|
DRAPE STERI-DRAPE SMALL TOWEL 1000
|
Facility
|
OP
|
$67.00
|
|
| Hospital Charge Code |
2963978
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.51 |
| Max. Negotiated Rate |
$64.11 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Aetna Managed Medicare |
$19.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.99
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.26
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: NAPHCARE Commercial |
$41.81
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$45.29
|
| Rate for Payer: Quartz Medicare Advantage |
$41.81
|
| Rate for Payer: The Alliance Commercial |
$34.84
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
DRAPE STERI-DRAPE SMALL TOWEL 1000
|
Facility
|
IP
|
$67.00
|
|
| Hospital Charge Code |
2963978
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.14 |
| Max. Negotiated Rate |
$64.11 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$41.81
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
DRAPE STERILE FIELD NON21003
|
Facility
|
IP
|
$9.00
|
|
| Hospital Charge Code |
2974357
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$5.62
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$6.93
|
|
|
DRAPE STERILE FIELD NON21003
|
Facility
|
OP
|
$9.00
|
|
| Hospital Charge Code |
2974357
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Aetna Managed Medicare |
$2.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.24
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.02
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: NAPHCARE Commercial |
$5.62
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$6.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5.62
|
| Rate for Payer: The Alliance Commercial |
$4.68
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$6.93
|
|
|
DRAPE STERI U LATEX FREE 1015
|
Facility
|
OP
|
$167.00
|
|
| Hospital Charge Code |
2963644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.63 |
| Max. Negotiated Rate |
$159.79 |
| Rate for Payer: Aetna Commercial |
$156.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.36
|
| Rate for Payer: Aetna Managed Medicare |
$48.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$112.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$86.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$83.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.05
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$159.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.19
|
| Rate for Payer: Health EOS Commercial |
$154.58
|
| Rate for Payer: HFN Commercial |
$159.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.26
|
| Rate for Payer: Multiplan Commercial |
$138.94
|
| Rate for Payer: NAPHCARE Commercial |
$104.21
|
| Rate for Payer: Preferred Network Access Commercial |
$159.79
|
| Rate for Payer: Quartz Beloit One Network |
$85.10
|
| Rate for Payer: Quartz Commercial |
$112.89
|
| Rate for Payer: Quartz Medicare Advantage |
$104.21
|
| Rate for Payer: The Alliance Commercial |
$86.84
|
| Rate for Payer: WEA Trust Commercial |
$95.52
|
| Rate for Payer: WPS Commercial |
$128.64
|
|
|
DRAPE STERI U LATEX FREE 1015
|
Facility
|
IP
|
$167.00
|
|
| Hospital Charge Code |
2963644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$85.10 |
| Max. Negotiated Rate |
$159.79 |
| Rate for Payer: Aetna Commercial |
$156.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.05
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$159.79
|
| Rate for Payer: Health EOS Commercial |
$154.58
|
| Rate for Payer: HFN Commercial |
$159.79
|
| Rate for Payer: Multiplan Commercial |
$138.94
|
| Rate for Payer: Preferred Network Access Commercial |
$159.79
|
| Rate for Payer: Quartz Beloit One Network |
$85.10
|
| Rate for Payer: Quartz Commercial |
$104.21
|
| Rate for Payer: WEA Trust Commercial |
$95.52
|
| Rate for Payer: WPS Commercial |
$128.64
|
|
|
Drape tape
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
3006908
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$37.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.62
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$80.50
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$80.50
|
| Rate for Payer: The Alliance Commercial |
$67.08
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
Drape tape
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
3006908
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
DRAPE TUR STERI M1071
|
Facility
|
OP
|
$503.00
|
|
| Hospital Charge Code |
2962979
