|
DRAPE INCISE LARGE IOBAN 6651EZ
|
Facility
OP
|
$93.00
|
|
| Hospital Charge Code |
2963908
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.04 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Aetna Managed Medicare |
$26.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.04
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.75
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$60.45
|
| Rate for Payer: Quartz Medicare Advantage |
$55.80
|
| Rate for Payer: The Alliance Commercial |
$372.00
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
DRAPE INCISE LARGE IOBAN 6651EZ
|
Facility
IP
|
$93.00
|
|
| Hospital Charge Code |
2963908
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.57 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$55.80
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
DRAPE IOBAN 29X29 6658
|
Facility
IP
|
$462.00
|
|
| Hospital Charge Code |
2965805
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.38 |
| Max. Negotiated Rate |
$425.04 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.86
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$425.04
|
| Rate for Payer: Health EOS Commercial |
$411.18
|
| Rate for Payer: HFN Commercial |
$425.04
|
| Rate for Payer: Multiplan Commercial |
$369.60
|
| Rate for Payer: NAPHCARE Commercial |
$277.20
|
| Rate for Payer: Preferred Network Access Commercial |
$425.04
|
| Rate for Payer: Quartz Beloit One Network |
$226.38
|
| Rate for Payer: Quartz Commercial |
$277.20
|
| Rate for Payer: WEA Trust Commercial |
$254.10
|
| Rate for Payer: WPS Commercial |
$342.20
|
|
|
DRAPE IOBAN 29X29 6658
|
Facility
OP
|
$462.00
|
|
| Hospital Charge Code |
2965805
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$129.36 |
| Max. Negotiated Rate |
$1,848.00 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$397.32
|
| Rate for Payer: Aetna Managed Medicare |
$129.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$300.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$231.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$221.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.86
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$425.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.54
|
| Rate for Payer: Health EOS Commercial |
$411.18
|
| Rate for Payer: HFN Commercial |
$425.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$346.50
|
| Rate for Payer: Multiplan Commercial |
$369.60
|
| Rate for Payer: NAPHCARE Commercial |
$277.20
|
| Rate for Payer: Preferred Network Access Commercial |
$425.04
|
| Rate for Payer: Quartz Beloit One Network |
$226.38
|
| Rate for Payer: Quartz Commercial |
$300.30
|
| Rate for Payer: Quartz Medicare Advantage |
$277.20
|
| Rate for Payer: The Alliance Commercial |
$1,848.00
|
| Rate for Payer: WEA Trust Commercial |
$254.10
|
| Rate for Payer: WPS Commercial |
$342.20
|
|
|
DRAPE ISOL.W/IRRIG.POUCH 9106-07
|
Facility
IP
|
$991.00
|
|
| Hospital Charge Code |
2962892
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$485.59 |
| Max. Negotiated Rate |
$911.72 |
| Rate for Payer: Aetna Commercial |
$891.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$525.23
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$911.72
|
| Rate for Payer: Health EOS Commercial |
$881.99
|
| Rate for Payer: HFN Commercial |
$911.72
|
| Rate for Payer: Multiplan Commercial |
$792.80
|
| Rate for Payer: NAPHCARE Commercial |
$594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$911.72
|
| Rate for Payer: Quartz Beloit One Network |
$485.59
|
| Rate for Payer: Quartz Commercial |
$594.60
|
| Rate for Payer: WEA Trust Commercial |
$545.05
|
| Rate for Payer: WPS Commercial |
$734.03
|
|
|
DRAPE ISOL.W/IRRIG.POUCH 9106-07
|
Facility
OP
|
$991.00
|
|
| Hospital Charge Code |
2962892
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.48 |
| Max. Negotiated Rate |
$3,964.00 |
| Rate for Payer: Aetna Commercial |
$891.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$852.26
|
| Rate for Payer: Aetna Managed Medicare |
$277.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$644.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$495.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$475.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$525.23
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$911.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$554.56
|
| Rate for Payer: Health EOS Commercial |
$881.99
|
| Rate for Payer: HFN Commercial |
$911.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$743.25
|
| Rate for Payer: Multiplan Commercial |
$792.80
|
| Rate for Payer: NAPHCARE Commercial |
$594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$911.72
|
| Rate for Payer: Quartz Beloit One Network |
$485.59
|
| Rate for Payer: Quartz Commercial |
$644.15
|
| Rate for Payer: Quartz Medicare Advantage |
$594.60
|
