|
TAPE MICROFOAM 3 LATEX FREE
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
HCPCS A4452
|
| Hospital Charge Code |
2962792
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$57.08 |
| Max. Negotiated Rate |
$107.16 |
| Rate for Payer: Aetna Commercial |
$104.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$100.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.73
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$107.16
|
| Rate for Payer: Health EOS Commercial |
$103.67
|
| Rate for Payer: HFN Commercial |
$107.16
|
| Rate for Payer: Multiplan Commercial |
$93.18
|
| Rate for Payer: Preferred Network Access Commercial |
$107.16
|
| Rate for Payer: Quartz Beloit One Network |
$57.08
|
| Rate for Payer: Quartz Commercial |
$69.89
|
| Rate for Payer: WEA Trust Commercial |
$64.06
|
| Rate for Payer: WPS Commercial |
$86.27
|
|
|
Tapentadol, Quant, Urine
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 80372
|
| Hospital Charge Code |
4618955
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
Tapentadol, Quant, Urine
|
Professional
|
Both
|
$151.00
|
|
|
Service Code
|
CPT 80372
|
| Hospital Charge Code |
4618955
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.10 |
| Max. Negotiated Rate |
$149.19 |
| Rate for Payer: Aetna Commercial |
$149.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$149.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.22
|
| Rate for Payer: Health EOS Commercial |
$142.91
|
| Rate for Payer: HFN Commercial |
$149.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$149.19
|
| Rate for Payer: Quartz Beloit One Network |
$69.10
|
| Rate for Payer: Quartz Commercial |
$89.51
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
Tapentadol, Quant, Urine
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 80372
|
| Hospital Charge Code |
4618955
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: United Healthcare PPO |
$117.78
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
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 |
$893.33 |
| Max. Negotiated Rate |
$1,677.27 |
| Rate for Payer: Aetna Commercial |
$1,640.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,567.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$966.25
|
| Rate for Payer: Cash Price |
$525.90
|
| Rate for Payer: Cigna Commercial |
$1,677.27
|
| Rate for Payer: Health EOS Commercial |
$1,622.58
|
| Rate for Payer: HFN Commercial |
$1,677.27
|
| Rate for Payer: Multiplan Commercial |
$1,458.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,677.27
|
| Rate for Payer: Quartz Beloit One Network |
$893.33
|
| Rate for Payer: Quartz Commercial |
$1,093.87
|
| Rate for Payer: WEA Trust Commercial |
$1,002.72
|
| Rate for Payer: WPS Commercial |
$1,350.34
|
|
|
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 |
$510.47 |
| Max. Negotiated Rate |
$1,677.27 |
| Rate for Payer: Aetna Commercial |
$1,640.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,567.88
|
| Rate for Payer: Aetna Managed Medicare |
$510.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,185.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$911.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$875.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$966.25
|
| Rate for Payer: Cash Price |
$525.90
|
| Rate for Payer: Cigna Commercial |
$1,677.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,020.25
|
| Rate for Payer: Health EOS Commercial |
$1,622.58
|
| Rate for Payer: HFN Commercial |
$1,677.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,367.34
|
| Rate for Payer: Multiplan Commercial |
$1,458.50
|
| Rate for Payer: NAPHCARE Commercial |
$1,093.87
|
| Rate for Payer: Preferred Network Access Commercial |
$1,677.27
|
| Rate for Payer: Quartz Beloit One Network |
$893.33
|
| Rate for Payer: Quartz Commercial |
$1,185.03
|
| Rate for Payer: Quartz Medicare Advantage |
$1,093.87
|
| Rate for Payer: The Alliance Commercial |
$911.56
|
| Rate for Payer: WEA Trust Commercial |
$1,002.72
|
| Rate for Payer: WPS Commercial |
$1,350.34
|
|
|
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 |
$232.38 |
| Max. Negotiated Rate |
$436.30 |
| Rate for Payer: Aetna Commercial |
