|
Surgicel 1 x 2" [Med]"
|
Facility
|
OP
|
$397.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2974983
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.61 |
| Max. Negotiated Rate |
$379.85 |
| Rate for Payer: Aetna Commercial |
$371.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.08
|
| Rate for Payer: Aetna Managed Medicare |
$115.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$268.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$206.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$198.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.83
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$379.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.05
|
| Rate for Payer: Health EOS Commercial |
$367.46
|
| Rate for Payer: HFN Commercial |
$379.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$309.66
|
| Rate for Payer: Multiplan Commercial |
$330.30
|
| Rate for Payer: NAPHCARE Commercial |
$247.73
|
| Rate for Payer: Preferred Network Access Commercial |
$379.85
|
| Rate for Payer: Quartz Beloit One Network |
$202.31
|
| Rate for Payer: Quartz Commercial |
$268.37
|
| Rate for Payer: Quartz Medicare Advantage |
$247.73
|
| Rate for Payer: The Alliance Commercial |
$206.44
|
| Rate for Payer: WEA Trust Commercial |
$227.08
|
| Rate for Payer: WPS Commercial |
$305.81
|
|
|
Surgicel 1 x 2" [Med]"
|
Facility
|
IP
|
$397.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2974983
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$202.31 |
| Max. Negotiated Rate |
$379.85 |
| Rate for Payer: Aetna Commercial |
$371.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.83
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$379.85
|
| Rate for Payer: Health EOS Commercial |
$367.46
|
| Rate for Payer: HFN Commercial |
$379.85
|
| Rate for Payer: Multiplan Commercial |
$330.30
|
| Rate for Payer: Preferred Network Access Commercial |
$379.85
|
| Rate for Payer: Quartz Beloit One Network |
$202.31
|
| Rate for Payer: Quartz Commercial |
$247.73
|
| Rate for Payer: WEA Trust Commercial |
$227.08
|
| Rate for Payer: WPS Commercial |
$305.81
|
|
|
SURGICEL 2 X 3 HEMOSTAT 1953
|
Facility
|
IP
|
$850.00
|
|
| Hospital Charge Code |
2974579
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$433.16 |
| Max. Negotiated Rate |
$813.28 |
| Rate for Payer: Aetna Commercial |
$795.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$760.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$468.52
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$813.28
|
| Rate for Payer: Health EOS Commercial |
$786.76
|
| Rate for Payer: HFN Commercial |
$813.28
|
| Rate for Payer: Multiplan Commercial |
$707.20
|
| Rate for Payer: Preferred Network Access Commercial |
$813.28
|
| Rate for Payer: Quartz Beloit One Network |
$433.16
|
| Rate for Payer: Quartz Commercial |
$530.40
|
| Rate for Payer: WEA Trust Commercial |
$486.20
|
| Rate for Payer: WPS Commercial |
$654.75
|
|
|
SURGICEL 2 X 3 HEMOSTAT 1953
|
Facility
|
OP
|
$850.00
|
|
| Hospital Charge Code |
2974579
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$247.52 |
| Max. Negotiated Rate |
$813.28 |
| Rate for Payer: Aetna Commercial |
$795.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$760.24
|
| Rate for Payer: Aetna Managed Medicare |
$247.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$574.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$442.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$424.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$468.52
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$813.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$494.70
|
| Rate for Payer: Health EOS Commercial |
$786.76
|
| Rate for Payer: HFN Commercial |
$813.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$663.00
|
| Rate for Payer: Multiplan Commercial |
$707.20
|
| Rate for Payer: NAPHCARE Commercial |
$530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$813.28
|
| Rate for Payer: Quartz Beloit One Network |
$433.16
|
| Rate for Payer: Quartz Commercial |
$574.60
|
| Rate for Payer: Quartz Medicare Advantage |
$530.40
|
| Rate for Payer: The Alliance Commercial |
$442.00
|
| Rate for Payer: WEA Trust Commercial |
$486.20
|
| Rate for Payer: WPS Commercial |
$654.75
|
|
|
Surgicel 2 x 3" [Med]"
|
Facility
|
IP
|
$255.00
|
|
| Hospital Charge Code |
2974984
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$129.95 |
| Max. Negotiated Rate |
$243.98 |
| Rate for Payer: Aetna Commercial |
$238.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.56
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$243.98
|
| Rate for Payer: Health EOS Commercial |
$236.03
|
| Rate for Payer: HFN Commercial |
$243.98
|
| Rate for Payer: Multiplan Commercial |
$212.16
|
| Rate for Payer: Preferred Network Access Commercial |