| Rate for Payer: The Alliance Commercial |
$3,964.00
|
| Rate for Payer: WEA Trust Commercial |
$545.05
|
| Rate for Payer: WPS Commercial |
$734.03
|
|
|
DRAPE LAPAROSCOPIC ABDOMINAL 89233
|
Facility
IP
|
$268.00
|
|
| Hospital Charge Code |
5240716
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$131.32 |
| Max. Negotiated Rate |
$246.56 |
| Rate for Payer: Aetna Commercial |
$241.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.04
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$246.56
|
| Rate for Payer: Health EOS Commercial |
$238.52
|
| Rate for Payer: HFN Commercial |
$246.56
|
| Rate for Payer: Multiplan Commercial |
$214.40
|
| Rate for Payer: NAPHCARE Commercial |
$160.80
|
| Rate for Payer: Preferred Network Access Commercial |
$246.56
|
| Rate for Payer: Quartz Beloit One Network |
$131.32
|
| Rate for Payer: Quartz Commercial |
$160.80
|
| Rate for Payer: WEA Trust Commercial |
$147.40
|
| Rate for Payer: WPS Commercial |
$198.51
|
|
|
DRAPE LAPAROSCOPIC ABDOMINAL 89233
|
Facility
OP
|
$268.00
|
|
| Hospital Charge Code |
5240716
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.04 |
| Max. Negotiated Rate |
$1,072.00 |
| Rate for Payer: Aetna Commercial |
$241.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.48
|
| Rate for Payer: Aetna Managed Medicare |
$75.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$174.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$134.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$128.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.04
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$246.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$149.97
|
| Rate for Payer: Health EOS Commercial |
$238.52
|
| Rate for Payer: HFN Commercial |
$246.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$201.00
|
| Rate for Payer: Multiplan Commercial |
$214.40
|
| Rate for Payer: NAPHCARE Commercial |
$160.80
|
| Rate for Payer: Preferred Network Access Commercial |
$246.56
|
| Rate for Payer: Quartz Beloit One Network |
$131.32
|
| Rate for Payer: Quartz Commercial |
$174.20
|
| Rate for Payer: Quartz Medicare Advantage |
$160.80
|
| Rate for Payer: The Alliance Commercial |
$1,072.00
|
| Rate for Payer: WEA Trust Commercial |
$147.40
|
| Rate for Payer: WPS Commercial |
$198.51
|
|
|
DRAPE LAPAROTOMY 89221
|
Facility
OP
|
$192.00
|
|
| Hospital Charge Code |
2963264
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.76 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$172.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.12
|
| Rate for Payer: Aetna Managed Medicare |
$53.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$124.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.76
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$176.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.44
|
| Rate for Payer: Health EOS Commercial |
$170.88
|
| Rate for Payer: HFN Commercial |
$176.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$153.60
|
| Rate for Payer: NAPHCARE Commercial |
$115.20
|
| Rate for Payer: Preferred Network Access Commercial |
$176.64
|
| Rate for Payer: Quartz Beloit One Network |
$94.08
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: Quartz Medicare Advantage |
$115.20
|
| Rate for Payer: The Alliance Commercial |
$768.00
|
| Rate for Payer: WEA Trust Commercial |
$105.60
|
| Rate for Payer: WPS Commercial |
$142.21
|
|
|
DRAPE LAPAROTOMY 89221
|
Facility
IP
|
$192.00
|
|
| Hospital Charge Code |
2963264
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.08 |
| Max. Negotiated Rate |
$176.64 |
| Rate for Payer: Aetna Commercial |
$172.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.76
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$176.64
|
| Rate for Payer: Health EOS Commercial |
$170.88
|
| Rate for Payer: HFN Commercial |
$176.64
|
| Rate for Payer: Multiplan Commercial |
$153.60
|
| Rate for Payer: NAPHCARE Commercial |
$115.20
|
| Rate for Payer: Preferred Network Access Commercial |
$176.64
|
| Rate for Payer: Quartz Beloit One Network |
$94.08
|
| Rate for Payer: Quartz Commercial |
$115.20
|
| Rate for Payer: WEA Trust Commercial |
$105.60
|
| Rate for Payer: WPS Commercial |
$142.21
|
|
|
DRAPE LINGEMAN LATEX FREE 1-0425
|
Facility
OP
|
$791.00
|
|
| Hospital Charge Code |
2962809
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.48 |
| Max. Negotiated Rate |
$3,164.00 |
| Rate for Payer: Aetna Commercial |
$711.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$680.26
|
| Rate for Payer: Aetna Managed Medicare |
$221.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$514.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$395.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$379.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$419.23
|
| Rate for Payer: Cash Price |
$237.30
|
| Rate for Payer: Cigna Commercial |
