|
BANDAGE ELASTIC MATRIX STRL 6 X 10YD LF DYNJ5157LF"
|
Facility
OP
|
$105.00
|
|
|
Service Code
|
HCPCS A6447
|
| Hospital Charge Code |
3911532
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Aetna Managed Medicare |
$29.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.76
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.75
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$68.25
|
| Rate for Payer: Quartz Medicare Advantage |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
BANDAGE ELASTIC MATRIX STRL 6 X 10YD LF DYNJ5157LF"
|
Facility
IP
|
$105.00
|
|
|
Service Code
|
HCPCS A6447
|
| Hospital Charge Code |
3911532
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.45 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
BANDAGE HEMCON PATCHPRO 1004
|
Facility
OP
|
$810.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
6211000
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.80 |
| Max. Negotiated Rate |
$745.20 |
| Rate for Payer: Aetna Commercial |
$729.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$696.60
|
| Rate for Payer: Aetna Managed Medicare |
$226.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$526.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$405.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$388.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$429.30
|
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: Cigna Commercial |
$745.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$453.28
|
| Rate for Payer: Health EOS Commercial |
$720.90
|
| Rate for Payer: HFN Commercial |
$745.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$607.50
|
| Rate for Payer: Multiplan Commercial |
$648.00
|
| Rate for Payer: NAPHCARE Commercial |
$486.00
|
| Rate for Payer: Preferred Network Access Commercial |
$745.20
|
| Rate for Payer: Quartz Beloit One Network |
$396.90
|
| Rate for Payer: Quartz Commercial |
$526.50
|
| Rate for Payer: Quartz Medicare Advantage |
$486.00
|
| Rate for Payer: WEA Trust Commercial |
$445.50
|
| Rate for Payer: WPS Commercial |
$599.97
|
|
|
BANDAGE HEMCON PATCHPRO 1004
|
Facility
IP
|
$810.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
6211000
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$396.90 |
| Max. Negotiated Rate |
$745.20 |
| Rate for Payer: Aetna Commercial |
$729.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$429.30
|
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: Cigna Commercial |
$745.20
|
| Rate for Payer: Health EOS Commercial |
$720.90
|
| Rate for Payer: HFN Commercial |
$745.20
|
| Rate for Payer: Multiplan Commercial |
$648.00
|
| Rate for Payer: NAPHCARE Commercial |
$486.00
|
| Rate for Payer: Preferred Network Access Commercial |
$745.20
|
| Rate for Payer: Quartz Beloit One Network |
$396.90
|
| Rate for Payer: Quartz Commercial |
$486.00
|
| Rate for Payer: WEA Trust Commercial |
$445.50
|
| Rate for Payer: WPS Commercial |
$599.97
|
|
|
Bandage Kling 4
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
3040319
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Aetna Managed Medicare |
$0.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.56
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.65
|
| Rate for Payer: Quartz Medicare Advantage |
$0.60
|
| Rate for Payer: The Alliance Commercial |
$4.00
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
Bandage Kling 4
|
Facility
IP
|
$1.00
|
|
| Hospital Charge Code |
3040319
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.60
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
BANDAGE SELF ADHRNT COBAN 2X5 TAN LF NS 2082"
|
Facility
IP
|
$56.00
|
|
|
Service Code
|
HCPCS A6453
|
| Hospital Charge Code |
2962795
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
BANDAGE SELF ADHRNT COBAN 2X5 TAN LF NS 2082"
|
Facility
OP
|
$56.00
|
|
|
Service Code
|
HCPCS A6453
|
| Hospital Charge Code |
2962795
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
BANDAGE STRETCH 2 X 10 YRS #45552
|
Facility
IP
|
$172.00
|
|
|
Service Code
|
HCPCS A6448
|
| Hospital Charge Code |
2969564
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$84.28 |
| Max. Negotiated Rate |
$158.24 |
| Rate for Payer: Aetna Commercial |
$154.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.16
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$158.24
|
| Rate for Payer: Health EOS Commercial |
$153.08
|
| Rate for Payer: HFN Commercial |
$158.24
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: NAPHCARE Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$158.24
|
| Rate for Payer: Quartz Beloit One Network |
$84.28
|
| Rate for Payer: Quartz Commercial |
$103.20
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$127.40
|
|
|
BANDAGE STRETCH 2 X 10 YRS #45552
|
Facility
OP
|
$172.00
|
|
|
Service Code
|
HCPCS A6448
|
| Hospital Charge Code |
2969564
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.16 |
| Max. Negotiated Rate |
$158.24 |
| Rate for Payer: Aetna Commercial |
$154.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Aetna Managed Medicare |
$48.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$86.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.16
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$158.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.25
|
| Rate for Payer: Health EOS Commercial |
$153.08
|
| Rate for Payer: HFN Commercial |
$158.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.00
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: NAPHCARE Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$158.24
|
| Rate for Payer: Quartz Beloit One Network |
$84.28
|
| Rate for Payer: Quartz Commercial |
$111.80
|
| Rate for Payer: Quartz Medicare Advantage |
$103.20
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$127.40
|
|
|
BANDAGE TIP STOP
|
Facility
OP
|
$63.00
|
|
| Hospital Charge Code |
2973585
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$252.00 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.18
|
| Rate for Payer: Aetna Managed Medicare |
$17.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.25
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.25
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$40.95
|
| Rate for Payer: Quartz Medicare Advantage |
$37.80
|
| Rate for Payer: The Alliance Commercial |
$252.00
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
BANDAGE TIP STOP
|
Facility
IP
|
$63.00
|
|
| Hospital Charge Code |
2973585
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.87 |
| Max. Negotiated Rate |
$57.96 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$37.80