$243.98
|
| Rate for Payer: Quartz Beloit One Network |
$129.95
|
| Rate for Payer: Quartz Commercial |
$159.12
|
| Rate for Payer: WEA Trust Commercial |
$145.86
|
| Rate for Payer: WPS Commercial |
$196.43
|
|
|
Surgicel 2 x 3" [Med]"
|
Facility
|
OP
|
$255.00
|
|
| Hospital Charge Code |
2974984
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$74.26 |
| Max. Negotiated Rate |
$243.98 |
| Rate for Payer: Aetna Commercial |
$238.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.07
|
| Rate for Payer: Aetna Managed Medicare |
$74.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$172.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$132.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$127.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.56
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$243.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.41
|
| Rate for Payer: Health EOS Commercial |
$236.03
|
| Rate for Payer: HFN Commercial |
$243.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$198.90
|
| Rate for Payer: Multiplan Commercial |
$212.16
|
| Rate for Payer: NAPHCARE Commercial |
$159.12
|
| Rate for Payer: Preferred Network Access Commercial |
$243.98
|
| Rate for Payer: Quartz Beloit One Network |
$129.95
|
| Rate for Payer: Quartz Commercial |
$172.38
|
| Rate for Payer: Quartz Medicare Advantage |
$159.12
|
| Rate for Payer: The Alliance Commercial |
$132.60
|
| Rate for Payer: WEA Trust Commercial |
$145.86
|
| Rate for Payer: WPS Commercial |
$196.43
|
|
|
Surgicel 3 x 4" [Med]"
|
Facility
|
IP
|
$379.00
|
|
| Hospital Charge Code |
2974985
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$193.14 |
| Max. Negotiated Rate |
$362.63 |
| Rate for Payer: Aetna Commercial |
$354.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.90
|
| Rate for Payer: Cash Price |
$113.70
|
| Rate for Payer: Cigna Commercial |
$362.63
|
| Rate for Payer: Health EOS Commercial |
$350.80
|
| Rate for Payer: HFN Commercial |
$362.63
|
| Rate for Payer: Multiplan Commercial |
$315.33
|
| Rate for Payer: Preferred Network Access Commercial |
$362.63
|
| Rate for Payer: Quartz Beloit One Network |
$193.14
|
| Rate for Payer: Quartz Commercial |
$236.50
|
| Rate for Payer: WEA Trust Commercial |
$216.79
|
| Rate for Payer: WPS Commercial |
$291.94
|
|
|
Surgicel 3 x 4" [Med]"
|
Facility
|
OP
|
$379.00
|
|
| Hospital Charge Code |
2974985
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$110.36 |
| Max. Negotiated Rate |
$362.63 |
| Rate for Payer: Aetna Commercial |
$354.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.98
|
| Rate for Payer: Aetna Managed Medicare |
$110.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$256.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$197.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$189.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.90
|
| Rate for Payer: Cash Price |
$113.70
|
| Rate for Payer: Cigna Commercial |
$362.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$220.58
|
| Rate for Payer: Health EOS Commercial |
$350.80
|
| Rate for Payer: HFN Commercial |
$362.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$295.62
|
| Rate for Payer: Multiplan Commercial |
$315.33
|
| Rate for Payer: NAPHCARE Commercial |
$236.50
|
| Rate for Payer: Preferred Network Access Commercial |
$362.63
|
| Rate for Payer: Quartz Beloit One Network |
$193.14
|
| Rate for Payer: Quartz Commercial |
$256.20
|
| Rate for Payer: Quartz Medicare Advantage |
$236.50
|
| Rate for Payer: The Alliance Commercial |
$197.08
|
| Rate for Payer: WEA Trust Commercial |
$216.79
|
| Rate for Payer: WPS Commercial |
$291.94
|
|
|
SURGICEL 5 X 2 HEMOSTAT"
|
Facility
|
IP
|
$467.00
|
|
| Hospital Charge Code |
2974442
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$237.98 |
| Max. Negotiated Rate |
$446.83 |
| Rate for Payer: Aetna Commercial |
$437.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$417.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$257.41
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cigna Commercial |
$446.83
|
| Rate for Payer: Health EOS Commercial |
$432.26
|
| Rate for Payer: HFN Commercial |
$446.83
|
| Rate for Payer: Multiplan Commercial |
$388.54
|
| Rate for Payer: Preferred Network Access Commercial |
$446.83
|
| Rate for Payer: Quartz Beloit One Network |
$237.98
|
| Rate for Payer: Quartz Commercial |
$291.41
|
| Rate for Payer: WEA Trust Commercial |
$267.12
|
| Rate for Payer: WPS Commercial |
$359.73
|
|
|
SURGICEL 5 X 2 HEMOSTAT"
|
Facility
|
OP
|
$467.00
|
|
| Hospital Charge Code |
2974442
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$135.99 |
| Max. Negotiated Rate |
$446.83 |
| Rate for Payer: Aetna Commercial |
$437.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$417.68
