer: WPS Commercial |
$5,444.14
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC
|
Facility
|
OP
|
$11,100.96
|
|
|
Service Code
|
CPT 46275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$11,100.96 |
| Rate for Payer: Aetna Managed Medicare |
$2,775.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$2,775.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,775.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,775.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,775.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,775.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,323.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,775.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,775.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,775.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,775.24
|
| Rate for Payer: NAPHCARE Commercial |
$4,162.86
|
| Rate for Payer: Quartz Medicare Advantage |
$2,775.24
|
| Rate for Payer: The Alliance Commercial |
$11,100.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,775.24
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$2,775.24
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS
|
Facility
|
OP
|
$11,100.96
|
|
|
Service Code
|
CPT 46270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$11,100.96 |
| Rate for Payer: Aetna Managed Medicare |
$2,775.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$2,775.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,775.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,775.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,775.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,775.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,323.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,775.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,775.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,775.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,775.24
|
| Rate for Payer: NAPHCARE Commercial |
$4,162.86
|
| Rate for Payer: Quartz Medicare Advantage |
$2,775.24
|
| Rate for Payer: The Alliance Commercial |
$11,100.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,775.24
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$2,775.24
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED
|
Facility
|
OP
|
$11,100.96
|
|
|
Service Code
|
CPT 46280
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$11,100.96 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,795.33
|
| Rate for Payer: Aetna Managed Medicare |
$2,775.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$2,775.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,775.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,775.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,775.24
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,775.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,323.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,775.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,775.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,775.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,775.24
|
| Rate for Payer: NAPHCARE Commercial |
$4,162.86
|
| Rate for Payer: Quartz Medicare Advantage |
$2,775.24
|
| Rate for Payer: The Alliance Commercial |
$11,100.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,775.24
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$2,775.24
|
|
|
Surgicel 1 x 2" [Med]"
|
Facility
|
OP
|
$397.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2974983
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.16 |
| Max. Negotiated Rate |
$1,588.00 |
| Rate for Payer: Aetna Commercial |
$357.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Aetna Managed Medicare |
$111.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$258.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$198.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$190.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.41
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$365.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.16
|
| Rate for Payer: Health EOS Commercial |
$353.33
|
| Rate for Payer: HFN Commercial |
$365.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$297.75
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: NAPHCARE Commercial |
$238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$365.24
|
| Rate for Payer: Quartz Beloit One Network |
$194.53
|
| Rate for Payer: Quartz Commercial |
$258.05
|
| Rate for Payer: Quartz Medicare Advantage |
$238.20
|
| Rate for Payer: The Alliance Commercial |
$1,588.00
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
Surgicel 1 x 2" [Med]"
|
Facility
|
IP
|
$397.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2974983
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$194.53 |
| Max. Negotiated Rate |
$365.24 |
| Rate for Payer: Aetna Commercial |
$357.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.41
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$365.24
|
| Rate for Payer: Health EOS Commercial |
$353.33
|
| Rate for Payer: HFN Commercial |
$365.24
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: NAPHCARE Commercial |
$238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$365.24
|
| Rate for Payer: Quartz Beloit One Network |
$194.53
|
| Rate for Payer: Quartz Commercial |
$238.20
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
SURGICEL 2 X 3 HEMOSTAT 1953
|
Facility
|
IP
|
$850.00
|
|
| Hospital Charge Code |
2974579
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$416.50 |
| Max. Negotiated Rate |
$782.00 |
| Rate for Payer: Aetna Commercial |
$765.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$731.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$450.50
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$782.00
|
| Rate for Payer: Health EOS Commercial |
$756.50
