|
Deoxycorticosterone
|
Facility
OP
|
$452.00
|
|
|
Service Code
|
CPT 82633
|
| Hospital Charge Code |
977923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.98 |
| Max. Negotiated Rate |
$1,808.00 |
| Rate for Payer: Aetna Commercial |
$406.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.72
|
| Rate for Payer: Aetna Managed Medicare |
$30.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$116.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.43
|
| Rate for Payer: Anthem Medicaid |
$32.01
|
| Rate for Payer: Anthem Medicare Advantage |
$30.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.98
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$415.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.01
|
| Rate for Payer: Dean Health Medicaid |
$32.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30.98
|
| Rate for Payer: Health EOS Commercial |
$402.28
|
| Rate for Payer: HFN Commercial |
$415.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.98
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$32.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.98
|
| Rate for Payer: Managed Health Services Medicaid |
$33.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30.98
|
| Rate for Payer: Multiplan Commercial |
$361.60
|
| Rate for Payer: NAPHCARE Commercial |
$46.47
|
| Rate for Payer: Preferred Network Access Commercial |
$415.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$32.01
|
| Rate for Payer: Quartz Beloit One Network |
$221.48
|
| Rate for Payer: Quartz Commercial |
$293.80
|
| Rate for Payer: Quartz Medicare Advantage |
$30.98
|
| Rate for Payer: The Alliance Commercial |
$1,808.00
|
| Rate for Payer: United Healthcare Medicaid |
$32.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.98
|
| Rate for Payer: United Healthcare PPO |
$339.00
|
| Rate for Payer: WEA Trust Commercial |
$248.60
|
| Rate for Payer: Wellcare Medicare |
$30.98
|
| Rate for Payer: WMAP Medicaid |
$32.01
|
| Rate for Payer: WPS Commercial |
$334.80
|
|
|
Deoxycorticosterone
|
Facility
IP
|
$452.00
|
|
|
Service Code
|
CPT 82633
|
| Hospital Charge Code |
977923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$221.48 |
| Max. Negotiated Rate |
$415.84 |
| Rate for Payer: Aetna Commercial |
$406.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.56
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$415.84
|
| Rate for Payer: Health EOS Commercial |
$402.28
|
| Rate for Payer: HFN Commercial |
$415.84
|
| Rate for Payer: Multiplan Commercial |
$361.60
|
| Rate for Payer: NAPHCARE Commercial |
$271.20
|
| Rate for Payer: Preferred Network Access Commercial |
$415.84
|
| Rate for Payer: Quartz Beloit One Network |
$221.48
|
| Rate for Payer: Quartz Commercial |
$271.20
|
| Rate for Payer: WEA Trust Commercial |
$248.60
|
| Rate for Payer: WPS Commercial |
$334.80
|
|
|
Depo Suspension 3.75 mg Charge
|
Facility
IP
|
$2,412.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
2958934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,181.88 |
| Max. Negotiated Rate |
$2,219.04 |
| Rate for Payer: Aetna Commercial |
$2,170.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,278.36
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,219.04
|
| Rate for Payer: Health EOS Commercial |
$2,146.68
|
| Rate for Payer: HFN Commercial |
$2,219.04
|
| Rate for Payer: Multiplan Commercial |
$1,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,447.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,219.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,181.88
|
| Rate for Payer: Quartz Commercial |
$1,447.20
|
| Rate for Payer: WEA Trust Commercial |
$1,326.60
|
| Rate for Payer: WPS Commercial |
$1,786.57
|
|
|
Depo Suspension 3.75 mg Charge
|
Facility
OP
|
$2,412.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
2958934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,157.76 |
| Max. Negotiated Rate |
$37,002.00 |
| Rate for Payer: Aetna Commercial |
$2,170.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,074.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,564.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,567.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,206.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,157.76
|
| Rate for Payer: Anthem Medicare Advantage |
$1,564.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,278.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,564.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,564.60
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,219.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,564.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,085.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,564.60
|