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
BANDAGE TIP STOP GTIN-14
|
Facility
OP
|
$63.00
|
|
| Hospital Charge Code |
6207062
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$252.00 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.18
|
| Rate for Payer: Aetna Managed Medicare |
$17.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.25
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.25
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$40.95
|
| Rate for Payer: Quartz Medicare Advantage |
$37.80
|
| Rate for Payer: The Alliance Commercial |
$252.00
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
BANDAGE TIP STOP GTIN-14
|
Facility
IP
|
$63.00
|
|
| Hospital Charge Code |
6207062
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.87 |
| Max. Negotiated Rate |
$57.96 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$37.80
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
BANDAGE TUBULAR ELASTIC SZ 2
|
Facility
IP
|
$3.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2964091
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.80
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
BANDAGE TUBULAR ELASTIC SZ 2
|
Facility
OP
|
$3.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2964091
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Aetna Managed Medicare |
$0.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.68
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1.80
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
BANDAGE TUBULAR ELASTIC SZ 3
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2964090
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.40
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
BANDAGE TUBULAR ELASTIC SZ 3
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2964090
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| Rate for Payer: Aetna Managed Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.24
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2.40
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
BANDAGE TUBULAR ELASTIC SZ 5
|
Facility
OP
|
$5.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2964088
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
BANDAGE TUBULAR ELASTIC SZ 5
|
Facility
IP
|
$5.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2964088
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
BANDAGE TUBULAR ELASTIC SZ 7
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2964086
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$4.80
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$5.93
|
|
|
BANDAGE TUBULAR ELASTIC SZ 7
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2964086
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.88
|
| Rate for Payer: Aetna Managed Medicare |
$2.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.48
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$5.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4.80
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$5.93
|
|
|
BAND ANNULOPLASTY SIMULUS
|
Facility
OP
|
$9,151.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973975
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,196.24 |
| Max. Negotiated Rate |
$8,418.92 |
| Rate for Payer: Aetna Commercial |
$8,235.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,869.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,562.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,948.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,575.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,392.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,850.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,418.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,120.90
|
| Rate for Payer: Health EOS Commercial |
$8,144.39
|
| Rate for Payer: HFN Commercial |
$8,418.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,863.25
|
| Rate for Payer: Multiplan Commercial |
$7,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,490.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,418.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,483.99
|
| Rate for Payer: Quartz Commercial |
$5,948.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,490.60
|
| Rate for Payer: The Alliance Commercial |
$1,196.24
|
| Rate for Payer: WEA Trust Commercial |
$5,033.05
|
| Rate for Payer: WPS Commercial |
$6,778.15
|
|
|
BAND ANNULOPLASTY SIMULUS
|
Facility
IP
|
$9,151.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973975
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,483.99 |
| Max. Negotiated Rate |
$8,418.92 |
| Rate for Payer: Aetna Commercial |
$8,235.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,850.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,418.92
|
| Rate for Payer: Health EOS Commercial |
$8,144.39
|
| Rate for Payer: HFN Commercial |
$8,418.92
|
| Rate for Payer: Multiplan Commercial |
$7,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,490.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,418.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,483.99
|
| Rate for Payer: Quartz Commercial |
$5,490.60
|
| Rate for Payer: WEA Trust Commercial |
$5,033.05
|
| Rate for Payer: WPS Commercial |
$6,778.15
|
|
|
BAND GREEN NOVAPLUS/ THERABAND NON-LATEX 50YD #566167
|
Facility
OP
|
$1,121.00
|
|
| Hospital Charge Code |
2969607
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$313.88 |
| Max. Negotiated Rate |
$4,484.00 |
| Rate for Payer: Aetna Commercial |
$1,008.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$964.06
|
| Rate for Payer: Aetna Managed Medicare |
$313.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$728.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$560.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$594.13
|
| Rate for Payer: Cash Price |
$336.30
|
| Rate for Payer: Cigna Commercial |
$1,031.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$627.31
|
| Rate for Payer: Health EOS Commercial |
$997.69
|
| Rate for Payer: HFN Commercial |
$1,031.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$840.75
|
| Rate for Payer: Multiplan Commercial |
$896.80
|
| Rate for Payer: NAPHCARE Commercial |
$672.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,031.32
|
| Rate for Payer: Quartz Beloit One Network |
$549.29
|
| Rate for Payer: Quartz Commercial |
$728.65
|
| Rate for Payer: Quartz Medicare Advantage |
$672.60
|
| Rate for Payer: The Alliance Commercial |
$4,484.00
|
| Rate for Payer: WEA Trust Commercial |
$616.55
|
| Rate for Payer: WPS Commercial |
$830.32
|
|