|
| Rate for Payer: HFN Commercial |
$782.00
|
| Rate for Payer: Multiplan Commercial |
$680.00
|
| Rate for Payer: NAPHCARE Commercial |
$510.00
|
| Rate for Payer: Preferred Network Access Commercial |
$782.00
|
| Rate for Payer: Quartz Beloit One Network |
$416.50
|
| Rate for Payer: Quartz Commercial |
$510.00
|
| Rate for Payer: WEA Trust Commercial |
$467.50
|
| Rate for Payer: WPS Commercial |
$629.60
|
|
|
SURGICEL 2 X 3 HEMOSTAT 1953
|
Facility
|
OP
|
$850.00
|
|
| Hospital Charge Code |
2974579
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.00 |
| Max. Negotiated Rate |
$3,400.00 |
| Rate for Payer: Aetna Commercial |
$765.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$731.00
|
| Rate for Payer: Aetna Managed Medicare |
$238.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$552.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$425.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$408.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$450.50
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$782.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$475.66
|
| Rate for Payer: Health EOS Commercial |
$756.50
|
| Rate for Payer: HFN Commercial |
$782.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$637.50
|
| Rate for Payer: Multiplan Commercial |
$680.00
|
| Rate for Payer: NAPHCARE Commercial |
$510.00
|
| Rate for Payer: Preferred Network Access Commercial |
$782.00
|
| Rate for Payer: Quartz Beloit One Network |
$416.50
|
| Rate for Payer: Quartz Commercial |
$552.50
|
| Rate for Payer: Quartz Medicare Advantage |
$510.00
|
| Rate for Payer: The Alliance Commercial |
$3,400.00
|
| Rate for Payer: WEA Trust Commercial |
$467.50
|
| Rate for Payer: WPS Commercial |
$629.60
|
|
|
Surgicel 2 x 3" [Med]"
|
Facility
|
OP
|
$255.00
|
|
| Hospital Charge Code |
2974984
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.40 |
| Max. Negotiated Rate |
$1,020.00 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$219.30
|
| Rate for Payer: Aetna Managed Medicare |
$71.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$165.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$127.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$122.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.15
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.70
|
| Rate for Payer: Health EOS Commercial |
$226.95
|
| Rate for Payer: HFN Commercial |
$234.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.25
|
| Rate for Payer: Multiplan Commercial |
$204.00
|
| Rate for Payer: NAPHCARE Commercial |
$153.00
|
| Rate for Payer: Preferred Network Access Commercial |
$234.60
|
| Rate for Payer: Quartz Beloit One Network |
$124.95
|
| Rate for Payer: Quartz Commercial |
$165.75
|
| Rate for Payer: Quartz Medicare Advantage |
$153.00
|
| Rate for Payer: The Alliance Commercial |
$1,020.00
|
| Rate for Payer: WEA Trust Commercial |
$140.25
|
| Rate for Payer: WPS Commercial |
$188.88
|
|
|
Surgicel 2 x 3" [Med]"
|
Facility
|
IP
|
$255.00
|
|
| Hospital Charge Code |
2974984
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$124.95 |
| Max. Negotiated Rate |
$234.60 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$219.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.15
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: Health EOS Commercial |
$226.95
|
| Rate for Payer: HFN Commercial |
$234.60
|
| Rate for Payer: Multiplan Commercial |
$204.00
|
| Rate for Payer: NAPHCARE Commercial |
$153.00
|
| Rate for Payer: Preferred Network Access Commercial |
$234.60
|
| Rate for Payer: Quartz Beloit One Network |
$124.95
|
| Rate for Payer: Quartz Commercial |
$153.00
|
| Rate for Payer: WEA Trust Commercial |
$140.25
|
| Rate for Payer: WPS Commercial |
$188.88
|
|
|
Surgicel 3 x 4" [Med]"
|
Facility
|
OP
|
$379.00
|
|
| Hospital Charge Code |
2974985
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$106.12 |
| Max. Negotiated Rate |
$1,516.00 |
| Rate for Payer: Aetna Commercial |
$341.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.94
|
| Rate for Payer: Aetna Managed Medicare |
$106.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$246.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$189.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$181.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$200.87
|
| Rate for Payer: Cash Price |
$113.70
|
| Rate for Payer: Cigna Commercial |
$348.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$212.09
|
| Rate for Payer: Health EOS Commercial |
$337.31
|
| Rate for Payer: HFN Commercial |
$348.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$284.25
|
| Rate for Payer: Multiplan Commercial |
$303.20
|
| Rate for Payer: NAPHCARE Commercial |
$227.40
|
| Rate for Payer: Preferred Network Access Commercial |
$348.68
|
| Rate for Payer: Quartz Beloit One Network |
$185.71
|
| Rate for Payer: Quartz Commercial |
$246.35
|
| Rate for Payer: Quartz Medicare Advantage |
$227.40
|
| Rate for Payer: The Alliance Commercial |
$1,516.00
|
| Rate for Payer: WEA Trust Commercial |
$208.45
|
| Rate for Payer: WPS Commercial |
$280.73
|
|
|
Surgicel 3 x 4" [Med]"
|
Facility
|
IP
|
$379.00
|
|
| Hospital Charge Code |
2974985
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$185.71 |
| Max. Negotiated Rate |
$348.68 |
| Rate for Payer: Aetna Commercial |
$341.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$200.87
|
| Rate for Payer: Cash Price |
$113.70
|
| Rate for Payer: Cigna Commercial |
$348.68
|
| Rate for Payer: Health EOS Commercial |
$337.31
|
| Rate for Payer: HFN Commercial |
$348.68
|
| Rate for Payer: Multiplan Commercial |
$303.20
|
| Rate for Payer: NAPHCARE Commercial |
$227.40
|
| Rate for Payer: Preferred Network Access Commercial |
$348.68
|
| Rate for Payer: Quartz Beloit One Network |
$185.71
|
| Rate for Payer: Quartz Commercial |
$227.40
|
