Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
MATRIX 12.5X10CM 125SQ CM RESTRATA SOFT NONFRIABLE ABSORBABLE WOUND STERILE LATEX FREE WHITE
The hospitals that file a Tricare rate for this code, one row per hospital and set of terms (billing class, payment method, setting). Rates under different terms are never blended, so the terms are shown under each hospital’s name. Figures are the hospital’s averages across its plans.
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70 hospital rates
| # | Plans | |||
|---|---|---|---|---|
| 1 | CLAIBORNE MEDICAL CENTER Tazewell, TN fee schedule · outpatient | 1 | $120.92 | $120.92 – $120.92 |
| 2 | CUMBERLAND MEDICAL CENTER, INC. Crossville, TN fee schedule · outpatient | 1 | $120.92 | $120.92 – $120.92 |
| 3 | Campbell County HMA, LLC LaFollette, TN facility · fee schedule · outpatient | 1 | $127.14 | $127.14 – $127.14 |
| 4 | Canton-Potsdam Hospital Potsdam, NY facility · fee schedule · outpatient | 1 | $108.80 | $108.80 – $108.80 |
| 5 | CentraState Medical Center Freehold Township, NJ other · outpatient | 2 | $2,122 | $2,122 – $2,122 |
| 6 | Central Maine Medical Center Lewiston, ME fee schedule · outpatient | 1 | $126.52 | $126.52 – $126.52 |
| 7 | Charleston Area Medical Center Charleston, WV percent of total billed charges · bothfrom % of charges | 1 | $7,656 | $5,400 – $9,912 |
| 8 | Chilton Medical Center Pompton Plains, NJ other · outpatient | 2 | $2,122 | $2,122 – $2,122 |
| 9 | Cocke County HMA, LLC Newport, TN facility · fee schedule · outpatient | 1 | $127.14 | $127.14 – $127.14 |
| 10 | Ellis Hospital NY 12308; 2210 Troy Schenectady Road Niskayuna, NY facility · fee schedule · outpatient | 1 | $127.14 | $127.14 – $127.14 |
| 11 | FORT LOUDOUN MEDICAL CENTER Lenoir City, TN fee schedule · outpatient | 1 | $112.91 | $112.91 – $112.91 |
| 12 | FORT SANDERS REGIONAL MEDICAL CENTER Knoxville, TN fee schedule · both | 1 | $112.91 | $112.91 – $112.91 |
| 13 | Fisher-Titus Medical Center Norwalk, OH facility · percent of total billed charges · inpatientfrom % of charges | 1 | $170.10 | $102.46 – $217.10 |
| 14 | Fisher-Titus Medical Center Norwalk, OH facility · percent of total billed charges · outpatientfrom % of charges | 1 | $159.47 | $96.06 – $203.54 |
| 15 | Hackettstown Medical Center Hackettstown, NJ other · outpatient | 2 | $2,122 | $2,122 – $2,122 |
| 16 | Holy Cross Germantown Hospital Germantown, MD facility · percent of total billed charges · bothfrom % of charges | 1 | $290.07 | $190.51 – $370.81 |
| 17 | Holy Cross Hospital-Silver Spring Silver Spring, MD facility · percent of total billed charges · bothfrom % of charges | 1 | $224.91 | $139.51 – $309.01 |
| 18 | Jefferson County HMA LLC Jefferson City, TN facility · fee schedule · outpatient | 1 | $127.14 | $127.14 – $127.14 |
| 19 | Kaleida Health Buffalo, NY fee schedule · outpatient | 1 | $147.58 | $147.58 – $147.58 |
| 20 | LECONTE MEDICAL CENTER Sevierville, TN fee schedule · outpatient | 1 | $120.92 | $120.92 – $120.92 |
| 21 | MCLAREN CARO REGION CARO, MI fee schedule | 1 | $122.30 | $122.30 – $122.30 |
| 22 | MCLAREN THUMB REGION AXE, MI fee schedule | 1 | $78.89 | $78.89 – $78.89 |
| 23 | METHODIST MEDICAL CENTER OF OAK RIDGE Oak Ridge, TN fee schedule · both | 1 | $112.91 | $112.91 – $112.91 |
| 24 | MORRISTOWN HAMBLEN HOSPITAL ASSOCIATION Morristown, TN fee schedule · outpatient | 1 | $112.91 | $112.91 – $112.91 |
| 25 | MedStar Franklin Square Medical Center Baltimore, MD percent of total billed charges · outpatientfrom % of charges | 1 | $5,788 | $1,556 – $14,830 |
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