| Rate for Payer: Health EOS Commercial |
$2,146.68
|
| Rate for Payer: HFN Commercial |
$2,219.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,820.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,564.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,564.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,564.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,564.60
|
| Rate for Payer: Multiplan Commercial |
$1,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,346.91
|
| Rate for Payer: Preferred Network Access Commercial |
$2,219.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,181.88
|
| Rate for Payer: Quartz Commercial |
$1,567.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,564.60
|
| Rate for Payer: The Alliance Commercial |
$37,002.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,564.60
|
| Rate for Payer: WEA Trust Commercial |
$1,326.60
|
| Rate for Payer: Wellcare Medicare |
$1,564.60
|
| Rate for Payer: WPS Commercial |
$3,940.30
|
|
|
Depo Suspension 3.75 mg Charge
|
Professional
|
$2,412.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
2958934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,061.28 |
| Max. Negotiated Rate |
$4,244.67 |
| Rate for Payer: Aetna Commercial |
$2,291.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,074.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,543.52
|
| Rate for Payer: Anthem Medicare Advantage |
$1,543.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,543.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,543.52
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,291.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,206.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,576.12
|
| Rate for Payer: Health EOS Commercial |
$2,194.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,851.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,851.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,543.52
|
| Rate for Payer: Multiplan Commercial |
$1,929.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,291.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,061.28
|
| Rate for Payer: Quartz Commercial |
$1,374.84
|
| Rate for Payer: Quartz Medicare Advantage |
$1,543.52
|
| Rate for Payer: The Alliance Commercial |
$4,244.67
|
| Rate for Payer: United Healthcare Medicaid |
$1,564.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,543.52
|
| Rate for Payer: WEA Trust Commercial |
$1,326.60
|
| Rate for Payer: WPS Commercial |
$3,940.30
|
|
|
DEPRESSIVE NEUROSES
|
Facility
IP
|
$24,421.00
|
|
|
Service Code
|
MS-DRG 881
|
| Min. Negotiated Rate |
$8,784.39 |
| Max. Negotiated Rate |
$24,421.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,784.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,091.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,633.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,902.98
|
| Rate for Payer: Anthem Medicare Advantage |
$8,784.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,784.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,784.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,784.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,433.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,784.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,676.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,784.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,784.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,784.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,784.39
|
| Rate for Payer: NAPHCARE Commercial |
$13,176.58
|
| Rate for Payer: Quartz Medicare Advantage |
$8,784.39
|
| Rate for Payer: The Alliance Commercial |
$24,421.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,784.39
|
| Rate for Payer: United Healthcare PPO |
$13,761.58
|
| Rate for Payer: Wellcare Medicare |
$8,784.39
|
|
|
DEPTH GAUGE/COUNTER SINK 3.0MM IS1104
|
Facility
OP
|
$4,846.00
|
|
| Hospital Charge Code |
5831690
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,356.88 |
| Max. Negotiated Rate |
$19,384.00 |
| Rate for Payer: Aetna Commercial |
$4,361.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,167.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,356.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,149.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,423.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,326.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,568.38
|
| Rate for Payer: Cash Price |
$1,453.80
|
| Rate for Payer: Cigna Commercial |
$4,458.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,711.82
|
| Rate for Payer: Health EOS Commercial |
$4,312.94
|
| Rate for Payer: HFN Commercial |
$4,458.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,634.50
