|
DRAPE OPMI EAR
|
Facility
|
OP
|
$383.00
|
|
| Hospital Charge Code |
2963295
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$111.53 |
| Max. Negotiated Rate |
$366.45 |
| Rate for Payer: Aetna Commercial |
$358.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.56
|
| Rate for Payer: Aetna Managed Medicare |
$111.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$258.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$199.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$191.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$211.11
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$366.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.91
|
| Rate for Payer: Health EOS Commercial |
$354.50
|
| Rate for Payer: HFN Commercial |
$366.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$298.74
|
| Rate for Payer: Multiplan Commercial |
$318.66
|
| Rate for Payer: NAPHCARE Commercial |
$238.99
|
| Rate for Payer: Preferred Network Access Commercial |
$366.45
|
| Rate for Payer: Quartz Beloit One Network |
$195.18
|
| Rate for Payer: Quartz Commercial |
$258.91
|
| Rate for Payer: Quartz Medicare Advantage |
$238.99
|
| Rate for Payer: The Alliance Commercial |
$199.16
|
| Rate for Payer: WEA Trust Commercial |
$219.08
|
| Rate for Payer: WPS Commercial |
$295.02
|
|
|
DRAPE ORTHOART LOWER EXTREMITY 89278
|
Facility
|
IP
|
$386.00
|
|
| Hospital Charge Code |
2963191
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$196.71 |
| Max. Negotiated Rate |
$369.32 |
| Rate for Payer: Aetna Commercial |
$361.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$345.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.76
|
| Rate for Payer: Cash Price |
$115.80
|
| Rate for Payer: Cigna Commercial |
$369.32
|
| Rate for Payer: Health EOS Commercial |
$357.28
|
| Rate for Payer: HFN Commercial |
$369.32
|
| Rate for Payer: Multiplan Commercial |
$321.15
|
| Rate for Payer: Preferred Network Access Commercial |
$369.32
|
| Rate for Payer: Quartz Beloit One Network |
$196.71
|
| Rate for Payer: Quartz Commercial |
$240.86
|
| Rate for Payer: WEA Trust Commercial |
$220.79
|
| Rate for Payer: WPS Commercial |
$297.34
|
|
|
DRAPE ORTHOART LOWER EXTREMITY 89278
|
Facility
|
OP
|
$386.00
|
|
| Hospital Charge Code |
2963191
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$112.40 |
| Max. Negotiated Rate |
$369.32 |
| Rate for Payer: Aetna Commercial |
$361.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$345.24
|
| Rate for Payer: Aetna Managed Medicare |
$112.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$260.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$200.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$192.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.76
|
| Rate for Payer: Cash Price |
$115.80
|
| Rate for Payer: Cigna Commercial |
$369.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$224.65
|
| Rate for Payer: Health EOS Commercial |
$357.28
|
| Rate for Payer: HFN Commercial |
$369.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$301.08
|
| Rate for Payer: Multiplan Commercial |
$321.15
|
| Rate for Payer: NAPHCARE Commercial |
$240.86
|
| Rate for Payer: Preferred Network Access Commercial |
$369.32
|
| Rate for Payer: Quartz Beloit One Network |
$196.71
|
| Rate for Payer: Quartz Commercial |
$260.94
|
| Rate for Payer: Quartz Medicare Advantage |
$240.86
|
| Rate for Payer: The Alliance Commercial |
$200.72
|
| Rate for Payer: WEA Trust Commercial |
$220.79
|
| Rate for Payer: WPS Commercial |
$297.34
|
|
|
DRAPE PLASTIC LASH 8065105520
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
5264716
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.08 |
| Max. Negotiated Rate |
$88.98 |
| Rate for Payer: Aetna Commercial |
$87.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.18
|
| Rate for Payer: Aetna Managed Medicare |
$27.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.26
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.13
|
| Rate for Payer: Health EOS Commercial |
$86.08
|
| Rate for Payer: HFN Commercial |
$88.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.54
|
| Rate for Payer: Multiplan Commercial |
$77.38
|
| Rate for Payer: NAPHCARE Commercial |
$58.03
|
| Rate for Payer: Preferred Network Access Commercial |
$88.98
|
| Rate for Payer: Quartz Beloit One Network |
$47.39
|
| Rate for Payer: Quartz Commercial |
$62.87
|
| Rate for Payer: Quartz Medicare Advantage |
$58.03
|
| Rate for Payer: The Alliance Commercial |
$48.36
|
| Rate for Payer: WEA Trust Commercial |
$53.20
|
| Rate for Payer: WPS Commercial |
$71.64
|
|
|
DRAPE PLASTIC LASH 8065105520
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
5264716
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.39 |
| Max. Negotiated Rate |
$88.98 |
| Rate for Payer: Aetna Commercial |
$87.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.26
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$86.08
|
| Rate for Payer: HFN Commercial |
$88.98
|
| Rate for Payer: Multiplan Commercial |
$77.38
|
| Rate for Payer: Preferred Network Access Commercial |
$88.98
|
| Rate for Payer: Quartz Beloit One Network |
$47.39
|
| Rate for Payer: Quartz Commercial |
$58.03
|
| Rate for Payer: WEA Trust Commercial |
$53.20
|
| Rate for Payer: WPS Commercial |
$71.64
|
|
|
DRAPE SHEET 3/4 47628
