|
2000770- Stoma adhesive
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
HCPCS A4362
|
| Hospital Charge Code |
5375230
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$43.32 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$53.04
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
2000770- Stoma adhesive
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
HCPCS A4362
|
| Hospital Charge Code |
5375230
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.51 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Aetna Managed Medicare |
$24.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.47
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.30
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: NAPHCARE Commercial |
$53.04
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$57.46
|
| Rate for Payer: Quartz Medicare Advantage |
$53.04
|
| Rate for Payer: The Alliance Commercial |
$17.51
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
2000791- Ostomy paste
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS A4406
|
| Hospital Charge Code |
5375208
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$92.75 |
| Max. Negotiated Rate |
$174.14 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$113.57
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$140.19
|
|
|
2000791- Ostomy paste
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS A4406
|
| Hospital Charge Code |
5375208
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.95 |
| Max. Negotiated Rate |
$174.14 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Aetna Managed Medicare |
$53.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$123.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$94.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$90.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.92
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.96
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: NAPHCARE Commercial |
$113.57
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$123.03
|
| Rate for Payer: Quartz Medicare Advantage |
$113.57
|
| Rate for Payer: The Alliance Commercial |
$33.95
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$140.19
|
|
|
2000792- Ostomy deodorant
|
Facility
|
IP
|
$367.00
|
|
| Hospital Charge Code |
5375210
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$187.02 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$229.01
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
2000792- Ostomy deodorant
|
Facility
|
OP
|
$367.00
|
|
| Hospital Charge Code |
5375210
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$106.87 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Aetna Managed Medicare |
$106.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$248.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$190.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$183.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$213.59
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.26
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: NAPHCARE Commercial |
$229.01
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$248.09
|
| Rate for Payer: Quartz Medicare Advantage |
$229.01
|
| Rate for Payer: The Alliance Commercial |
$190.84
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
2000793- Ostomy powder
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
HCPCS A4371
|
| Hospital Charge Code |
5375209
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.63 |
| Max. Negotiated Rate |
$135.87 |
| Rate for Payer: Aetna Commercial |
$132.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.00
|
| Rate for Payer: Aetna Managed Medicare |
$41.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.27
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$135.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.64
|
| Rate for Payer: Health EOS Commercial |
$131.44
|
| Rate for Payer: HFN Commercial |
$135.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$110.76
|
| Rate for Payer: Multiplan Commercial |
$118.14
|
| Rate for Payer: NAPHCARE Commercial |
$88.61
|
| Rate for Payer: Preferred Network Access Commercial |
$135.87
|
| Rate for Payer: Quartz Beloit One Network |
$72.36
|
| Rate for Payer: Quartz Commercial |
$95.99
|
| Rate for Payer: Quartz Medicare Advantage |
$88.61
|
| Rate for Payer: The Alliance Commercial |
$21.63
|
| Rate for Payer: WEA Trust Commercial |
$81.22
|
| Rate for Payer: WPS Commercial |
$109.38
|
|
|
2000793- Ostomy powder
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
HCPCS A4371
|
| Hospital Charge Code |
5375209
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$72.36 |
| Max. Negotiated Rate |
$135.87 |
| Rate for Payer: Aetna Commercial |
$132.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.27
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$135.87
|
| Rate for Payer: Health EOS Commercial |
$131.44
|
| Rate for Payer: HFN Commercial |
$135.87
|
| Rate for Payer: Multiplan Commercial |
$118.14
|
| Rate for Payer: Preferred Network Access Commercial |
$135.87
|
| Rate for Payer: Quartz Beloit One Network |
$72.36
|
| Rate for Payer: Quartz Commercial |
$88.61
|
| Rate for Payer: WEA Trust Commercial |
$81.22
|
| Rate for Payer: WPS Commercial |
$109.38
|
|
|
2001364- One piece appliance- Urostomy
|
Facility
|
IP
|
$116.00
|
|
| Hospital Charge Code |
5375214
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$59.11 |
| Max. Negotiated Rate |
$110.99 |
| Rate for Payer: Aetna Commercial |
$108.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.94
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.99
|
| Rate for Payer: Health EOS Commercial |
$107.37
|
| Rate for Payer: HFN Commercial |
$110.99
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: Preferred Network Access Commercial |
$110.99
|
| Rate for Payer: Quartz Beloit One Network |
$59.11
|
| Rate for Payer: Quartz Commercial |
$72.38
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$89.35
|
|
|
2001364- One piece appliance- Urostomy
|
Facility
|
OP
|
$116.00
|
|
| Hospital Charge Code |
5375214
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$33.78 |
| Max. Negotiated Rate |
$110.99 |
| Rate for Payer: Aetna Commercial |
$108.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Aetna Managed Medicare |
$33.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.94
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.51
|
| Rate for Payer: Health EOS Commercial |
$107.37
|
| Rate for Payer: HFN Commercial |
$110.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.48
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: NAPHCARE Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$110.99
|
| Rate for Payer: Quartz Beloit One Network |
$59.11
|
| Rate for Payer: Quartz Commercial |
$78.42
|
| Rate for Payer: Quartz Medicare Advantage |
$72.38
|
| Rate for Payer: The Alliance Commercial |
$60.32
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$89.35
|
|
|
2001557- 4 inch one piece wound appliance
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS A6154
|
| Hospital Charge Code |
5375224
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
2001557- 4 inch one piece wound appliance