|
| Rate for Payer: Aetna Managed Medicare |
$135.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$315.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$242.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$233.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$257.41
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cigna Commercial |
$446.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$271.79
|
| Rate for Payer: Health EOS Commercial |
$432.26
|
| Rate for Payer: HFN Commercial |
$446.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$364.26
|
| Rate for Payer: Multiplan Commercial |
$388.54
|
| Rate for Payer: NAPHCARE Commercial |
$291.41
|
| Rate for Payer: Preferred Network Access Commercial |
$446.83
|
| Rate for Payer: Quartz Beloit One Network |
$237.98
|
| Rate for Payer: Quartz Commercial |
$315.69
|
| Rate for Payer: Quartz Medicare Advantage |
$291.41
|
| Rate for Payer: The Alliance Commercial |
$242.84
|
| Rate for Payer: WEA Trust Commercial |
$267.12
|
| Rate for Payer: WPS Commercial |
$359.73
|
|
|
SURGICEL FIBRILLAR 1 X 2" 1961"
|
Facility
|
OP
|
$404.00
|
|
| Hospital Charge Code |
4595417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$117.64 |
| Max. Negotiated Rate |
$386.55 |
| Rate for Payer: Aetna Commercial |
$378.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$361.34
|
| Rate for Payer: Aetna Managed Medicare |
$117.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$273.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$210.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$201.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$222.68
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cigna Commercial |
$386.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.13
|
| Rate for Payer: Health EOS Commercial |
$373.94
|
| Rate for Payer: HFN Commercial |
$386.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$315.12
|
| Rate for Payer: Multiplan Commercial |
$336.13
|
| Rate for Payer: NAPHCARE Commercial |
$252.10
|
| Rate for Payer: Preferred Network Access Commercial |
$386.55
|
| Rate for Payer: Quartz Beloit One Network |
$205.88
|
| Rate for Payer: Quartz Commercial |
$273.10
|
| Rate for Payer: Quartz Medicare Advantage |
$252.10
|
| Rate for Payer: The Alliance Commercial |
$210.08
|
| Rate for Payer: WEA Trust Commercial |
$231.09
|
| Rate for Payer: WPS Commercial |
$311.20
|
|
|
SURGICEL FIBRILLAR 1 X 2" 1961"
|
Facility
|
IP
|
$404.00
|
|
| Hospital Charge Code |
4595417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$205.88 |
| Max. Negotiated Rate |
$386.55 |
| Rate for Payer: Aetna Commercial |
$378.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$361.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$222.68
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cigna Commercial |
$386.55
|
| Rate for Payer: Health EOS Commercial |
$373.94
|
| Rate for Payer: HFN Commercial |
$386.55
|
| Rate for Payer: Multiplan Commercial |
$336.13
|
| Rate for Payer: Preferred Network Access Commercial |
$386.55
|
| Rate for Payer: Quartz Beloit One Network |
$205.88
|
| Rate for Payer: Quartz Commercial |
$252.10
|
| Rate for Payer: WEA Trust Commercial |
$231.09
|
| Rate for Payer: WPS Commercial |
$311.20
|
|
|
SURGICLIP LARGE 134048
|
Facility
|
IP
|
$1,274.00
|
|
| Hospital Charge Code |
2962951
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$649.23 |
| Max. Negotiated Rate |
$1,218.96 |
| Rate for Payer: Aetna Commercial |
$1,192.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,139.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.23
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,218.96
|
| Rate for Payer: Health EOS Commercial |
$1,179.21
|
| Rate for Payer: HFN Commercial |
$1,218.96
|
| Rate for Payer: Multiplan Commercial |
$1,059.97
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.96
|
| Rate for Payer: Quartz Beloit One Network |
$649.23
|
| Rate for Payer: Quartz Commercial |
$794.98
|
| Rate for Payer: WEA Trust Commercial |
$728.73
|
| Rate for Payer: WPS Commercial |
$981.36
|
|
|
SURGICLIP LARGE 134048
|
Facility
|
OP
|
$1,274.00
|
|
| Hospital Charge Code |
2962951
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$370.99 |
| Max. Negotiated Rate |
$1,218.96 |
| Rate for Payer: Aetna Commercial |
$1,192.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,139.47
|
| Rate for Payer: Aetna Managed Medicare |
$370.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$861.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$662.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$635.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.23
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,218.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$741.47