$426.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$407.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.35
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$436.30
|
| Rate for Payer: Health EOS Commercial |
$422.07
|
| Rate for Payer: HFN Commercial |
$436.30
|
| Rate for Payer: Multiplan Commercial |
$379.39
|
| Rate for Payer: Preferred Network Access Commercial |
$436.30
|
| Rate for Payer: Quartz Beloit One Network |
$232.38
|
| Rate for Payer: Quartz Commercial |
$284.54
|
| Rate for Payer: WEA Trust Commercial |
$260.83
|
| Rate for Payer: WPS Commercial |
$351.26
|
|
|
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 |
$132.79 |
| Max. Negotiated Rate |
$436.30 |
| Rate for Payer: Aetna Commercial |
$426.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$407.85
|
| Rate for Payer: Aetna Managed Medicare |
$132.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$308.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$237.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$227.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.35
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$436.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$265.39
|
| Rate for Payer: Health EOS Commercial |
$422.07
|
| Rate for Payer: HFN Commercial |
$436.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$355.68
|
| Rate for Payer: Multiplan Commercial |
$379.39
|
| Rate for Payer: NAPHCARE Commercial |
$284.54
|
| Rate for Payer: Preferred Network Access Commercial |
$436.30
|
| Rate for Payer: Quartz Beloit One Network |
$232.38
|
| Rate for Payer: Quartz Commercial |
$308.26
|
| Rate for Payer: Quartz Medicare Advantage |
$284.54
|
| Rate for Payer: The Alliance Commercial |
$237.12
|
| Rate for Payer: WEA Trust Commercial |
$260.83
|
| Rate for Payer: WPS Commercial |
$351.26
|
|
|
TAPER PLUG NEXGEN 00-5960-099-00
|
Facility
|
IP
|
$4,711.00
|
|
| Hospital Charge Code |
3269464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,400.73 |
| Max. Negotiated Rate |
$4,507.48 |
| Rate for Payer: Aetna Commercial |
$4,409.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,213.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,596.70
|
| Rate for Payer: Cash Price |
$1,413.30
|
| Rate for Payer: Cigna Commercial |
$4,507.48
|
| Rate for Payer: Health EOS Commercial |
$4,360.50
|
| Rate for Payer: HFN Commercial |
$4,507.48
|
| Rate for Payer: Multiplan Commercial |
$3,919.55
|
| Rate for Payer: Preferred Network Access Commercial |
$4,507.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,400.73
|
| Rate for Payer: Quartz Commercial |
$2,939.66
|
| Rate for Payer: WEA Trust Commercial |
$2,694.69
|
| Rate for Payer: WPS Commercial |
$3,628.88
|
|
|
TAPER PLUG NEXGEN 00-5960-099-00
|
Facility
|
OP
|
$4,711.00
|
|
| Hospital Charge Code |
3269464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,371.84 |
| Max. Negotiated Rate |
$4,507.48 |
| Rate for Payer: Aetna Commercial |
$4,409.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,213.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,371.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,184.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,449.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,351.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,596.70
|
| Rate for Payer: Cash Price |
$1,413.30
|
| Rate for Payer: Cigna Commercial |
$4,507.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,741.80
|
| Rate for Payer: Health EOS Commercial |
$4,360.50
|
| Rate for Payer: HFN Commercial |
$4,507.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,674.58
|
| Rate for Payer: Multiplan Commercial |
$3,919.55
|
| Rate for Payer: NAPHCARE Commercial |
$2,939.66
|
| Rate for Payer: Preferred Network Access Commercial |
$4,507.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,400.73
|
| Rate for Payer: Quartz Commercial |
$3,184.64
|
| Rate for Payer: Quartz Medicare Advantage |
$2,939.66
|
| Rate for Payer: The Alliance Commercial |
$2,449.72
|
| Rate for Payer: WEA Trust Commercial |
$2,694.69
|
| Rate for Payer: WPS Commercial |
$3,628.88
|
|
|
TAPER POST 12mm
|
Facility
|
OP
|
$4,978.00
|
|
| Hospital Charge Code |
2964733