$727.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$442.64
|
| Rate for Payer: Health EOS Commercial |
$703.99
|
| Rate for Payer: HFN Commercial |
$727.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$593.25
|
| Rate for Payer: Multiplan Commercial |
$632.80
|
| Rate for Payer: NAPHCARE Commercial |
$474.60
|
| Rate for Payer: Preferred Network Access Commercial |
$727.72
|
| Rate for Payer: Quartz Beloit One Network |
$387.59
|
| Rate for Payer: Quartz Commercial |
$514.15
|
| Rate for Payer: Quartz Medicare Advantage |
$474.60
|
| Rate for Payer: The Alliance Commercial |
$3,164.00
|
| Rate for Payer: WEA Trust Commercial |
$435.05
|
| Rate for Payer: WPS Commercial |
$585.89
|
|
|
DRAPE LINGEMAN LATEX FREE 1-0425
|
Facility
IP
|
$791.00
|
|
| Hospital Charge Code |
2962809
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$387.59 |
| Max. Negotiated Rate |
$727.72 |
| Rate for Payer: Aetna Commercial |
$711.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$419.23
|
| Rate for Payer: Cash Price |
$237.30
|
| Rate for Payer: Cigna Commercial |
$727.72
|
| Rate for Payer: Health EOS Commercial |
$703.99
|
| Rate for Payer: HFN Commercial |
$727.72
|
| Rate for Payer: Multiplan Commercial |
$632.80
|
| Rate for Payer: NAPHCARE Commercial |
$474.60
|
| Rate for Payer: Preferred Network Access Commercial |
$727.72
|
| Rate for Payer: Quartz Beloit One Network |
$387.59
|
| Rate for Payer: Quartz Commercial |
$474.60
|
| Rate for Payer: WEA Trust Commercial |
$435.05
|
| Rate for Payer: WPS Commercial |
$585.89
|
|
|
DRAPE MEDIUM 47617
|
Facility
OP
|
$62.00
|
|
| Hospital Charge Code |
2963468
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.36 |
| Max. Negotiated Rate |
$248.00 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Aetna Managed Medicare |
$17.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.70
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.50
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$40.30
|
| Rate for Payer: Quartz Medicare Advantage |
$37.20
|
| Rate for Payer: The Alliance Commercial |
$248.00
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
DRAPE MEDIUM 47617
|
Facility
IP
|
$62.00
|
|
| Hospital Charge Code |
2963468
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.38 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$37.20
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
DRAPE MICROSCOPE 20 X 64
|
Facility
IP
|
$226.00
|
|
| Hospital Charge Code |
2963175
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$110.74 |
| Max. Negotiated Rate |
$207.92 |
| Rate for Payer: Aetna Commercial |
$203.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$119.78
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cigna Commercial |
$207.92
|
| Rate for Payer: Health EOS Commercial |
$201.14
|
| Rate for Payer: HFN Commercial |
$207.92
|
| Rate for Payer: Multiplan Commercial |
$180.80
|
| Rate for Payer: NAPHCARE Commercial |
$135.60
|
| Rate for Payer: Preferred Network Access Commercial |
$207.92
|
| Rate for Payer: Quartz Beloit One Network |
$110.74
|
| Rate for Payer: Quartz Commercial |
$135.60
|
| Rate for Payer: WEA Trust Commercial |
$124.30
|
| Rate for Payer: WPS Commercial |
$167.40
|
|
|
DRAPE MICROSCOPE 20 X 64
|
Facility
OP
|
$226.00
|
|
| Hospital Charge Code |
2963175
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.28 |
| Max. Negotiated Rate |
$904.00 |
| Rate for Payer: Aetna Commercial |
$203.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$194.36
|
| Rate for Payer: Aetna Managed Medicare |
$63.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$146.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$113.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$108.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$119.78
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cigna Commercial |
$207.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$126.47
|
| Rate for Payer: Health EOS Commercial |
$201.14
|
| Rate for Payer: HFN Commercial |
$207.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$169.50
|
| Rate for Payer: Multiplan Commercial |
$180.80
|
| Rate for Payer: NAPHCARE Commercial |
$135.60
|
| Rate for Payer: Preferred Network Access Commercial |
$207.92
|
| Rate for Payer: Quartz Beloit One Network |
$110.74
|
| Rate for Payer: Quartz Commercial |
$146.90
|
| Rate for Payer: Quartz Medicare Advantage |
$135.60
|
| Rate for Payer: The Alliance Commercial |
$904.00
|
| Rate for Payer: WEA Trust Commercial |
$124.30
|
| Rate for Payer: WPS Commercial |
$167.40
|
|
|
DRAPE OPHTHALMIC INCISE 8065-1050-20
|
Facility
OP
|
$120.00
|
|
| Hospital Charge Code |
2964171
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Aetna Managed Medicare |
$33.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.15
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: Quartz Medicare Advantage |