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.47 |
| Max. Negotiated Rate |
$481.27 |
| Rate for Payer: Aetna Commercial |
$470.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$449.88
|
| Rate for Payer: Aetna Managed Medicare |
$146.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$340.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$261.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$277.25
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cigna Commercial |
$481.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$292.75
|
| Rate for Payer: Health EOS Commercial |
$465.58
|
| Rate for Payer: HFN Commercial |
$481.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$392.34
|
| Rate for Payer: Multiplan Commercial |
$418.50
|
| Rate for Payer: NAPHCARE Commercial |
$313.87
|
| Rate for Payer: Preferred Network Access Commercial |
$481.27
|
| Rate for Payer: Quartz Beloit One Network |
$256.33
|
| Rate for Payer: Quartz Commercial |
$340.03
|
| Rate for Payer: Quartz Medicare Advantage |
$313.87
|
| Rate for Payer: The Alliance Commercial |
$261.56
|
| Rate for Payer: WEA Trust Commercial |
$287.72
|
| Rate for Payer: WPS Commercial |
$387.46
|
|
|
DRAPE TUR STERI M1071
|
Facility
|
IP
|
$503.00
|
|
| Hospital Charge Code |
2962979
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$256.33 |
| Max. Negotiated Rate |
$481.27 |
| Rate for Payer: Aetna Commercial |
$470.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$449.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$277.25
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cigna Commercial |
$481.27
|
| Rate for Payer: Health EOS Commercial |
$465.58
|
| Rate for Payer: HFN Commercial |
$481.27
|
| Rate for Payer: Multiplan Commercial |
$418.50
|
| Rate for Payer: Preferred Network Access Commercial |
$481.27
|
| Rate for Payer: Quartz Beloit One Network |
$256.33
|
| Rate for Payer: Quartz Commercial |
$313.87
|
| Rate for Payer: WEA Trust Commercial |
$287.72
|
| Rate for Payer: WPS Commercial |
$387.46
|
|
|
DRAPE UTILITY 15 X 16 DYNJP2406
|
Facility
|
IP
|
$62.00
|
|
| Hospital Charge Code |
4124761
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.60 |
| Max. Negotiated Rate |
$59.32 |
| Rate for Payer: Aetna Commercial |
$58.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.17
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$59.32
|
| Rate for Payer: Health EOS Commercial |
$57.39
|
| Rate for Payer: HFN Commercial |
$59.32
|
| Rate for Payer: Multiplan Commercial |
$51.58
|
| Rate for Payer: Preferred Network Access Commercial |
$59.32
|
| Rate for Payer: Quartz Beloit One Network |
$31.60
|
| Rate for Payer: Quartz Commercial |
$38.69
|
| Rate for Payer: WEA Trust Commercial |
$35.46
|
| Rate for Payer: WPS Commercial |
$47.76
|
|
|
DRAPE UTILITY 15 X 16 DYNJP2406
|
Facility
|
OP
|
$62.00
|
|
| Hospital Charge Code |
4124761
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$59.32 |
| Rate for Payer: Aetna Commercial |
$58.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.45
|
| Rate for Payer: Aetna Managed Medicare |
$18.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.17
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$59.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.08
|
| Rate for Payer: Health EOS Commercial |
$57.39
|
| Rate for Payer: HFN Commercial |
$59.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.36
|
| Rate for Payer: Multiplan Commercial |
$51.58
|
| Rate for Payer: NAPHCARE Commercial |
$38.69
|
| Rate for Payer: Preferred Network Access Commercial |
$59.32
|
| Rate for Payer: Quartz Beloit One Network |
$31.60
|
| Rate for Payer: Quartz Commercial |
$41.91
|
| Rate for Payer: Quartz Medicare Advantage |
$38.69
|
| Rate for Payer: The Alliance Commercial |
$32.24
|
| Rate for Payer: WEA Trust Commercial |
$35.46
|
| Rate for Payer: WPS Commercial |
$47.76
|
|
|
DRAPE V.A.C. STANDARD M6275009/10
|
Facility
|
IP
|
$208.00
|
|
| Hospital Charge Code |
2974083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.00 |
| Max. Negotiated Rate |
$199.01 |
| Rate for Payer: Aetna Commercial |
$194.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.65
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$199.01
|
| Rate for Payer: Health EOS Commercial |
$192.52
|
| Rate for Payer: HFN Commercial |
$199.01
|
| Rate for Payer: Multiplan Commercial |
$173.06
|
| Rate for Payer: Preferred Network Access Commercial |
$199.01
|
| Rate for Payer: Quartz Beloit One Network |