| Rate for Payer: WEA Trust Commercial |
$208.45
|
| Rate for Payer: WPS Commercial |
$280.73
|
|
|
SURGICEL 5 X 2 HEMOSTAT"
|
Facility
|
IP
|
$467.00
|
|
| Hospital Charge Code |
2974442
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$228.83 |
| Max. Negotiated Rate |
$429.64 |
| Rate for Payer: Aetna Commercial |
$420.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$401.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$247.51
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cigna Commercial |
$429.64
|
| Rate for Payer: Health EOS Commercial |
$415.63
|
| Rate for Payer: HFN Commercial |
$429.64
|
| Rate for Payer: Multiplan Commercial |
$373.60
|
| Rate for Payer: NAPHCARE Commercial |
$280.20
|
| Rate for Payer: Preferred Network Access Commercial |
$429.64
|
| Rate for Payer: Quartz Beloit One Network |
$228.83
|
| Rate for Payer: Quartz Commercial |
$280.20
|
| Rate for Payer: WEA Trust Commercial |
$256.85
|
| Rate for Payer: WPS Commercial |
$345.91
|
|
|
SURGICEL 5 X 2 HEMOSTAT"
|
Facility
|
OP
|
$467.00
|
|
| Hospital Charge Code |
2974442
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$130.76 |
| Max. Negotiated Rate |
$1,868.00 |
| Rate for Payer: Aetna Commercial |
$420.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$401.62
|
| Rate for Payer: Aetna Managed Medicare |
$130.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$303.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$233.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$224.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$247.51
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cigna Commercial |
$429.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$261.33
|
| Rate for Payer: Health EOS Commercial |
$415.63
|
| Rate for Payer: HFN Commercial |
$429.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$350.25
|
| Rate for Payer: Multiplan Commercial |
$373.60
|
| Rate for Payer: NAPHCARE Commercial |
$280.20
|
| Rate for Payer: Preferred Network Access Commercial |
$429.64
|
| Rate for Payer: Quartz Beloit One Network |
$228.83
|
| Rate for Payer: Quartz Commercial |
$303.55
|
| Rate for Payer: Quartz Medicare Advantage |
$280.20
|
| Rate for Payer: The Alliance Commercial |
$1,868.00
|
| Rate for Payer: WEA Trust Commercial |
$256.85
|
| Rate for Payer: WPS Commercial |
$345.91
|
|
|
SURGICEL FIBRILLAR 1 X 2" 1961"
|
Facility
|
IP
|
$404.00
|
|
| Hospital Charge Code |
4595417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$197.96 |
| Max. Negotiated Rate |
$371.68 |
| Rate for Payer: Aetna Commercial |
$363.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.12
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cigna Commercial |
$371.68
|
| Rate for Payer: Health EOS Commercial |
$359.56
|
| Rate for Payer: HFN Commercial |
$371.68
|
| Rate for Payer: Multiplan Commercial |
$323.20
|
| Rate for Payer: NAPHCARE Commercial |
$242.40
|
| Rate for Payer: Preferred Network Access Commercial |
$371.68
|
| Rate for Payer: Quartz Beloit One Network |
$197.96
|
| Rate for Payer: Quartz Commercial |
$242.40
|
| Rate for Payer: WEA Trust Commercial |
$222.20
|
| Rate for Payer: WPS Commercial |
$299.24
|
|
|
SURGICEL FIBRILLAR 1 X 2" 1961"
|
Facility
|
OP
|
$404.00
|
|
| Hospital Charge Code |
4595417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$113.12 |
| Max. Negotiated Rate |
$1,616.00 |
| Rate for Payer: Aetna Commercial |
$363.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.44
|
| Rate for Payer: Aetna Managed Medicare |
$113.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$262.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$202.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$193.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.12
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cigna Commercial |
$371.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.08
|
| Rate for Payer: Health EOS Commercial |
$359.56
|
| Rate for Payer: HFN Commercial |
$371.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$303.00
|
| Rate for Payer: Multiplan Commercial |
$323.20
|
| Rate for Payer: NAPHCARE Commercial |
$242.40
|
| Rate for Payer: Preferred Network Access Commercial |
$371.68
|
| Rate for Payer: Quartz Beloit One Network |
$197.96
|
| Rate for Payer: Quartz Commercial |
$262.60
|
| Rate for Payer: Quartz Medicare Advantage |
$242.40
|
| Rate for Payer: The Alliance Commercial |
$1,616.00
|
| Rate for Payer: WEA Trust Commercial |
$222.20
|
| Rate for Payer: WPS Commercial |
$299.24
|
|
|
SURGICLIP LARGE 134048
|
Facility
|
OP
|
$1,274.00
|
|
| Hospital Charge Code |
2962951
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$356.72 |
| Max. Negotiated Rate |
$5,096.00 |
| Rate for Payer: Aetna Commercial |
$1,146.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,095.64
|
| Rate for Payer: Aetna Managed Medicare |
$356.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$828.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$637.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$611.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$675.22
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,172.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$712.93
|
| Rate for Payer: Health EOS Commercial |
$1,133.86
|
| Rate for Payer: HFN Commercial |
$1,172.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$955.50
|
| Rate for Payer: Multiplan Commercial |
$1,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$764.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,172.08
|
| Rate for Payer: Quartz Beloit One Network |
$624.26
|
| Rate for Payer: Quartz Commercial |
$828.10
|
| Rate for Payer: Quartz Medicare Advantage |
$764.40
|
| Rate for Payer: The Alliance Commercial |
$5,096.00
|
| Rate for Payer: WEA Trust Commercial |
$700.70
|
| Rate for Payer: WPS Commercial |
$943.65
|
|