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
2963523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$52.42
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
DRAPE SHEET 3/4 47628
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
2963523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Aetna Managed Medicare |
$24.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.89
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: NAPHCARE Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$56.78
|
| Rate for Payer: Quartz Medicare Advantage |
$52.42
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
DRAPE SHOULDER PACK FLUID CONT 29367
|
Facility
|
IP
|
$207.00
|
|
| Hospital Charge Code |
2969220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$105.49 |
| Max. Negotiated Rate |
$198.06 |
| Rate for Payer: Aetna Commercial |
$193.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$198.06
|
| Rate for Payer: Health EOS Commercial |
$191.60
|
| Rate for Payer: HFN Commercial |
$198.06
|
| Rate for Payer: Multiplan Commercial |
$172.22
|
| Rate for Payer: Preferred Network Access Commercial |
$198.06
|
| Rate for Payer: Quartz Beloit One Network |
$105.49
|
| Rate for Payer: Quartz Commercial |
$129.17
|
| Rate for Payer: WEA Trust Commercial |
$118.40
|
| Rate for Payer: WPS Commercial |
$159.45
|
|
|
DRAPE SHOULDER PACK FLUID CONT 29367
|
Facility
|
OP
|
$207.00
|
|
| Hospital Charge Code |
2969220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$60.28 |
| Max. Negotiated Rate |
$198.06 |
| Rate for Payer: Aetna Commercial |
$193.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.14
|
| Rate for Payer: Aetna Managed Medicare |
$60.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$139.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$107.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$103.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$198.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$120.47
|
| Rate for Payer: Health EOS Commercial |
$191.60
|
| Rate for Payer: HFN Commercial |
$198.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$161.46
|
| Rate for Payer: Multiplan Commercial |
$172.22
|
| Rate for Payer: NAPHCARE Commercial |
$129.17
|
| Rate for Payer: Preferred Network Access Commercial |
$198.06
|
| Rate for Payer: Quartz Beloit One Network |
$105.49
|
| Rate for Payer: Quartz Commercial |
$139.93
|
| Rate for Payer: Quartz Medicare Advantage |
$129.17
|
| Rate for Payer: The Alliance Commercial |
$107.64
|
| Rate for Payer: WEA Trust Commercial |
$118.40
|
| Rate for Payer: WPS Commercial |
$159.45
|
|
|
DRAPE SMALL FENESTRATED 76X124 MINOR PROCEDURE 89209
|
Facility
|
OP
|
$156.00
|
|
| Hospital Charge Code |
2963254
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.43 |
| Max. Negotiated Rate |
$149.26 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Aetna Managed Medicare |
$45.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$105.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.79
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.68
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: NAPHCARE Commercial |
$97.34
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$105.46
|
| Rate for Payer: Quartz Medicare Advantage |
$97.34
|
| Rate for Payer: The Alliance Commercial |
$81.12
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
DRAPE SMALL FENESTRATED 76X124 MINOR PROCEDURE 89209
|
Facility
|
IP
|
$156.00
|
|
| Hospital Charge Code |
2963254
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$149.26 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$97.34
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
DRAPE SOLUTION WARMER ORS-300
|
Facility
|
OP
|
$864.00
|
|
| Hospital Charge Code |
2962879
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.60 |
| Max. Negotiated Rate |
$826.68 |
| Rate for Payer: Aetna Commercial |
$808.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.76
|
| Rate for Payer: Aetna Managed Medicare |
$251.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$584.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$449.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$431.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$476.24
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$826.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$502.85
|
| Rate for Payer: Health EOS Commercial |
$799.72
|
| Rate for Payer: HFN Commercial |
$826.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$673.92
|
| Rate for Payer: Multiplan Commercial |
$718.85
|
| Rate for Payer: NAPHCARE Commercial |
$539.14
|
| Rate for Payer: Preferred Network Access Commercial |
$826.68
|
| Rate for Payer: Quartz Beloit One Network |
$440.29
|
| Rate for Payer: Quartz Commercial |
$584.06
|
| Rate for Payer: Quartz Medicare Advantage |
$539.14
|
| Rate for Payer: The Alliance Commercial |
$449.28
|
| Rate for Payer: WEA Trust Commercial |
$494.21
|
| Rate for Payer: WPS Commercial |
$665.54
|
|
|
DRAPE SOLUTION WARMER ORS-300
|
Facility
|
IP
|
$864.00
|
|
| Hospital Charge Code |
2962879
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$440.29 |
| Max. Negotiated Rate |
$826.68 |
| Rate for Payer: Aetna Commercial |
$808.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$476.24
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$826.68
|
