|
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: 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 TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC
|
Facility
OP
|
$13,286.32
|
|
|
Service Code
|
CPT 46275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$13,286.32 |
| Rate for Payer: Anthem Medicare Advantage |
$2,775.24
|
| 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: 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 |
$13,286.32
|
| 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
|
$13,286.32
|
|
|
Service Code
|
CPT 46270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$13,286.32 |
| 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 |
$13,286.32
|
| 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
|
$13,286.32
|
|
|
Service Code
|
CPT 46280
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$13,286.32 |
| 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 |
$7,795.33
|
| 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 |
$13,286.32
|
| 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
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: 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 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 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: 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 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 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: 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 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
|
|
|
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: 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
|
|
|
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
|
|
|
SURGICLIP LARGE 134048
|
Facility
IP
|
$1,274.00
|
|
| Hospital Charge Code |
2962951
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$624.26 |
| Max. Negotiated Rate |
$1,172.08 |
| Rate for Payer: Aetna Commercial |
$1,146.60
|
| 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: Health EOS Commercial |
$1,133.86
|
| Rate for Payer: HFN Commercial |
$1,172.08
|
| 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 |
$764.40
|
| Rate for Payer: WEA Trust Commercial |
$700.70
|
| Rate for Payer: WPS Commercial |
$943.65
|
|
|
SURGICLIP MEDIUM 134031
|
Facility
IP
|
$1,308.00
|
|
| Hospital Charge Code |
2962932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$640.92 |
| Max. Negotiated Rate |
$1,203.36 |
| Rate for Payer: Aetna Commercial |
$1,177.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$693.24
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$1,203.36
|
| Rate for Payer: Health EOS Commercial |
$1,164.12
|
| Rate for Payer: HFN Commercial |
$1,203.36
|
| Rate for Payer: Multiplan Commercial |
$1,046.40
|
| Rate for Payer: NAPHCARE Commercial |
$784.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,203.36
|
| Rate for Payer: Quartz Beloit One Network |
$640.92
|
| Rate for Payer: Quartz Commercial |
$784.80
|
| Rate for Payer: WEA Trust Commercial |
$719.40
|
| Rate for Payer: WPS Commercial |
$968.84
|
|
|
SURGICLIP MEDIUM 134031
|
Facility
OP
|
$1,308.00
|
|
| Hospital Charge Code |
2962932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$366.24 |
| Max. Negotiated Rate |
$5,232.00 |
| Rate for Payer: Aetna Commercial |
$1,177.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,124.88
|
| Rate for Payer: Aetna Managed Medicare |
$366.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$850.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$654.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$627.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$693.24
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$1,203.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$731.96
|
| Rate for Payer: Health EOS Commercial |
$1,164.12
|
| Rate for Payer: HFN Commercial |
$1,203.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$981.00
|
| Rate for Payer: Multiplan Commercial |
$1,046.40
|
| Rate for Payer: NAPHCARE Commercial |
$784.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,203.36
|
| Rate for Payer: Quartz Beloit One Network |
$640.92
|
| Rate for Payer: Quartz Commercial |
$850.20
|
| Rate for Payer: Quartz Medicare Advantage |
$784.80
|
| Rate for Payer: The Alliance Commercial |
$5,232.00
|
| Rate for Payer: WEA Trust Commercial |
$719.40
|
| Rate for Payer: WPS Commercial |
$968.84
|
|
|
SURGIFOAM 1974 (MED)
|
Facility
OP
|
$115.00
|
|
| Hospital Charge Code |
5831803
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$460.00 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Aetna Managed Medicare |
$32.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.35
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.25
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$74.75
|
| Rate for Payer: Quartz Medicare Advantage |
$69.00
|
| Rate for Payer: The Alliance Commercial |
$460.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
SURGIFOAM 1974 (MED)
|
Facility
IP
|
$115.00
|
|
| Hospital Charge Code |
5831803
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$105.80 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
SURGIFOAM POWDER 1978 (MED)
|
Facility
OP
|
$718.00
|
|
| Hospital Charge Code |
6246271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$201.04 |
| Max. Negotiated Rate |
$2,872.00 |
| Rate for Payer: Aetna Commercial |
$646.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$617.48
|
| Rate for Payer: Aetna Managed Medicare |
$201.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$466.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$359.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$344.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$380.54
|
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$660.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$401.79
|
| Rate for Payer: Health EOS Commercial |
$639.02
|
| Rate for Payer: HFN Commercial |
$660.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$538.50
|
| Rate for Payer: Multiplan Commercial |
$574.40
|
| Rate for Payer: NAPHCARE Commercial |
$430.80
|
| Rate for Payer: Preferred Network Access Commercial |
$660.56
|
| Rate for Payer: Quartz Beloit One Network |
$351.82
|
| Rate for Payer: Quartz Commercial |
$466.70
|
| Rate for Payer: Quartz Medicare Advantage |
$430.80
|
| Rate for Payer: The Alliance Commercial |
$2,872.00
|
| Rate for Payer: WEA Trust Commercial |
$394.90
|
| Rate for Payer: WPS Commercial |
$531.82
|
|
|
SURGIFOAM POWDER 1978 (MED)
|
Facility
IP
|
$718.00
|
|
| Hospital Charge Code |
6246271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$351.82 |
| Max. Negotiated Rate |
$660.56 |
| Rate for Payer: Aetna Commercial |
$646.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$380.54
|
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$660.56
|
| Rate for Payer: Health EOS Commercial |
$639.02
|
| Rate for Payer: HFN Commercial |
$660.56
|
| Rate for Payer: Multiplan Commercial |
$574.40
|
| Rate for Payer: NAPHCARE Commercial |
$430.80
|
| Rate for Payer: Preferred Network Access Commercial |
$660.56
|
| Rate for Payer: Quartz Beloit One Network |
$351.82
|
| Rate for Payer: Quartz Commercial |
$430.80
|
| Rate for Payer: WEA Trust Commercial |
$394.90
|
| Rate for Payer: WPS Commercial |
$531.82
|
|
|
SURGILUBE JELLY 2 OZ. TUBE 0281-0205-12
|
Facility
IP
|
$28.00
|
|
|
Service Code
|
HCPCS A4332
|
| Hospital Charge Code |
2968920
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
SURGILUBE JELLY 2 OZ. TUBE 0281-0205-12
|
Facility
OP
|
$28.00
|
|
|
Service Code
|
HCPCS A4332
|
| Hospital Charge Code |
2968920
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Aetna Managed Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.67
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$18.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
Susceptibility, Aerobic to Mayo
|
Facility
IP
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
4620678
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.04 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$117.60
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
Susceptibility, Aerobic to Mayo
|
Facility
OP
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
4620678
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$784.00 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Aetna Managed Medicare |
$8.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.36
|
| Rate for Payer: Anthem Medicaid |
$8.94
|
| Rate for Payer: Anthem Medicare Advantage |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.65
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.94
|
| Rate for Payer: Dean Health Medicaid |
$8.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.65
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.65
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.65
|
| Rate for Payer: Managed Health Services Medicaid |
$9.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.65
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$12.98
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.94
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$127.40
|
| Rate for Payer: Quartz Medicare Advantage |
$8.65
|
| Rate for Payer: The Alliance Commercial |
$784.00
|
| Rate for Payer: United Healthcare Medicaid |
$8.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.65
|
| Rate for Payer: United Healthcare PPO |
$147.00
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: Wellcare Medicare |
$8.65
|
| Rate for Payer: WMAP Medicaid |
$8.94
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
Susceptibility, Aerobic to Mayo
|
Professional
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
4620678
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$186.20 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Aetna Managed Medicare |
$8.65
|
| Rate for Payer: Anthem Medicare Advantage |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.65
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$98.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.65
|
| Rate for Payer: Health EOS Commercial |
$178.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.65
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: Preferred Network Access Commercial |
$186.20
|
| Rate for Payer: Quartz Beloit One Network |
$86.24
|
| Rate for Payer: Quartz Commercial |
$111.72
|
| Rate for Payer: Quartz Medicare Advantage |
$8.65
|
| Rate for Payer: The Alliance Commercial |
$34.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.65
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$38.06
|
|
