|
STOCKINETTE 3 NON-STERILE 75 FT"
|
Facility
|
IP
|
$7.00
|
|
| Hospital Charge Code |
2963747
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
STOCKINETTE 4 NON-STERILE
|
Facility
|
IP
|
$7.00
|
|
| Hospital Charge Code |
2963846
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
STOCKINETTE 4 NON-STERILE
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
2963846
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.07
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$3.64
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
STOCKINETTE IMPERVIOUS 12x48 89821
|
Facility
|
OP
|
$167.00
|
|
| Hospital Charge Code |
2963174
|
|
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
|
|
|
STOCKINETTE IMPERVIOUS 12x48 89821
|
Facility
|
IP
|
$167.00
|
|
| Hospital Charge Code |
2963174
|
|
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
|
|
|
STOCKINETTE IMPERVIOUS 9 X 44 MEDIUM 89811
|
Facility
|
OP
|
$167.00
|
|
| Hospital Charge Code |
2963052
|
|
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
|
|
|
STOCKINETTE IMPERVIOUS 9 X 44 MEDIUM 89811
|
Facility
|
IP
|
$167.00
|
|
| Hospital Charge Code |
2963052
|
|
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
|
|
|
STOCKINETTE STERILE 4X48 DBL"
|
Facility
|
IP
|
$148.00
|
|
| Hospital Charge Code |
2963214
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.42 |
| Max. Negotiated Rate |
$141.61 |
| Rate for Payer: Aetna Commercial |
$138.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.58
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$141.61
|
| Rate for Payer: Health EOS Commercial |
$136.99
|
| Rate for Payer: HFN Commercial |
$141.61
|
| Rate for Payer: Multiplan Commercial |
$123.14
|
| Rate for Payer: Preferred Network Access Commercial |
$141.61
|
| Rate for Payer: Quartz Beloit One Network |
$75.42
|
| Rate for Payer: Quartz Commercial |
$92.35
|
| Rate for Payer: WEA Trust Commercial |
$84.66
|
| Rate for Payer: WPS Commercial |
$114.00
|
|
|
STOCKINETTE STERILE 4X48 DBL"
|
Facility
|
OP
|
$148.00
|
|
| Hospital Charge Code |
2963214
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.10 |
| Max. Negotiated Rate |
$141.61 |
| Rate for Payer: Aetna Commercial |
$138.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.37
|
| Rate for Payer: Aetna Managed Medicare |
$43.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$100.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.58
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$141.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.14
|
| Rate for Payer: Health EOS Commercial |
$136.99
|
| Rate for Payer: HFN Commercial |
$141.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.44
|
| Rate for Payer: Multiplan Commercial |
$123.14
|
| Rate for Payer: NAPHCARE Commercial |
$92.35
|
| Rate for Payer: Preferred Network Access Commercial |
$141.61
|
| Rate for Payer: Quartz Beloit One Network |
$75.42
|
| Rate for Payer: Quartz Commercial |
$100.05
|
| Rate for Payer: Quartz Medicare Advantage |
$92.35
|
| Rate for Payer: The Alliance Commercial |
$76.96
|
| Rate for Payer: WEA Trust Commercial |
$84.66
|
| Rate for Payer: WPS Commercial |
$114.00
|
|
|
STOCKINETTE STERILE 6X48 DBL 9606-48"
|
Facility
|
IP
|
$170.00
|
|
| Hospital Charge Code |
2963138
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$86.63 |
| Max. Negotiated Rate |
$162.66 |
| Rate for Payer: Aetna Commercial |
$159.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$93.70
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$162.66
|
| Rate for Payer: Health EOS Commercial |
$157.35
|
| Rate for Payer: HFN Commercial |
$162.66
|
| Rate for Payer: Multiplan Commercial |
$141.44
|
| Rate for Payer: Preferred Network Access Commercial |
$162.66
|
| Rate for Payer: Quartz Beloit One Network |
$86.63
|
| Rate for Payer: Quartz Commercial |
$106.08
|
| Rate for Payer: WEA Trust Commercial |
$97.24
|
| Rate for Payer: WPS Commercial |
$130.95
|
|
|
STOCKINETTE STERILE 6X48 DBL 9606-48"
|
Facility
|
OP
|
$170.00
|
|
| Hospital Charge Code |
2963138
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$162.66 |
| Rate for Payer: Aetna Commercial |
$159.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.05
|
| Rate for Payer: Aetna Managed Medicare |
$49.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$114.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$88.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$84.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$93.70
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$162.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$98.94
|
| Rate for Payer: Health EOS Commercial |
$157.35
|
| Rate for Payer: HFN Commercial |
$162.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$132.60
|
| Rate for Payer: Multiplan Commercial |
$141.44
|
| Rate for Payer: NAPHCARE Commercial |
$106.08
|
| Rate for Payer: Preferred Network Access Commercial |
$162.66
|
| Rate for Payer: Quartz Beloit One Network |
$86.63
|
| Rate for Payer: Quartz Commercial |
$114.92
|
| Rate for Payer: Quartz Medicare Advantage |
$106.08
|
| Rate for Payer: The Alliance Commercial |
$88.40
|
| Rate for Payer: WEA Trust Commercial |
$97.24
|
| Rate for Payer: WPS Commercial |
$130.95
|
|
|
STOCKING KNEE XXL LONG 7471LF
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
4494184
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.77 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
STOCKING KNEE XXL LONG 7471LF
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
4494184
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.30 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Aetna Managed Medicare |
$23.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.56