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,449.59 |
| Max. Negotiated Rate |
$4,762.95 |
| Rate for Payer: Aetna Commercial |
$4,659.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,452.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,449.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,365.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,588.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,485.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,743.87
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,762.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,897.20
|
| Rate for Payer: Health EOS Commercial |
$4,607.64
|
| Rate for Payer: HFN Commercial |
$4,762.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,882.84
|
| Rate for Payer: Multiplan Commercial |
$4,141.70
|
| Rate for Payer: NAPHCARE Commercial |
$3,106.27
|
| Rate for Payer: Preferred Network Access Commercial |
$4,762.95
|
| Rate for Payer: Quartz Beloit One Network |
$2,536.79
|
| Rate for Payer: Quartz Commercial |
$3,365.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,106.27
|
| Rate for Payer: The Alliance Commercial |
$2,588.56
|
| Rate for Payer: WEA Trust Commercial |
$2,847.42
|
| Rate for Payer: WPS Commercial |
$3,834.55
|
|
|
TAPER POST 12mm
|
Facility
|
IP
|
$4,978.00
|
|
| Hospital Charge Code |
2964733
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,536.79 |
| Max. Negotiated Rate |
$4,762.95 |
| Rate for Payer: Aetna Commercial |
$4,659.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,452.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,743.87
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,762.95
|
| Rate for Payer: Health EOS Commercial |
$4,607.64
|
| Rate for Payer: HFN Commercial |
$4,762.95
|
| Rate for Payer: Multiplan Commercial |
$4,141.70
|
| Rate for Payer: Preferred Network Access Commercial |
$4,762.95
|
| Rate for Payer: Quartz Beloit One Network |
$2,536.79
|
| Rate for Payer: Quartz Commercial |
$3,106.27
|
| Rate for Payer: WEA Trust Commercial |
$2,847.42
|
| Rate for Payer: WPS Commercial |
$3,834.55
|
|
|
TAPER POST 13.7mm
|
Facility
|
IP
|
$5,284.00
|
|
| Hospital Charge Code |
2964734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,692.73 |
| Max. Negotiated Rate |
$5,055.73 |
| Rate for Payer: Aetna Commercial |
$4,945.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,726.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,912.54
|
| Rate for Payer: Cash Price |
$1,585.20
|
| Rate for Payer: Cigna Commercial |
$5,055.73
|
| Rate for Payer: Health EOS Commercial |
$4,890.87
|
| Rate for Payer: HFN Commercial |
$5,055.73
|
| Rate for Payer: Multiplan Commercial |
$4,396.29
|
| Rate for Payer: Preferred Network Access Commercial |
$5,055.73
|
| Rate for Payer: Quartz Beloit One Network |
$2,692.73
|
| Rate for Payer: Quartz Commercial |
$3,297.22
|
| Rate for Payer: WEA Trust Commercial |
$3,022.45
|
| Rate for Payer: WPS Commercial |
$4,070.27
|
|
|
TAPER POST 13.7mm
|
Facility
|
OP
|
$5,284.00
|
|
| Hospital Charge Code |
2964734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,538.70 |
| Max. Negotiated Rate |
$5,055.73 |
| Rate for Payer: Aetna Commercial |
$4,945.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,726.01
|
| Rate for Payer: Aetna Managed Medicare |
$1,538.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,571.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,747.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,637.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,912.54
|
| Rate for Payer: Cash Price |
$1,585.20
|
| Rate for Payer: Cigna Commercial |
$5,055.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,075.29
|
| Rate for Payer: Health EOS Commercial |
$4,890.87
|
| Rate for Payer: HFN Commercial |
$5,055.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,121.52
|
| Rate for Payer: Multiplan Commercial |
$4,396.29
|
| Rate for Payer: NAPHCARE Commercial |
$3,297.22
|
| Rate for Payer: Preferred Network Access Commercial |
$5,055.73
|
| Rate for Payer: Quartz Beloit One Network |
$2,692.73
|
| Rate for Payer: Quartz Commercial |
$3,571.98
|
| Rate for Payer: Quartz Medicare Advantage |
$3,297.22
|
| Rate for Payer: The Alliance Commercial |