|
| Rate for Payer: Health EOS Commercial |
$1,179.21
|
| Rate for Payer: HFN Commercial |
$1,218.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$993.72
|
| Rate for Payer: Multiplan Commercial |
$1,059.97
|
| Rate for Payer: NAPHCARE Commercial |
$794.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.96
|
| Rate for Payer: Quartz Beloit One Network |
$649.23
|
| Rate for Payer: Quartz Commercial |
$861.22
|
| Rate for Payer: Quartz Medicare Advantage |
$794.98
|
| Rate for Payer: The Alliance Commercial |
$662.48
|
| Rate for Payer: WEA Trust Commercial |
$728.73
|
| Rate for Payer: WPS Commercial |
$981.36
|
|
|
SURGICLIP MEDIUM 134031
|
Facility
|
OP
|
$1,308.00
|
|
| Hospital Charge Code |
2962932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$380.89 |
| Max. Negotiated Rate |
$1,251.49 |
| Rate for Payer: Aetna Commercial |
$1,224.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,169.88
|
| Rate for Payer: Aetna Managed Medicare |
$380.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$884.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$680.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$652.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$720.97
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$1,251.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$761.26
|
| Rate for Payer: Health EOS Commercial |
$1,210.68
|
| Rate for Payer: HFN Commercial |
$1,251.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,020.24
|
| Rate for Payer: Multiplan Commercial |
$1,088.26
|
| Rate for Payer: NAPHCARE Commercial |
$816.19
|
| Rate for Payer: Preferred Network Access Commercial |
$1,251.49
|
| Rate for Payer: Quartz Beloit One Network |
$666.56
|
| Rate for Payer: Quartz Commercial |
$884.21
|
| Rate for Payer: Quartz Medicare Advantage |
$816.19
|
| Rate for Payer: The Alliance Commercial |
$680.16
|
| Rate for Payer: WEA Trust Commercial |
$748.18
|
| Rate for Payer: WPS Commercial |
$1,007.55
|
|
|
SURGICLIP MEDIUM 134031
|
Facility
|
IP
|
$1,308.00
|
|
| Hospital Charge Code |
2962932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$666.56 |
| Max. Negotiated Rate |
$1,251.49 |
| Rate for Payer: Aetna Commercial |
$1,224.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,169.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$720.97
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$1,251.49
|
| Rate for Payer: Health EOS Commercial |
$1,210.68
|
| Rate for Payer: HFN Commercial |
$1,251.49
|
| Rate for Payer: Multiplan Commercial |
$1,088.26
|
| Rate for Payer: Preferred Network Access Commercial |
$1,251.49
|
| Rate for Payer: Quartz Beloit One Network |
$666.56
|
| Rate for Payer: Quartz Commercial |
$816.19
|
| Rate for Payer: WEA Trust Commercial |
$748.18
|
| Rate for Payer: WPS Commercial |
$1,007.55
|
|
|
SURGIFOAM 1974 (MED)
|
Facility
|
IP
|
$115.00
|
|
| Hospital Charge Code |
5831803
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$58.60 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
SURGIFOAM 1974 (MED)
|
Facility
|
OP
|
$115.00
|
|
| Hospital Charge Code |
5831803
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$33.49 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Aetna Managed Medicare |
$33.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.93
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.70
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: NAPHCARE Commercial |
$71.76
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$77.74
|
| Rate for Payer: Quartz Medicare Advantage |
$71.76
|
| Rate for Payer: The Alliance Commercial |
$59.80
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
SURGIFOAM POWDER 1978 (MED)
|
Facility
|
IP
|
$718.00
|
|
| Hospital Charge Code |
6246271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$365.89 |
| Max. Negotiated Rate |
$686.98 |
| Rate for Payer: Aetna Commercial |
$672.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$642.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$395.76
|
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$686.98
|
| Rate for Payer: Health EOS Commercial |
$664.58
|
| Rate for Payer: HFN Commercial |
$686.98
|
| Rate for Payer: Multiplan Commercial |
$597.38
|
| Rate for Payer: Preferred Network Access Commercial |
$686.98
|
| Rate for Payer: Quartz Beloit One Network |
$365.89
|
| Rate for Payer: Quartz Commercial |
$448.03
|
| Rate for Payer: WEA Trust Commercial |
$410.70
|
| Rate for Payer: WPS Commercial |
$553.08
|
|
|
SURGIFOAM POWDER 1978 (MED)
|
Facility
|
OP
|
$718.00
|
|
| Hospital Charge Code |
6246271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$209.08 |
| Max. Negotiated Rate |
$686.98 |
| Rate for Payer: Aetna Commercial |
$672.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$642.18