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: NAPHCARE Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$54.08
|
| Rate for Payer: Quartz Medicare Advantage |
$49.92
|
| Rate for Payer: The Alliance Commercial |
$41.60
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
STOCKING KNEE XXL REG 7470LF
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
4494183
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.30 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Aetna Managed Medicare |
$23.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.56
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: NAPHCARE Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$54.08
|
| Rate for Payer: Quartz Medicare Advantage |
$49.92
|
| Rate for Payer: The Alliance Commercial |
$41.60
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
STOCKING KNEE XXL REG 7470LF
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
4494183
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.77 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
STOCKING KNEE XXXL LONG 7473LF
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
4494186
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.77 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
STOCKING KNEE XXXL LONG 7473LF
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
4494186
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.30 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Aetna Managed Medicare |
$23.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.56
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: NAPHCARE Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$54.08
|
| Rate for Payer: Quartz Medicare Advantage |
$49.92
|
| Rate for Payer: The Alliance Commercial |
$41.60
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
STOCKING KNEE XXXL REG 7472LF
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
4494185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.30 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Aetna Managed Medicare |
$23.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.56
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: NAPHCARE Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$54.08
|
| Rate for Payer: Quartz Medicare Advantage |
$49.92
|
| Rate for Payer: The Alliance Commercial |
$41.60
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
STOCKING KNEE XXXL REG 7472LF
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
4494185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.77 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
STOCKING LARGE LONG KNEE 7594
|
Facility
|
IP
|
$210.00
|
|
| Hospital Charge Code |
2963628
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$107.02 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$131.04
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
|
STOCKING LARGE LONG KNEE 7594
|
Facility
|
OP
|
$210.00
|
|
| Hospital Charge Code |
2963628
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$61.15 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Aetna Managed Medicare |
$61.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$141.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$109.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.22
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$163.80
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: NAPHCARE Commercial |
$131.04
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$141.96
|
| Rate for Payer: Quartz Medicare Advantage |
$131.04
|
| Rate for Payer: The Alliance Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
|
STOCKING LARGE LONG THIGH 3856LF
|
Facility
|
IP
|
$210.00
|
|
| Hospital Charge Code |
2963620
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$107.02 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$131.04
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
|
STOCKING LARGE LONG THIGH 3856LF
|
Facility
|
OP
|
$210.00
|
|
| Hospital Charge Code |
2963620
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$61.15 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Aetna Managed Medicare |
$61.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$141.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$109.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.22
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$163.80
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: NAPHCARE Commercial |
$131.04
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$141.96
|
| Rate for Payer: Quartz Medicare Advantage |
$131.04
|
| Rate for Payer: The Alliance Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
|
STOCKING LARGE REG KNEE 7203
|
Facility
|
OP
|
$210.00
|
|
| Hospital Charge Code |
2963630
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$61.15 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Aetna Managed Medicare |
$61.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$141.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$109.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.22
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$163.80
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: NAPHCARE Commercial |
$131.04
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$141.96
|
| Rate for Payer: Quartz Medicare Advantage |
$131.04
|
| Rate for Payer: The Alliance Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
|
STOCKING LARGE REG KNEE 7203
|
Facility
|
IP
|
$210.00
|
|
| Hospital Charge Code |
2963630
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$107.02 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$131.04
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