$2,747.68
|
| Rate for Payer: WEA Trust Commercial |
$3,022.45
|
| Rate for Payer: WPS Commercial |
$4,070.27
|
|
|
TAPER POST HEMI-CAP 9095-0018-W
|
Facility
|
OP
|
$4,819.00
|
|
| Hospital Charge Code |
2965213
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,403.29 |
| Max. Negotiated Rate |
$4,610.82 |
| Rate for Payer: Aetna Commercial |
$4,510.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,310.11
|
| Rate for Payer: Aetna Managed Medicare |
$1,403.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,257.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,505.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,405.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,656.23
|
| Rate for Payer: Cash Price |
$1,445.70
|
| Rate for Payer: Cigna Commercial |
$4,610.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,804.66
|
| Rate for Payer: Health EOS Commercial |
$4,460.47
|
| Rate for Payer: HFN Commercial |
$4,610.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,758.82
|
| Rate for Payer: Multiplan Commercial |
$4,009.41
|
| Rate for Payer: NAPHCARE Commercial |
$3,007.06
|
| Rate for Payer: Preferred Network Access Commercial |
$4,610.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,455.76
|
| Rate for Payer: Quartz Commercial |
$3,257.64
|
| Rate for Payer: Quartz Medicare Advantage |
$3,007.06
|
| Rate for Payer: The Alliance Commercial |
$2,505.88
|
| Rate for Payer: WEA Trust Commercial |
$2,756.47
|
| Rate for Payer: WPS Commercial |
$3,712.08
|
|
|
TAPER POST HEMI-CAP 9095-0018-W
|
Facility
|
IP
|
$4,819.00
|
|
| Hospital Charge Code |
2965213
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,455.76 |
| Max. Negotiated Rate |
$4,610.82 |
| Rate for Payer: Aetna Commercial |
$4,510.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,310.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,656.23
|
| Rate for Payer: Cash Price |
$1,445.70
|
| Rate for Payer: Cigna Commercial |
$4,610.82
|
| Rate for Payer: Health EOS Commercial |
$4,460.47
|
| Rate for Payer: HFN Commercial |
$4,610.82
|
| Rate for Payer: Multiplan Commercial |
$4,009.41
|
| Rate for Payer: Preferred Network Access Commercial |
$4,610.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,455.76
|
| Rate for Payer: Quartz Commercial |
$3,007.06
|
| Rate for Payer: WEA Trust Commercial |
$2,756.47
|
| Rate for Payer: WPS Commercial |
$3,712.08
|
|
|
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 |
$24.46 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Aetna Managed Medicare |
$24.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.89
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: NAPHCARE Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$56.78
|
| Rate for Payer: Quartz Medicare Advantage |
$52.42
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
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 |
$42.81 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$52.42
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
TAPE-STRIPS 4 x 18 3524
|
Facility
|
IP
|
$156.00
|
|
| Hospital Charge Code |
2964008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$149.26 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$97.34
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
TAPE-STRIPS 4 x 18 3524
|
Facility
|
OP
|
$156.00
|
|
| Hospital Charge Code |
2964008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.43 |
| Max. Negotiated Rate |
$149.26 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Aetna Managed Medicare |
$45.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$105.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.79
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.68
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: NAPHCARE Commercial |
$97.34
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$105.46
|
| Rate for Payer: Quartz Medicare Advantage |
$97.34
|
| Rate for Payer: The Alliance Commercial |
$81.12
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
TAPE UMBILICAL 1/8 X 18
|
Facility
|
IP
|
$72.00
|
|
| Hospital Charge Code |
2963600
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.69 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$44.93