$106.00
|
| Rate for Payer: Quartz Commercial |
$129.79
|
| Rate for Payer: WEA Trust Commercial |
$118.98
|
| Rate for Payer: WPS Commercial |
$160.22
|
|
|
DRAPE V.A.C. STANDARD M6275009/10
|
Facility
|
OP
|
$208.00
|
|
| Hospital Charge Code |
2974083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$60.57 |
| Max. Negotiated Rate |
$199.01 |
| Rate for Payer: Aetna Commercial |
$194.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.04
|
| Rate for Payer: Aetna Managed Medicare |
$60.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$140.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$108.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$103.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.65
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$199.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.06
|
| Rate for Payer: Health EOS Commercial |
$192.52
|
| Rate for Payer: HFN Commercial |
$199.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$162.24
|
| Rate for Payer: Multiplan Commercial |
$173.06
|
| Rate for Payer: NAPHCARE Commercial |
$129.79
|
| Rate for Payer: Preferred Network Access Commercial |
$199.01
|
| Rate for Payer: Quartz Beloit One Network |
$106.00
|
| Rate for Payer: Quartz Commercial |
$140.61
|
| Rate for Payer: Quartz Medicare Advantage |
$129.79
|
| Rate for Payer: The Alliance Commercial |
$108.16
|
| Rate for Payer: WEA Trust Commercial |
$118.98
|
| Rate for Payer: WPS Commercial |
$160.22
|
|
|
Draw Blood From Venous Device
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
CPT 36591
|
| Hospital Charge Code |
5665628
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$90.71 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$111.07
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
Draw Blood From Venous Device
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
CPT 36591
|
| Hospital Charge Code |
5665628
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$88.86 |
| Max. Negotiated Rate |
$560.06 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$120.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.86
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$120.33
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
DRBC CPD AS5 500
|
Facility
|
IP
|
$615.00
|
|
|
Service Code
|
HCPCS P9021
|
| Hospital Charge Code |
1052813
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$313.40 |
| Max. Negotiated Rate |
$588.43 |
| Rate for Payer: Aetna Commercial |
$575.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$550.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$338.99
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$588.43
|
| Rate for Payer: Health EOS Commercial |
$569.24
|
| Rate for Payer: HFN Commercial |
$588.43
|
| Rate for Payer: Multiplan Commercial |
$511.68
|
| Rate for Payer: Preferred Network Access Commercial |
$588.43
|
| Rate for Payer: Quartz Beloit One Network |
$313.40
|
| Rate for Payer: Quartz Commercial |
$383.76
|
| Rate for Payer: WEA Trust Commercial |
$351.78
|
| Rate for Payer: WPS Commercial |
$473.73
|
|
|
DRBC CPD AS5 500
|
Facility
|
OP
|
$615.00
|
|
|
Service Code
|
HCPCS P9021
|
| Hospital Charge Code |
1052813
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$155.10 |
| Max. Negotiated Rate |
$620.38 |
| Rate for Payer: Aetna Commercial |
$575.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$550.06
|
| Rate for Payer: Aetna Managed Medicare |
$155.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$415.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$319.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$307.01
|
| Rate for Payer: Anthem Medicare Advantage |
$155.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$338.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$155.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$155.10
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$588.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$155.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$357.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$155.10
|
| Rate for Payer: Health EOS Commercial |
$569.24
|
| Rate for Payer: HFN Commercial |
$588.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$576.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$155.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$155.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$155.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$155.10
|
| Rate for Payer: Multiplan Commercial |
$511.68
|
| Rate for Payer: NAPHCARE Commercial |
$232.64
|
| Rate for Payer: Preferred Network Access Commercial |
$588.43
|
| Rate for Payer: Quartz Beloit One Network |
$313.40
|
| Rate for Payer: Quartz Commercial |
$415.74
|
| Rate for Payer: Quartz Medicare Advantage |
$155.10
|
| Rate for Payer: The Alliance Commercial |
$620.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$155.10
|
| Rate for Payer: United Healthcare PPO |
$479.70
|
| Rate for Payer: WEA Trust Commercial |
$351.78
|
| Rate for Payer: Wellcare Medicare |
$155.10
|
| Rate for Payer: WPS Commercial |
$473.73
|
|
|
DREAMWIRE 260CM STIFF 5612
|
Facility
|
IP
|
$2,280.00
|
|
| Hospital Charge Code |
3072561
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,161.89 |
| Max. Negotiated Rate |
$2,181.50 |
| Rate for Payer: Aetna Commercial |
$2,134.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,039.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,256.74
|
| Rate for Payer: Cash Price |
$684.00
|
| Rate for Payer: Cigna Commercial |
$2,181.50
|
| Rate for Payer: Health EOS Commercial |
$2,110.37
|
| Rate for Payer: HFN Commercial |
$2,181.50
|
| Rate for Payer: Multiplan Commercial |
$1,896.96
|
| Rate for Payer: Preferred Network Access Commercial |
$2,181.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,161.89
|
| Rate for Payer: Quartz Commercial |
$1,422.72
|
| Rate for Payer: WEA Trust Commercial |
$1,304.16
|
| Rate for Payer: WPS Commercial |
$1,756.28
|
|
|
DREAMWIRE 260CM STIFF 5612
|
Facility
|
OP
|
$2,280.00
|
|
| Hospital Charge Code |
3072561
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$663.94 |
| Max. Negotiated Rate |
$2,181.50 |
| Rate for Payer: Aetna Commercial |
$2,134.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,039.23
|
| Rate for Payer: Aetna Managed Medicare |
$663.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,541.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,185.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,138.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,256.74
|
| Rate for Payer: Cash Price |
$684.00
|
| Rate for Payer: Cigna Commercial |
$2,181.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,326.96
|
| Rate for Payer: Health EOS Commercial |
$2,110.37
|
| Rate for Payer: HFN Commercial |
$2,181.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,778.40
|
| Rate for Payer: Multiplan Commercial |
$1,896.96
|
| Rate for Payer: NAPHCARE Commercial |
$1,422.72
|
| Rate for Payer: Preferred Network Access Commercial |
$2,181.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,161.89
|
| Rate for Payer: Quartz Commercial |
$1,541.28
|
| Rate for Payer: Quartz Medicare Advantage |
$1,422.72
|
| Rate for Payer: The Alliance Commercial |
$1,185.60
|
| Rate for Payer: WEA Trust Commercial |
$1,304.16
|
| Rate for Payer: WPS Commercial |
$1,756.28
|
|
|
DREAMWIRE M0556161
|
Facility
|
IP
|
$2,280.00
|
|
| Hospital Charge Code |
3072503
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,161.89 |
| Max. Negotiated Rate |
$2,181.50 |
| Rate for Payer: Aetna Commercial |
$2,134.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,039.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,256.74
|
| Rate for Payer: Cash Price |
$684.00
|
| Rate for Payer: Cigna Commercial |
$2,181.50
|
| Rate for Payer: Health EOS Commercial |
$2,110.37
|
| Rate for Payer: HFN Commercial |
$2,181.50
|
| Rate for Payer: Multiplan Commercial |
$1,896.96
|
| Rate for Payer: Preferred Network Access Commercial |
$2,181.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,161.89
|
| Rate for Payer: Quartz Commercial |
$1,422.72
|
| Rate for Payer: WEA Trust Commercial |
$1,304.16
|
| Rate for Payer: WPS Commercial |
$1,756.28
|
|
|
DREAMWIRE M0556161
|
Facility
|
OP
|
$2,280.00
|
|
| Hospital Charge Code |
3072503
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$663.94 |
| Max. Negotiated Rate |
$2,181.50 |
| Rate for Payer: Aetna Commercial |
$2,134.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,039.23
|
| Rate for Payer: Aetna Managed Medicare |
$663.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,541.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,185.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,138.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,256.74
|
| Rate for Payer: Cash Price |
$684.00
|
| Rate for Payer: Cigna Commercial |
$2,181.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,326.96
|
| Rate for Payer: Health EOS Commercial |
$2,110.37
|
| Rate for Payer: HFN Commercial |
$2,181.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,778.40
|
| Rate for Payer: Multiplan Commercial |
$1,896.96
|
| Rate for Payer: NAPHCARE Commercial |
$1,422.72
|
| Rate for Payer: Preferred Network Access Commercial |
$2,181.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,161.89
|
| Rate for Payer: Quartz Commercial |
$1,541.28
|
| Rate for Payer: Quartz Medicare Advantage |
$1,422.72
|
| Rate for Payer: The Alliance Commercial |
$1,185.60
|
| Rate for Payer: WEA Trust Commercial |
$1,304.16
|
| Rate for Payer: WPS Commercial |
$1,756.28
|
|
|
DREAMWIRE STRAIGHT .035 450CM M00556141
|
Facility
|
IP
|
$2,281.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
3211485
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,162.40 |
| Max. Negotiated Rate |
$2,182.46 |
| Rate for Payer: Aetna Commercial |
$2,135.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,040.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,257.29
|
| Rate for Payer: Cash Price |
$684.30
|
| Rate for Payer: Cigna Commercial |
$2,182.46
|
| Rate for Payer: Health EOS Commercial |
$2,111.29
|
| Rate for Payer: HFN Commercial |
$2,182.46
|
| Rate for Payer: Multiplan Commercial |
$1,897.79
|
| Rate for Payer: Preferred Network Access Commercial |
$2,182.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,162.40
|
| Rate for Payer: Quartz Commercial |
$1,423.34
|
| Rate for Payer: WEA Trust Commercial |
$1,304.73
|
| Rate for Payer: WPS Commercial |
$1,757.05
|
|
|
DREAMWIRE STRAIGHT .035 450CM M00556141
|
Facility
|
OP
|
$2,281.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
3211485
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$664.23 |
| Max. Negotiated Rate |
$2,182.46 |
| Rate for Payer: Aetna Commercial |
$2,135.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,040.13
|
| Rate for Payer: Aetna Managed Medicare |
$664.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,541.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,186.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,138.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,257.29
|
| Rate for Payer: Cash Price |
$684.30
|
| Rate for Payer: Cigna Commercial |
$2,182.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,327.54
|
| Rate for Payer: Health EOS Commercial |
$2,111.29
|
| Rate for Payer: HFN Commercial |
$2,182.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,779.18
|
| Rate for Payer: Multiplan Commercial |
$1,897.79
|
| Rate for Payer: NAPHCARE Commercial |
$1,423.34
|
| Rate for Payer: Preferred Network Access Commercial |
$2,182.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,162.40
|
| Rate for Payer: Quartz Commercial |
$1,541.96
|
| Rate for Payer: Quartz Medicare Advantage |
$1,423.34
|
| Rate for Payer: The Alliance Commercial |
$1,186.12
|
| Rate for Payer: WEA Trust Commercial |
$1,304.73
|
| Rate for Payer: WPS Commercial |
$1,757.05
|
|
|
Dress/Debrid P-Thick Burn 16025
|
Professional
|
Both
|
$470.00
|
|
|
Service Code
|
CPT 16025
|
| Hospital Charge Code |
4536607
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.82 |
| Max. Negotiated Rate |
$464.36 |
| Rate for Payer: Aetna Commercial |
$464.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.37
|
| Rate for Payer: Aetna Managed Medicare |
$97.88
|
| Rate for Payer: Anthem Medicare Advantage |
$97.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$97.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$97.88
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$464.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.88
|
| Rate for Payer: Health EOS Commercial |
$444.81
|
| Rate for Payer: HFN Commercial |
$464.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$379.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$379.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$97.88
|
| Rate for Payer: Multiplan Commercial |
$391.04
|
| Rate for Payer: NAPHCARE Commercial |
$146.83
|
| Rate for Payer: Preferred Network Access Commercial |
$464.36
|
| Rate for Payer: Quartz Beloit One Network |
$215.07
|
| Rate for Payer: Quartz Commercial |
$278.62
|
| Rate for Payer: Quartz Medicare Advantage |
$97.88
|
| Rate for Payer: The Alliance Commercial |
$416.01
|
| Rate for Payer: United Healthcare Medicaid |
$44.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$97.88
|
| Rate for Payer: WEA Trust Commercial |
$268.84
|
| Rate for Payer: WPS Commercial |
$440.48
|
|