|
| Rate for Payer: Multiplan Commercial |
$3,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,907.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,458.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,374.54
|
| Rate for Payer: Quartz Commercial |
$3,149.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,907.60
|
| Rate for Payer: The Alliance Commercial |
$19,384.00
|
| Rate for Payer: WEA Trust Commercial |
$2,665.30
|
| Rate for Payer: WPS Commercial |
$3,589.43
|
|
|
DEPTH GAUGE/COUNTER SINK 3.0MM IS1104
|
Facility
IP
|
$4,846.00
|
|
| Hospital Charge Code |
5831690
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,374.54 |
| Max. Negotiated Rate |
$4,458.32 |
| Rate for Payer: Aetna Commercial |
$4,361.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,568.38
|
| Rate for Payer: Cash Price |
$1,453.80
|
| Rate for Payer: Cigna Commercial |
$4,458.32
|
| Rate for Payer: Health EOS Commercial |
$4,312.94
|
| Rate for Payer: HFN Commercial |
$4,458.32
|
| Rate for Payer: Multiplan Commercial |
$3,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,907.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,458.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,374.54
|
| Rate for Payer: Quartz Commercial |
$2,907.60
|
| Rate for Payer: WEA Trust Commercial |
$2,665.30
|
| Rate for Payer: WPS Commercial |
$3,589.43
|
|
|
DE QUERVAIN'S RELEASE
|
Facility
OP
|
$1,337.00
|
|
| Hospital Charge Code |
2959994
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$374.36 |
| Max. Negotiated Rate |
$5,348.00 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Aetna Managed Medicare |
$374.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$869.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$668.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$641.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$748.19
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,002.75
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$869.05
|
| Rate for Payer: Quartz Medicare Advantage |
$802.20
|
| Rate for Payer: The Alliance Commercial |
$5,348.00
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
DE QUERVAIN'S RELEASE
|
Facility
IP
|
$1,337.00
|
|
| Hospital Charge Code |
2959994
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$655.13 |
| Max. Negotiated Rate |
$1,230.04 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$802.20
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM CLR222US
|
Facility
IP
|
$1,274.00
|
|
| Hospital Charge Code |
5349538
|
|
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
|
|
|
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM CLR222US
|
Facility
OP
|
$1,274.00
|
|
| Hospital Charge Code |
5349538
|
|
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
|
|
|
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM CLR422US
|
Facility
OP
|
$1,634.00
|
|
| Hospital Charge Code |
5384952
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$457.52 |
| Max. Negotiated Rate |
$6,536.00 |
| Rate for Payer: Aetna Commercial |
$1,470.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,405.24
|
| Rate for Payer: Aetna Managed Medicare |
$457.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,062.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$817.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$784.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$866.02
|
| Rate for Payer: Cash Price |
$490.20
|
| Rate for Payer: Cigna Commercial |
$1,503.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$914.39
|
| Rate for Payer: Health EOS Commercial |
$1,454.26
|
| Rate for Payer: HFN Commercial |
$1,503.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,225.50
|
| Rate for Payer: Multiplan Commercial |
$1,307.20
|
| Rate for Payer: NAPHCARE Commercial |
$980.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,503.28
|
| Rate for Payer: Quartz Beloit One Network |
$800.66
|
| Rate for Payer: Quartz Commercial |
$1,062.10
|
| Rate for Payer: Quartz Medicare Advantage |
$980.40
|
| Rate for Payer: The Alliance Commercial |
$6,536.00
|
| Rate for Payer: WEA Trust Commercial |
$898.70
|
| Rate for Payer: WPS Commercial |
$1,210.30
|
|
|
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM CLR422US
|
Facility
IP
|
$1,634.00
|
|
| Hospital Charge Code |
5384952
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$800.66 |
| Max. Negotiated Rate |
$1,503.28 |
| Rate for Payer: Aetna Commercial |
$1,470.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$866.02
|
| Rate for Payer: Cash Price |
$490.20
|
| Rate for Payer: Cigna Commercial |
$1,503.28
|
| Rate for Payer: Health EOS Commercial |
$1,454.26
|
| Rate for Payer: HFN Commercial |
$1,503.28