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
TAPE UMBILICAL 1/8 X 18
|
Facility
|
OP
|
$72.00
|
|
| Hospital Charge Code |
2963600
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.97 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Aetna Managed Medicare |
$20.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.90
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.16
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: NAPHCARE Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: Quartz Medicare Advantage |
$44.93
|
| Rate for Payer: The Alliance Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
TAPE WRAP PREM BLACK 2IN #2640-09
|
Facility
|
OP
|
$902.00
|
|
| Hospital Charge Code |
2974053
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$262.66 |
| Max. Negotiated Rate |
$863.03 |
| Rate for Payer: Aetna Commercial |
$844.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$806.75
|
| Rate for Payer: Aetna Managed Medicare |
$262.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$609.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$469.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$450.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$497.18
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna Commercial |
$863.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$524.96
|
| Rate for Payer: Health EOS Commercial |
$834.89
|
| Rate for Payer: HFN Commercial |
$863.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$703.56
|
| Rate for Payer: Multiplan Commercial |
$750.46
|
| Rate for Payer: NAPHCARE Commercial |
$562.85
|
| Rate for Payer: Preferred Network Access Commercial |
$863.03
|
| Rate for Payer: Quartz Beloit One Network |
$459.66
|
| Rate for Payer: Quartz Commercial |
$609.75
|
| Rate for Payer: Quartz Medicare Advantage |
$562.85
|
| Rate for Payer: The Alliance Commercial |
$469.04
|
| Rate for Payer: WEA Trust Commercial |
$515.94
|
| Rate for Payer: WPS Commercial |
$694.81
|
|
|
TAPE WRAP PREM BLACK 2IN #2640-09
|
Facility
|
IP
|
$902.00
|
|
| Hospital Charge Code |
2974053
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$459.66 |
| Max. Negotiated Rate |
$863.03 |
| Rate for Payer: Aetna Commercial |
$844.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$806.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$497.18
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna Commercial |
$863.03
|
| Rate for Payer: Health EOS Commercial |
$834.89
|
| Rate for Payer: HFN Commercial |
$863.03
|
| Rate for Payer: Multiplan Commercial |
$750.46
|
| Rate for Payer: Preferred Network Access Commercial |
$863.03
|
| Rate for Payer: Quartz Beloit One Network |
$459.66
|
| Rate for Payer: Quartz Commercial |
$562.85
|
| Rate for Payer: WEA Trust Commercial |
$515.94
|
| Rate for Payer: WPS Commercial |
$694.81
|
|
|
TAPE WRAP PREM WHITE #2640-10
|
Facility
|
OP
|
$902.00
|
|
| Hospital Charge Code |
2974054
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$262.66 |
| Max. Negotiated Rate |
$863.03 |
| Rate for Payer: Aetna Commercial |
$844.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$806.75
|
| Rate for Payer: Aetna Managed Medicare |
$262.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$609.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$469.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$450.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$497.18
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna Commercial |
$863.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$524.96
|
| Rate for Payer: Health EOS Commercial |
$834.89
|
| Rate for Payer: HFN Commercial |
$863.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$703.56
|
| Rate for Payer: Multiplan Commercial |
$750.46
|
| Rate for Payer: NAPHCARE Commercial |
$562.85
|
| Rate for Payer: Preferred Network Access Commercial |
$863.03
|
| Rate for Payer: Quartz Beloit One Network |
$459.66
|
| Rate for Payer: Quartz Commercial |
$609.75
|
| Rate for Payer: Quartz Medicare Advantage |
$562.85
|
| Rate for Payer: The Alliance Commercial |
$469.04
|
| Rate for Payer: WEA Trust Commercial |
$515.94
|
| Rate for Payer: WPS Commercial |
$694.81
|
|