|
| Rate for Payer: Aetna Managed Medicare |
$209.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$485.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$373.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$358.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$395.76
|
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$686.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$417.88
|
| Rate for Payer: Health EOS Commercial |
$664.58
|
| Rate for Payer: HFN Commercial |
$686.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$560.04
|
| Rate for Payer: Multiplan Commercial |
$597.38
|
| Rate for Payer: NAPHCARE Commercial |
$448.03
|
| Rate for Payer: Preferred Network Access Commercial |
$686.98
|
| Rate for Payer: Quartz Beloit One Network |
$365.89
|
| Rate for Payer: Quartz Commercial |
$485.37
|
| Rate for Payer: Quartz Medicare Advantage |
$448.03
|
| Rate for Payer: The Alliance Commercial |
$373.36
|
| Rate for Payer: WEA Trust Commercial |
$410.70
|
| Rate for Payer: WPS Commercial |
$553.08
|
|
|
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 |
$14.27 |
| Max. Negotiated Rate |
$26.79 |
| Rate for Payer: Aetna Commercial |
$26.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.43
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.79
|
| Rate for Payer: Health EOS Commercial |
$25.92
|
| Rate for Payer: HFN Commercial |
$26.79
|
| Rate for Payer: Multiplan Commercial |
$23.30
|
| Rate for Payer: Preferred Network Access Commercial |
$26.79
|
| Rate for Payer: Quartz Beloit One Network |
$14.27
|
| Rate for Payer: Quartz Commercial |
$17.47
|
| Rate for Payer: WEA Trust Commercial |
$16.02
|
| Rate for Payer: WPS Commercial |
$21.57
|
|
|
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 |
$0.62 |
| Max. Negotiated Rate |
$26.79 |
| Rate for Payer: Aetna Commercial |
$26.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.04
|
| Rate for Payer: Aetna Managed Medicare |
$8.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.43
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.30
|
| Rate for Payer: Health EOS Commercial |
$25.92
|
| Rate for Payer: HFN Commercial |
$26.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.84
|
| Rate for Payer: Multiplan Commercial |
$23.30
|
| Rate for Payer: NAPHCARE Commercial |
$17.47
|
| Rate for Payer: Preferred Network Access Commercial |
$26.79
|
| Rate for Payer: Quartz Beloit One Network |
$14.27
|
| Rate for Payer: Quartz Commercial |
$18.93
|
| Rate for Payer: Quartz Medicare Advantage |
$17.47
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$16.02
|
| Rate for Payer: WPS Commercial |
$21.57
|
|
|
Susceptibility, Aerobic to Mayo
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
4620678
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$9.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.93
|
| Rate for Payer: Anthem Medicare Advantage |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.00
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.00
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$13.49
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$132.50
|
| Rate for Payer: Quartz Medicare Advantage |
$9.00
|
| Rate for Payer: The Alliance Commercial |
$35.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.00
|
| Rate for Payer: United Healthcare PPO |
$152.88
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: Wellcare Medicare |
$9.00
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
Susceptibility, Aerobic to Mayo
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
4620678
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$122.30
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
Susceptibility, Aerobic to Mayo
|
Professional
|
Both
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
4620678
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$193.65 |
| Rate for Payer: Aetna Commercial |
$193.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$9.00
|
| Rate for Payer: Anthem Medicare Advantage |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.00
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$193.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$101.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.00
|
| Rate for Payer: Health EOS Commercial |
$185.49
|
| Rate for Payer: HFN Commercial |
$193.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$13.49
|
| Rate for Payer: Preferred Network Access Commercial |
$193.65
|
| Rate for Payer: Quartz Beloit One Network |
$89.69
|
| Rate for Payer: Quartz Commercial |
$116.19
|
| Rate for Payer: Quartz Medicare Advantage |
$9.00
|
| Rate for Payer: The Alliance Commercial |
$35.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.00
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$39.58
|
|