|
| Rate for Payer: Multiplan Commercial |
$1,307.20
|
| Rate for Payer: NAPHCARE Commercial |
$980.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,503.28
|
| Rate for Payer: Quartz Beloit One Network |
$800.66
|
| Rate for Payer: Quartz Commercial |
$980.40
|
| Rate for Payer: WEA Trust Commercial |
$898.70
|
| Rate for Payer: WPS Commercial |
$1,210.30
|
|
|
DERMABOND SKIN ADHESIVE
|
Facility
OP
|
$547.00
|
|
| Hospital Charge Code |
2973470
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$153.16 |
| Max. Negotiated Rate |
$2,188.00 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.42
|
| Rate for Payer: Aetna Managed Medicare |
$153.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$355.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$273.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$262.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.10
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$410.25
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$355.55
|
| Rate for Payer: Quartz Medicare Advantage |
$328.20
|
| Rate for Payer: The Alliance Commercial |
$2,188.00
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
DERMABOND SKIN ADHESIVE
|
Facility
IP
|
$547.00
|
|
| Hospital Charge Code |
2973470
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.03 |
| Max. Negotiated Rate |
$503.24 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$328.20
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
Dermabond UD Packet [Med]
|
Facility
IP
|
$78.00
|
|
| Hospital Charge Code |
2974927
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
Dermabond UD Packet [Med]
|
Facility
OP
|
$78.00
|
|
| Hospital Charge Code |
2974927
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Aetna Managed Medicare |
$21.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.65
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.50
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$50.70
|
| Rate for Payer: Quartz Medicare Advantage |
$46.80
|
| Rate for Payer: The Alliance Commercial |
$312.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
DERMABRASION SEGMENTAL FACE 15781
|
Professional
|
$973.00
|
|
|
Service Code
|
CPT 15781
|
| Hospital Charge Code |
6113632
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$404.19 |
| Max. Negotiated Rate |
$1,818.86 |
| Rate for Payer: Aetna Commercial |
$924.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$836.78
|
| Rate for Payer: Aetna Managed Medicare |
$404.19
|
| Rate for Payer: Anthem Medicare Advantage |
$404.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$404.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$404.19
|
| Rate for Payer: Cash Price |
$291.90
|
| Rate for Payer: Cash Price |
$291.90
|
| Rate for Payer: Cigna Commercial |
$924.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$486.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$404.19
|
| Rate for Payer: Health EOS Commercial |
$885.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,430.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,430.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$404.19
|
| Rate for Payer: Multiplan Commercial |
$778.40
|
| Rate for Payer: Preferred Network Access Commercial |
$924.35
|
| Rate for Payer: Quartz Beloit One Network |
$428.12
|
| Rate for Payer: Quartz Commercial |
$554.61
|
| Rate for Payer: Quartz Medicare Advantage |
$404.19
|
| Rate for Payer: The Alliance Commercial |
$1,717.81
|
| Rate for Payer: United Healthcare Medicaid |
$736.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$404.19
|
| Rate for Payer: WEA Trust Commercial |
$535.15
|
| Rate for Payer: WPS Commercial |
$1,818.86
|
|
|
DERMACARRIER 8 STERILE 00-7708-000-10
|
Facility
IP
|
$657.00
|
|
| Hospital Charge Code |
2967417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$321.93 |
| Max. Negotiated Rate |
$604.44 |
| Rate for Payer: Aetna Commercial |
$591.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$348.21
|
| Rate for Payer: Cash Price |
$197.10
|
| Rate for Payer: Cigna Commercial |
$604.44
|
| Rate for Payer: Health EOS Commercial |
$584.73
|
| Rate for Payer: HFN Commercial |
$604.44
|
| Rate for Payer: Multiplan Commercial |
$525.60
|
| Rate for Payer: NAPHCARE Commercial |
$394.20
|
| Rate for Payer: Preferred Network Access Commercial |
$604.44
|
| Rate for Payer: Quartz Beloit One Network |
$321.93
|
| Rate for Payer: Quartz Commercial |
$394.20
|
| Rate for Payer: WEA Trust Commercial |
$361.35
|
| Rate for Payer: WPS Commercial |
$486.64
|
|
|
DERMACARRIER 8 STERILE 00-7708-000-10
|
Facility
OP
|
$657.00
|
|
| Hospital Charge Code |
2967417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.96 |
| Max. Negotiated Rate |
$2,628.00 |