$72.00
|
| Rate for Payer: The Alliance Commercial |
$480.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
DRAPE OPHTHALMIC INCISE 8065-1050-20
|
Facility
IP
|
$120.00
|
|
| Hospital Charge Code |
2964171
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
DRAPE OPMI EAR
|
Facility
OP
|
$383.00
|
|
| Hospital Charge Code |
2963295
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.24 |
| Max. Negotiated Rate |
$1,532.00 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| Rate for Payer: Aetna Managed Medicare |
$107.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$248.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$191.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$183.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.99
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$214.33
|
| Rate for Payer: Health EOS Commercial |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$287.25
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$229.80
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$248.95
|
| Rate for Payer: Quartz Medicare Advantage |
$229.80
|
| Rate for Payer: The Alliance Commercial |
$1,532.00
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
DRAPE OPMI EAR
|
Facility
IP
|
$383.00
|
|
| Hospital Charge Code |
2963295
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$187.67 |
| Max. Negotiated Rate |
$352.36 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.99
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| Rate for Payer: Health EOS Commercial |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$229.80
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$229.80
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
DRAPE ORTHOART LOWER EXTREMITY 89278
|
Facility
IP
|
$386.00
|
|
| Hospital Charge Code |
2963191
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$189.14 |
| Max. Negotiated Rate |
$355.12 |
| Rate for Payer: Aetna Commercial |
$347.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.58
|
| Rate for Payer: Cash Price |
$115.80
|
| Rate for Payer: Cigna Commercial |
$355.12
|
| Rate for Payer: Health EOS Commercial |
$343.54
|
| Rate for Payer: HFN Commercial |
$355.12
|
| Rate for Payer: Multiplan Commercial |
$308.80
|
| Rate for Payer: NAPHCARE Commercial |
$231.60
|
| Rate for Payer: Preferred Network Access Commercial |
$355.12
|
| Rate for Payer: Quartz Beloit One Network |
$189.14
|
| Rate for Payer: Quartz Commercial |
$231.60
|
| Rate for Payer: WEA Trust Commercial |
$212.30
|
| Rate for Payer: WPS Commercial |
$285.91
|
|
|
DRAPE ORTHOART LOWER EXTREMITY 89278
|
Facility
OP
|
$386.00
|
|
| Hospital Charge Code |
2963191
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$108.08 |
| Max. Negotiated Rate |
$1,544.00 |
| Rate for Payer: Aetna Commercial |
$347.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.96
|
| Rate for Payer: Aetna Managed Medicare |
$108.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$250.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$193.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$185.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.58
|
| Rate for Payer: Cash Price |
$115.80
|
| Rate for Payer: Cigna Commercial |
$355.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$216.01
|
| Rate for Payer: Health EOS Commercial |
$343.54
|
| Rate for Payer: HFN Commercial |
$355.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$289.50
|
| Rate for Payer: Multiplan Commercial |
$308.80
|
| Rate for Payer: NAPHCARE Commercial |
$231.60
|
| Rate for Payer: Preferred Network Access Commercial |
$355.12
|
| Rate for Payer: Quartz Beloit One Network |
$189.14
|
| Rate for Payer: Quartz Commercial |
$250.90
|
| Rate for Payer: Quartz Medicare Advantage |
$231.60
|
| Rate for Payer: The Alliance Commercial |
$1,544.00
|
| Rate for Payer: WEA Trust Commercial |
$212.30
|
| Rate for Payer: WPS Commercial |
$285.91
|
|
|
DRAPE PLASTIC LASH 8065105520
|
Facility
OP
|
$93.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
5264716
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.04 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Aetna Managed Medicare |
$26.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.04
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.75
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$60.45
|
| Rate for Payer: Quartz Medicare Advantage |
$55.80
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
DRAPE PLASTIC LASH 8065105520
|
Facility
IP
|
$93.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
5264716
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.57 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$55.80
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
DRAPE SHEET 3/4 47628
|
Facility
OP
|
$84.00
|
|
| Hospital Charge Code |
2963523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