| Rate for Payer: Health EOS Commercial |
$799.72
|
| Rate for Payer: HFN Commercial |
$826.68
|
| Rate for Payer: Multiplan Commercial |
$718.85
|
| Rate for Payer: Preferred Network Access Commercial |
$826.68
|
| Rate for Payer: Quartz Beloit One Network |
$440.29
|
| Rate for Payer: Quartz Commercial |
$539.14
|
| Rate for Payer: WEA Trust Commercial |
$494.21
|
| Rate for Payer: WPS Commercial |
$665.54
|
|
|
DRAPE SPLIT BILATERAL DYNJP4007
|
Facility
|
OP
|
$145.00
|
|
| Hospital Charge Code |
3953375
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.22 |
| Max. Negotiated Rate |
$138.74 |
| Rate for Payer: Aetna Commercial |
$135.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.69
|
| Rate for Payer: Aetna Managed Medicare |
$42.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.92
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$138.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.39
|
| Rate for Payer: Health EOS Commercial |
$134.21
|
| Rate for Payer: HFN Commercial |
$138.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.10
|
| Rate for Payer: Multiplan Commercial |
$120.64
|
| Rate for Payer: NAPHCARE Commercial |
$90.48
|
| Rate for Payer: Preferred Network Access Commercial |
$138.74
|
| Rate for Payer: Quartz Beloit One Network |
$73.89
|
| Rate for Payer: Quartz Commercial |
$98.02
|
| Rate for Payer: Quartz Medicare Advantage |
$90.48
|
| Rate for Payer: The Alliance Commercial |
$75.40
|
| Rate for Payer: WEA Trust Commercial |
$82.94
|
| Rate for Payer: WPS Commercial |
$111.69
|
|
|
DRAPE SPLIT BILATERAL DYNJP4007
|
Facility
|
IP
|
$145.00
|
|
| Hospital Charge Code |
3953375
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.89 |
| Max. Negotiated Rate |
$138.74 |
| Rate for Payer: Aetna Commercial |
$135.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.92
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$138.74
|
| Rate for Payer: Health EOS Commercial |
$134.21
|
| Rate for Payer: HFN Commercial |
$138.74
|
| Rate for Payer: Multiplan Commercial |
$120.64
|
| Rate for Payer: Preferred Network Access Commercial |
$138.74
|
| Rate for Payer: Quartz Beloit One Network |
$73.89
|
| Rate for Payer: Quartz Commercial |
$90.48
|
| Rate for Payer: WEA Trust Commercial |
$82.94
|
| Rate for Payer: WPS Commercial |
$111.69
|
|
|
DRAPE SPLIT CVMAX DYNJP4013
|
Facility
|
IP
|
$439.00
|
|
| Hospital Charge Code |
3953374
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$223.71 |
| Max. Negotiated Rate |
$420.04 |
| Rate for Payer: Aetna Commercial |
$410.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.98
|
| Rate for Payer: Cash Price |
$131.70
|
| Rate for Payer: Cigna Commercial |
$420.04
|
| Rate for Payer: Health EOS Commercial |
$406.34
|
| Rate for Payer: HFN Commercial |
$420.04
|
| Rate for Payer: Multiplan Commercial |
$365.25
|
| Rate for Payer: Preferred Network Access Commercial |
$420.04
|
| Rate for Payer: Quartz Beloit One Network |
$223.71
|
| Rate for Payer: Quartz Commercial |
$273.94
|
| Rate for Payer: WEA Trust Commercial |
$251.11
|
| Rate for Payer: WPS Commercial |
$338.16
|
|
|
DRAPE SPLIT CVMAX DYNJP4013
|
Facility
|
OP
|
$439.00
|
|
| Hospital Charge Code |
3953374
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$127.84 |
| Max. Negotiated Rate |
$420.04 |
| Rate for Payer: Aetna Commercial |
$410.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.64
|
| Rate for Payer: Aetna Managed Medicare |
$127.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$296.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$219.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.98
|
| Rate for Payer: Cash Price |
$131.70
|
| Rate for Payer: Cigna Commercial |
$420.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$255.50
|
| Rate for Payer: Health EOS Commercial |
$406.34
|
| Rate for Payer: HFN Commercial |
$420.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$342.42
|
| Rate for Payer: Multiplan Commercial |
$365.25
|
| Rate for Payer: NAPHCARE Commercial |
$273.94
|
| Rate for Payer: Preferred Network Access Commercial |
$420.04
|
| Rate for Payer: Quartz Beloit One Network |
$223.71
|
| Rate for Payer: Quartz Commercial |
$296.76
|
| Rate for Payer: Quartz Medicare Advantage |
$273.94
|
| Rate for Payer: The Alliance Commercial |
$228.28
|
| Rate for Payer: WEA Trust Commercial |
$251.11
|
| Rate for Payer: WPS Commercial |
$338.16
|
|
|
DRAPE STERI DRAPE ISOLATION BAG 1003
|
Facility
|
OP
|
$225.00
|
|
| Hospital Charge Code |
2964043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$65.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$152.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$117.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$112.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.50
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$140.40
|
| Rate for Payer: The Alliance Commercial |
$117.00
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
DRAPE STERI DRAPE ISOLATION BAG 1003
|
Facility
|
IP
|
$225.00
|
|
| Hospital Charge Code |
2964043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
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 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: The Alliance Commercial |
$34.84
|
| 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: 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
|
|