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS A6154
|
| Hospital Charge Code |
5375224
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.21 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Aetna Managed Medicare |
$26.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.38
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.20
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: NAPHCARE Commercial |
$56.16
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$60.84
|
| Rate for Payer: Quartz Medicare Advantage |
$56.16
|
| Rate for Payer: The Alliance Commercial |
$85.24
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
2001699- No sting skin prep wipes
|
Facility
|
IP
|
$10.00
|
|
| Hospital Charge Code |
5375231
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
2001699- No sting skin prep wipes
|
Facility
|
OP
|
$10.00
|
|
| Hospital Charge Code |
5375231
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Aetna Managed Medicare |
$2.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.82
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.80
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: NAPHCARE Commercial |
$6.24
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.76
|
| Rate for Payer: Quartz Medicare Advantage |
$6.24
|
| Rate for Payer: The Alliance Commercial |
$5.20
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
2001706- 2 3/4 Wafer- 2 pc app
|
Facility
|
IP
|
$61.00
|
|
| Hospital Charge Code |
5375222
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$31.09 |
| Max. Negotiated Rate |
$58.36 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$38.06
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
2001706- 2 3/4 Wafer- 2 pc app
|
Facility
|
OP
|
$61.00
|
|
| Hospital Charge Code |
5375222
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.76 |
| Max. Negotiated Rate |
$58.36 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Aetna Managed Medicare |
$17.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.50
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.58
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: NAPHCARE Commercial |
$38.06
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$41.24
|
| Rate for Payer: Quartz Medicare Advantage |
$38.06
|
| Rate for Payer: The Alliance Commercial |
$31.72
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
2001891- 2 3/4 Urostomy- 2 pc app
|
Facility
|
OP
|
$104.00
|
|
| Hospital Charge Code |
5375221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$30.28 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Aetna Managed Medicare |
$30.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.53
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.12
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: NAPHCARE Commercial |
$64.90
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$70.30
|
| Rate for Payer: Quartz Medicare Advantage |
$64.90
|
| Rate for Payer: The Alliance Commercial |
$54.08
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
2001891- 2 3/4 Urostomy- 2 pc app
|
Facility
|
IP
|
$104.00
|
|
| Hospital Charge Code |
5375221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$53.00 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
2001892- Adapt rings 2 inch
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS A4385
|
| Hospital Charge Code |
5375225
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.71 |
| Max. Negotiated Rate |
$70.80 |
| Rate for Payer: Aetna Commercial |
$69.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.79
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$70.80
|
| Rate for Payer: Health EOS Commercial |
$68.49
|
| Rate for Payer: HFN Commercial |
$70.80
|
| Rate for Payer: Multiplan Commercial |
$61.57
|
| Rate for Payer: Preferred Network Access Commercial |
$70.80
|
| Rate for Payer: Quartz Beloit One Network |
$37.71
|
| Rate for Payer: Quartz Commercial |
$46.18
|
| Rate for Payer: WEA Trust Commercial |
$42.33
|
| Rate for Payer: WPS Commercial |
$57.00
|
|
|
2001892- Adapt rings 2 inch
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS A4385
|
| Hospital Charge Code |
5375225
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.55 |
| Max. Negotiated Rate |
$70.80 |
| Rate for Payer: Aetna Commercial |
$69.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.19
|
| Rate for Payer: Aetna Managed Medicare |
$21.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.79
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$70.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.07
|
| Rate for Payer: Health EOS Commercial |
$68.49
|
| Rate for Payer: HFN Commercial |
$70.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.72
|
| Rate for Payer: Multiplan Commercial |
$61.57
|
| Rate for Payer: NAPHCARE Commercial |
$46.18
|
| Rate for Payer: Preferred Network Access Commercial |
$70.80
|
| Rate for Payer: Quartz Beloit One Network |
$37.71
|
| Rate for Payer: Quartz Commercial |
$50.02
|
| Rate for Payer: Quartz Medicare Advantage |
$46.18
|
| Rate for Payer: The Alliance Commercial |
$30.20
|
| Rate for Payer: WEA Trust Commercial |
$42.33
|
| Rate for Payer: WPS Commercial |
$57.00
|
|
|
2001893- 2 1/4 Urostomy- 2 pc app
|
Facility
|
OP
|
$104.00
|
|
| Hospital Charge Code |
5375218
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.28 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Aetna Managed Medicare |
$30.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.53
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.12
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: NAPHCARE Commercial |
$64.90
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$70.30
|
| Rate for Payer: Quartz Medicare Advantage |
$64.90
|
| Rate for Payer: The Alliance Commercial |
$54.08
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
2001893- 2 1/4 Urostomy- 2 pc app
|
Facility
|
IP
|
$104.00
|
|
| Hospital Charge Code |
5375218
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$53.00 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
2001894- 2 3/4 Pouch- 2 pc app
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS A5063
|
| Hospital Charge Code |
5375220
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.33 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$21.22
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
2001894- 2 3/4 Pouch- 2 pc app
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
HCPCS A5063
|
| Hospital Charge Code |
5375220
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Aetna Managed Medicare |
$9.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.79
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.52
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: NAPHCARE Commercial |
$21.22
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$22.98
|
| Rate for Payer: Quartz Medicare Advantage |
$21.22
|
| Rate for Payer: The Alliance Commercial |
$16.06
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
2001895- 2 1/4 Wafer- 2 pc app
|
Facility
|
IP
|
$56.00
|
|
| Hospital Charge Code |
5375219
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$34.94
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