| Rate for Payer: Aetna Commercial |
$591.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$565.02
|
| Rate for Payer: Aetna Managed Medicare |
$183.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$427.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$328.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$315.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$348.21
|
| Rate for Payer: Cash Price |
$197.10
|
| Rate for Payer: Cigna Commercial |
$604.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$367.66
|
| Rate for Payer: Health EOS Commercial |
$584.73
|
| Rate for Payer: HFN Commercial |
$604.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$492.75
|
| Rate for Payer: Multiplan Commercial |
$525.60
|
| Rate for Payer: NAPHCARE Commercial |
$394.20
|
| Rate for Payer: Preferred Network Access Commercial |
$604.44
|
| Rate for Payer: Quartz Beloit One Network |
$321.93
|
| Rate for Payer: Quartz Commercial |
$427.05
|
| Rate for Payer: Quartz Medicare Advantage |
$394.20
|
| Rate for Payer: The Alliance Commercial |
$2,628.00
|
| Rate for Payer: WEA Trust Commercial |
$361.35
|
| Rate for Payer: WPS Commercial |
$486.64
|
|
|
Dermagraft per sq cm Q4106
|
Professional
|
$123.00
|
|
|
Service Code
|
HCPCS Q4106
|
| Hospital Charge Code |
3133667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.48 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Aetna Commercial |
$116.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Aetna Managed Medicare |
$34.48
|
| Rate for Payer: Anthem Medicare Advantage |
$34.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$34.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$34.48
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$116.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.48
|
| Rate for Payer: Health EOS Commercial |
$111.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$111.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$111.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$34.48
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$116.85
|
| Rate for Payer: Quartz Beloit One Network |
$54.12
|
| Rate for Payer: Quartz Commercial |
$70.11
|
| Rate for Payer: Quartz Medicare Advantage |
$34.48
|
| Rate for Payer: The Alliance Commercial |
$94.81
|
| Rate for Payer: United Healthcare Medicaid |
$35.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34.48
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$60.34
|
|
|
Dermagraft per sq cm Q4106
|
Facility
OP
|
$123.00
|
|
|
Service Code
|
HCPCS Q4106
|
| Hospital Charge Code |
3133667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.44 |
| Max. Negotiated Rate |
$607.64 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Aetna Managed Medicare |
$34.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.83
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.25
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$79.95
|
| Rate for Payer: Quartz Medicare Advantage |
$73.80
|
| Rate for Payer: The Alliance Commercial |
$607.64
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
Dermagraft per sq cm Q4106
|
Facility
IP
|
$123.00
|
|
|
Service Code
|
HCPCS Q4106
|
| Hospital Charge Code |
3133667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.27 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$73.80
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
Dermatopathology Consult
|
Professional
|
$207.00
|
|
|
Service Code
|
CPT 88321
|
| Hospital Charge Code |
3781385
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.91 |
| Max. Negotiated Rate |
$351.60 |
| Rate for Payer: Aetna Commercial |
$196.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.02
|
| Rate for Payer: Aetna Managed Medicare |
$79.91
|
| Rate for Payer: Anthem Medicare Advantage |
$79.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$79.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$79.91
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$196.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$103.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79.91
|
| Rate for Payer: Health EOS Commercial |
$188.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$334.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$79.91
|
| Rate for Payer: Multiplan Commercial |
$165.60
|
| Rate for Payer: Preferred Network Access Commercial |
$196.65
|
| Rate for Payer: Quartz Beloit One Network |
$91.08
|
| Rate for Payer: Quartz Commercial |
$117.99
|
| Rate for Payer: Quartz Medicare Advantage |
$79.91
|
| Rate for Payer: The Alliance Commercial |
$315.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$79.91
|
| Rate for Payer: WEA Trust Commercial |
$113.85
|
| Rate for Payer: WPS Commercial |
$351.60
|
|
