|
TAPE KINESIO TEX 3 081605088"
|
Facility
|
IP
|
$356.00
|
|
| Hospital Charge Code |
2971984
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$174.44 |
| Max. Negotiated Rate |
$327.52 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$213.60
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$213.60
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
TAPE KINESIO TEX 3 081605088"
|
Facility
|
OP
|
$356.00
|
|
| Hospital Charge Code |
2971984
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$99.68 |
| Max. Negotiated Rate |
$1,424.00 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Aetna Managed Medicare |
$99.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$231.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$178.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$170.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.22
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$267.00
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$213.60
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$231.40
|
| Rate for Payer: Quartz Medicare Advantage |
$213.60
|
| Rate for Payer: The Alliance Commercial |
$1,424.00
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
TAPE KINESIO TEX BLUE #0816-05-153
|
Facility
|
OP
|
$1,493.00
|
|
| Hospital Charge Code |
2969869
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$418.04 |
| Max. Negotiated Rate |
$5,972.00 |
| Rate for Payer: Aetna Commercial |
$1,343.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,283.98
|
| Rate for Payer: Aetna Managed Medicare |
$418.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$970.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$746.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$716.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$791.29
|
| Rate for Payer: Cash Price |
$447.90
|
| Rate for Payer: Cigna Commercial |
$1,373.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$835.48
|
| Rate for Payer: Health EOS Commercial |
$1,328.77
|
| Rate for Payer: HFN Commercial |
$1,373.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,119.75
|
| Rate for Payer: Multiplan Commercial |
$1,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$895.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,373.56
|
| Rate for Payer: Quartz Beloit One Network |
$731.57
|
| Rate for Payer: Quartz Commercial |
$970.45
|
| Rate for Payer: Quartz Medicare Advantage |
$895.80
|
| Rate for Payer: The Alliance Commercial |
$5,972.00
|
| Rate for Payer: WEA Trust Commercial |
$821.15
|
| Rate for Payer: WPS Commercial |
$1,105.87
|
|
|
TAPE KINESIO TEX BLUE #0816-05-153
|
Facility
|
IP
|
$1,493.00
|
|
| Hospital Charge Code |
2969869
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$731.57 |
| Max. Negotiated Rate |
$1,373.56 |
| Rate for Payer: Aetna Commercial |
$1,343.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,283.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$791.29
|
| Rate for Payer: Cash Price |
$447.90
|
| Rate for Payer: Cigna Commercial |
$1,373.56
|
| Rate for Payer: Health EOS Commercial |
$1,328.77
|
| Rate for Payer: HFN Commercial |
$1,373.56
|
| Rate for Payer: Multiplan Commercial |
$1,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$895.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,373.56
|
| Rate for Payer: Quartz Beloit One Network |
$731.57
|
| Rate for Payer: Quartz Commercial |
$895.80
|
| Rate for Payer: WEA Trust Commercial |
$821.15
|
| Rate for Payer: WPS Commercial |
$1,105.87
|
|
|
TAPE KINESIO TEX FP -BLACK 0816-05-179
|
Facility
|
IP
|
$1,493.00
|
|
| Hospital Charge Code |
2969870
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$731.57 |
| Max. Negotiated Rate |
$1,373.56 |
| Rate for Payer: Aetna Commercial |
$1,343.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,283.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$791.29
|
| Rate for Payer: Cash Price |
$447.90
|
| Rate for Payer: Cigna Commercial |
$1,373.56
|
| Rate for Payer: Health EOS Commercial |
$1,328.77
|
| Rate for Payer: HFN Commercial |
$1,373.56
|
| Rate for Payer: Multiplan Commercial |
$1,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$895.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,373.56
|
| Rate for Payer: Quartz Beloit One Network |
$731.57
|
| Rate for Payer: Quartz Commercial |
$895.80
|
| Rate for Payer: WEA Trust Commercial |
$821.15
|
| Rate for Payer: WPS Commercial |
$1,105.87
|
|
|
TAPE KINESIO TEX FP -BLACK 0816-05-179
|
Facility
|
OP
|
$1,493.00
|
|
| Hospital Charge Code |
2969870
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$418.04 |
| Max. Negotiated Rate |
$5,972.00 |
| Rate for Payer: Aetna Commercial |
$1,343.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,283.98
|
| Rate for Payer: Aetna Managed Medicare |
$418.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$970.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$746.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$716.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$791.29
|
| Rate for Payer: Cash Price |
$447.90
|
| Rate for Payer: Cigna Commercial |
$1,373.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$835.48
|
| Rate for Payer: Health EOS Commercial |
$1,328.77
|
| Rate for Payer: HFN Commercial |
$1,373.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,119.75
|
| Rate for Payer: Multiplan Commercial |
$1,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$895.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,373.56
|
| Rate for Payer: Quartz Beloit One Network |
$731.57
|
| Rate for Payer: Quartz Commercial |
$970.45
|
| Rate for Payer: Quartz Medicare Advantage |
$895.80
|
| Rate for Payer: The Alliance Commercial |
$5,972.00
|
| Rate for Payer: WEA Trust Commercial |
$821.15
|
| Rate for Payer: WPS Commercial |
$1,105.87
|
|
|
TAPE MICROFOAM 3 LATEX FREE
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
HCPCS A4452
|
| Hospital Charge Code |
2962792
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$31.36 |
| Max. Negotiated Rate |
$448.00 |
| Rate for Payer: Aetna Commercial |
$100.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.32
|
| Rate for Payer: Aetna Managed Medicare |
$31.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.36
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$103.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.68
|
| Rate for Payer: Health EOS Commercial |
$99.68
|
| Rate for Payer: HFN Commercial |
$103.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$84.00
|
| Rate for Payer: Multiplan Commercial |
$89.60
|
| Rate for Payer: NAPHCARE Commercial |
$67.20
|
| Rate for Payer: Preferred Network Access Commercial |
$103.04
|
| Rate for Payer: Quartz Beloit One Network |
$54.88
|
| Rate for Payer: Quartz Commercial |
$72.80
|
| Rate for Payer: Quartz Medicare Advantage |
$67.20
|
| Rate for Payer: The Alliance Commercial |
$448.00
|
| Rate for Payer: WEA Trust Commercial |
$61.60
|
| Rate for Payer: WPS Commercial |
$82.96
|
|
|
TAPE MICROFOAM 3 LATEX FREE
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
HCPCS A4452
|
| Hospital Charge Code |
2962792
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$103.04 |
| Rate for Payer: Aetna Commercial |
$100.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.36
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$103.04
|
| Rate for Payer: Health EOS Commercial |
$99.68
|
| Rate for Payer: HFN Commercial |
$103.04
|
| Rate for Payer: Multiplan Commercial |
$89.60
|
| Rate for Payer: NAPHCARE Commercial |
$67.20
|
| Rate for Payer: Preferred Network Access Commercial |
$103.04
|
| Rate for Payer: Quartz Beloit One Network |
$54.88
|
| Rate for Payer: Quartz Commercial |
$67.20
|
| Rate for Payer: WEA Trust Commercial |
$61.60
|
| Rate for Payer: WPS Commercial |
$82.96
|
|
|
Tapentadol, Quant, Urine
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 80372
|
| Hospital Charge Code |
4618955
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.28 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$42.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.50
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.25
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$98.15
|
| Rate for Payer: Quartz Medicare Advantage |
$90.60
|
| Rate for Payer: The Alliance Commercial |
$604.00
|
| Rate for Payer: United Healthcare PPO |
$113.25
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
Tapentadol, Quant, Urine
|
Professional
|
Both
|
$151.00
|
|
|
Service Code
|
CPT 80372
|
| Hospital Charge Code |
4618955
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.44 |
| Max. Negotiated Rate |
$143.45 |
| Rate for Payer: Aetna Commercial |
$143.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$143.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.60
|
| Rate for Payer: Health EOS Commercial |
$137.41
|
| Rate for Payer: HFN Commercial |
$143.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: Preferred Network Access Commercial |
$143.45
|
| Rate for Payer: Quartz Beloit One Network |
$66.44
|
| Rate for Payer: Quartz Commercial |
$86.07
|
| Rate for Payer: The Alliance Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
Tapentadol, Quant, Urine
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 80372
|
| Hospital Charge Code |
4618955
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$138.92 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$90.60
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
TAPER ADAPTER BIOLOX +6 650-1068
|
Facility
|
OP
|
$1,753.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5685732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.84 |
| Max. Negotiated Rate |
$7,012.00 |
| Rate for Payer: Aetna Commercial |
$1,577.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,507.58
|
| Rate for Payer: Aetna Managed Medicare |
$490.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,139.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$876.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$841.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$929.09
|
| Rate for Payer: Cash Price |
$525.90
|
| Rate for Payer: Cigna Commercial |
$1,612.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$980.98
|
| Rate for Payer: Health EOS Commercial |
$1,560.17
|
| Rate for Payer: HFN Commercial |
$1,612.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,314.75
|
| Rate for Payer: Multiplan Commercial |
$1,402.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,051.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,612.76
|
| Rate for Payer: Quartz Beloit One Network |
$858.97
|
| Rate for Payer: Quartz Commercial |
$1,139.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,051.80
|
| Rate for Payer: The Alliance Commercial |
$7,012.00
|
| Rate for Payer: WEA Trust Commercial |
$964.15
|
| Rate for Payer: WPS Commercial |
$1,298.45
|
|
|
TAPER ADAPTER BIOLOX +6 650-1068
|
Facility
|
IP
|
$1,753.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5685732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$858.97 |
| Max. Negotiated Rate |
$1,612.76 |
| Rate for Payer: Aetna Commercial |
$1,577.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,507.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$929.09
|
| Rate for Payer: Cash Price |
$525.90
|
| Rate for Payer: Cigna Commercial |
$1,612.76
|
| Rate for Payer: Health EOS Commercial |
$1,560.17
|
| Rate for Payer: HFN Commercial |
$1,612.76
|
| Rate for Payer: Multiplan Commercial |
$1,402.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,051.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,612.76
|
| Rate for Payer: Quartz Beloit One Network |
$858.97
|
| Rate for Payer: Quartz Commercial |
$1,051.80
|
| Rate for Payer: WEA Trust Commercial |
$964.15
|
| Rate for Payer: WPS Commercial |
$1,298.45
|
|
|
TAPE RETRACT-O-TAPE VASCULAR LOOPS 12X X 18G 1041"
|
Facility
|
OP
|
$456.00
|
|
| Hospital Charge Code |
4998636
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$127.68 |
| Max. Negotiated Rate |
$1,824.00 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Aetna Managed Medicare |
$127.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$296.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$218.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$255.18
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$342.00
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$296.40
|
| Rate for Payer: Quartz Medicare Advantage |
$273.60
|
| Rate for Payer: The Alliance Commercial |
$1,824.00
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
TAPE RETRACT-O-TAPE VASCULAR LOOPS 12X X 18G 1041"
|
Facility
|
IP
|
$456.00
|
|
| Hospital Charge Code |
4998636
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$223.44 |
| Max. Negotiated Rate |
$419.52 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$273.60
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
TAPER PLUG NEXGEN 00-5960-099-00
|
Facility
|
OP
|
$4,711.00
|
|
| Hospital Charge Code |
3269464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,319.08 |
| Max. Negotiated Rate |
$18,844.00 |
| Rate for Payer: Aetna Commercial |
$4,239.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,051.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,319.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,062.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,355.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,261.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,496.83
|
| Rate for Payer: Cash Price |
$1,413.30
|
| Rate for Payer: Cigna Commercial |
$4,334.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,636.28
|
| Rate for Payer: Health EOS Commercial |
$4,192.79
|
| Rate for Payer: HFN Commercial |
$4,334.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,533.25
|
| Rate for Payer: Multiplan Commercial |
$3,768.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,826.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,334.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,308.39
|
| Rate for Payer: Quartz Commercial |
$3,062.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,826.60
|
| Rate for Payer: The Alliance Commercial |
$18,844.00
|
| Rate for Payer: WEA Trust Commercial |
$2,591.05
|
| Rate for Payer: WPS Commercial |
$3,489.44
|
|
|
TAPER PLUG NEXGEN 00-5960-099-00
|
Facility
|
IP
|
$4,711.00
|
|
| Hospital Charge Code |
3269464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,308.39 |
| Max. Negotiated Rate |
$4,334.12 |
| Rate for Payer: Aetna Commercial |
$4,239.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,051.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,496.83
|
| Rate for Payer: Cash Price |
$1,413.30
|
| Rate for Payer: Cigna Commercial |
$4,334.12
|
| Rate for Payer: Health EOS Commercial |
$4,192.79
|
| Rate for Payer: HFN Commercial |
$4,334.12
|
| Rate for Payer: Multiplan Commercial |
$3,768.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,826.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,334.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,308.39
|
| Rate for Payer: Quartz Commercial |
$2,826.60
|
| Rate for Payer: WEA Trust Commercial |
$2,591.05
|
| Rate for Payer: WPS Commercial |
$3,489.44
|
|
|
TAPER POST 12mm
|
Facility
|
IP
|
$4,978.00
|
|
| Hospital Charge Code |
2964733
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.22 |
| Max. Negotiated Rate |
$4,579.76 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$2,986.80
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
TAPER POST 12mm
|
Facility
|
OP
|
$4,978.00
|
|
| Hospital Charge Code |
2964733
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,393.84 |
| Max. Negotiated Rate |
$19,912.00 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,393.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,235.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,489.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,389.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,785.69
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.50
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$3,235.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,986.80
|
| Rate for Payer: The Alliance Commercial |
$19,912.00
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
TAPER POST 13.7mm
|
Facility
|
IP
|
$5,284.00
|
|
| Hospital Charge Code |
2964734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,589.16 |
| Max. Negotiated Rate |
$4,861.28 |
| Rate for Payer: Aetna Commercial |
$4,755.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,544.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,800.52
|
| Rate for Payer: Cash Price |
$1,585.20
|
| Rate for Payer: Cigna Commercial |
$4,861.28
|
| Rate for Payer: Health EOS Commercial |
$4,702.76
|
| Rate for Payer: HFN Commercial |
$4,861.28
|
| Rate for Payer: Multiplan Commercial |
$4,227.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,170.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,861.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,589.16
|
| Rate for Payer: Quartz Commercial |
$3,170.40
|
| Rate for Payer: WEA Trust Commercial |
$2,906.20
|
| Rate for Payer: WPS Commercial |
$3,913.86
|
|
|
TAPER POST 13.7mm
|
Facility
|
OP
|
$5,284.00
|
|
| Hospital Charge Code |
2964734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,479.52 |
| Max. Negotiated Rate |
$21,136.00 |
| Rate for Payer: Aetna Commercial |
$4,755.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,544.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,479.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,434.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,642.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,536.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,800.52
|
| Rate for Payer: Cash Price |
$1,585.20
|
| Rate for Payer: Cigna Commercial |
$4,861.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,956.93
|
| Rate for Payer: Health EOS Commercial |
$4,702.76
|
| Rate for Payer: HFN Commercial |
$4,861.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,963.00
|
| Rate for Payer: Multiplan Commercial |
$4,227.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,170.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,861.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,589.16
|
| Rate for Payer: Quartz Commercial |
$3,434.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,170.40
|
| Rate for Payer: The Alliance Commercial |
$21,136.00
|
| Rate for Payer: WEA Trust Commercial |
$2,906.20
|
| Rate for Payer: WPS Commercial |
$3,913.86
|
|
|
TAPER POST HEMI-CAP 9095-0018-W
|
Facility
|
OP
|
$4,819.00
|
|
| Hospital Charge Code |
2965213
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,349.32 |
| Max. Negotiated Rate |
$19,276.00 |
| Rate for Payer: Aetna Commercial |
$4,337.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,144.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,349.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,132.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,409.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,313.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,554.07
|
| Rate for Payer: Cash Price |
$1,445.70
|
| Rate for Payer: Cigna Commercial |
$4,433.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,696.71
|
| Rate for Payer: Health EOS Commercial |
$4,288.91
|
| Rate for Payer: HFN Commercial |
$4,433.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,614.25
|
| Rate for Payer: Multiplan Commercial |
$3,855.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,891.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,433.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,361.31
|
| Rate for Payer: Quartz Commercial |
$3,132.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,891.40
|
| Rate for Payer: The Alliance Commercial |
$19,276.00
|
| Rate for Payer: WEA Trust Commercial |
$2,650.45
|
| Rate for Payer: WPS Commercial |
$3,569.43
|
|
|
TAPER POST HEMI-CAP 9095-0018-W
|
Facility
|
IP
|
$4,819.00
|
|
| Hospital Charge Code |
2965213
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,361.31 |
| Max. Negotiated Rate |
$4,433.48 |
| Rate for Payer: Aetna Commercial |
$4,337.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,144.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,554.07
|
| Rate for Payer: Cash Price |
$1,445.70
|
| Rate for Payer: Cigna Commercial |
$4,433.48
|
| Rate for Payer: Health EOS Commercial |
$4,288.91
|
| Rate for Payer: HFN Commercial |
$4,433.48
|
| Rate for Payer: Multiplan Commercial |
$3,855.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,891.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,433.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,361.31
|
| Rate for Payer: Quartz Commercial |
$2,891.40
|
| Rate for Payer: WEA Trust Commercial |
$2,650.45
|
| Rate for Payer: WPS Commercial |
$3,569.43
|
|
|
TAPE SILK DURAPORE 3'x 10 yrd
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS A4452
|
| Hospital Charge Code |
2962793
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
TAPE SILK DURAPORE 3'x 10 yrd
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS A4452
|
| Hospital Charge Code |
2962793
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
