|
BANDAGE COFLEX FOAM STERILE LF 4 DYNJ089004"
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
HCPCS A6454
|
| Hospital Charge Code |
4508617
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.66 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Aetna Managed Medicare |
$23.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.72
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.96
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: NAPHCARE Commercial |
$51.17
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$55.43
|
| Rate for Payer: Quartz Medicare Advantage |
$51.17
|
| Rate for Payer: The Alliance Commercial |
$4.66
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
BANDAGE COFLEX FOAM STERILE LF 4 DYNJ089004"
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
HCPCS A6454
|
| Hospital Charge Code |
4508617
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.79 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$51.17
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
BANDAGE COFLEX FOAM STERILE LF 6 DYNJ089006"
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
HCPCS A6455
|
| Hospital Charge Code |
4508616
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$67.27 |
| Max. Negotiated Rate |
$126.30 |
| Rate for Payer: Aetna Commercial |
$123.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.76
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$126.30
|
| Rate for Payer: Health EOS Commercial |
$122.18
|
| Rate for Payer: HFN Commercial |
$126.30
|
| Rate for Payer: Multiplan Commercial |
$109.82
|
| Rate for Payer: Preferred Network Access Commercial |
$126.30
|
| Rate for Payer: Quartz Beloit One Network |
$67.27
|
| Rate for Payer: Quartz Commercial |
$82.37
|
| Rate for Payer: WEA Trust Commercial |
$75.50
|
| Rate for Payer: WPS Commercial |
$101.68
|
|
|
BANDAGE COFLEX FOAM STERILE LF 6 DYNJ089006"
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
HCPCS A6455
|
| Hospital Charge Code |
4508616
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.28 |
| Max. Negotiated Rate |
$126.30 |
| Rate for Payer: Aetna Commercial |
$123.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.06
|
| Rate for Payer: Aetna Managed Medicare |
$38.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$89.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$68.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$65.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.76
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$126.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.82
|
| Rate for Payer: Health EOS Commercial |
$122.18
|
| Rate for Payer: HFN Commercial |
$126.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.96
|
| Rate for Payer: Multiplan Commercial |
$109.82
|
| Rate for Payer: NAPHCARE Commercial |
$82.37
|
| Rate for Payer: Preferred Network Access Commercial |
$126.30
|
| Rate for Payer: Quartz Beloit One Network |
$67.27
|
| Rate for Payer: Quartz Commercial |
$89.23
|
| Rate for Payer: Quartz Medicare Advantage |
$82.37
|
| Rate for Payer: The Alliance Commercial |
$8.28
|
| Rate for Payer: WEA Trust Commercial |
$75.50
|
| Rate for Payer: WPS Commercial |
$101.68
|
|
|
BANDAGE COMPRILAN 10cm x 5m 4.0 #01028000
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS A6443
|
| Hospital Charge Code |
2969553
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$91.22 |
| Max. Negotiated Rate |
$171.27 |
| Rate for Payer: Aetna Commercial |
$167.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.66
|
| Rate for Payer: Cash Price |
$53.70
|
| Rate for Payer: Cigna Commercial |
$171.27
|
| Rate for Payer: Health EOS Commercial |
$165.68
|
| Rate for Payer: HFN Commercial |
$171.27
|
| Rate for Payer: Multiplan Commercial |
$148.93
|
| Rate for Payer: Preferred Network Access Commercial |
$171.27
|
| Rate for Payer: Quartz Beloit One Network |
$91.22
|
| Rate for Payer: Quartz Commercial |
$111.70
|
| Rate for Payer: WEA Trust Commercial |
$102.39
|
| Rate for Payer: WPS Commercial |
$137.88
|
|
|
BANDAGE COMPRILAN 10cm x 5m 4.0 #01028000
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS A6443
|
| Hospital Charge Code |
2969553
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$171.27 |
| Rate for Payer: Aetna Commercial |
$167.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.10
|
| Rate for Payer: Aetna Managed Medicare |
$52.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$121.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$89.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.66
|
| Rate for Payer: Cash Price |
$53.70
|
| Rate for Payer: Cash Price |
$53.70
|
| Rate for Payer: Cigna Commercial |
$171.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.18
|
| Rate for Payer: Health EOS Commercial |
$165.68
|
| Rate for Payer: HFN Commercial |
$171.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$139.62
|
| Rate for Payer: Multiplan Commercial |
$148.93
|
| Rate for Payer: NAPHCARE Commercial |
$111.70
|
| Rate for Payer: Preferred Network Access Commercial |
$171.27
|
| Rate for Payer: Quartz Beloit One Network |
$91.22
|
| Rate for Payer: Quartz Commercial |
$121.00
|
| Rate for Payer: Quartz Medicare Advantage |
$111.70
|
| Rate for Payer: The Alliance Commercial |
$1.66
|
| Rate for Payer: WEA Trust Commercial |
$102.39
|
| Rate for Payer: WPS Commercial |
$137.88
|
|
|
BANDAGE COMPRILAN 10cm x 5m 4.5 #01029000
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
HCPCS A6443
|
| Hospital Charge Code |
2969554
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$199.97 |
| Rate for Payer: Aetna Commercial |
$195.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.93
|
| Rate for Payer: Aetna Managed Medicare |
$60.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$141.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$108.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.20
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$199.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.64
|
| Rate for Payer: Health EOS Commercial |
$193.45
|
| Rate for Payer: HFN Commercial |
$199.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$163.02
|
| Rate for Payer: Multiplan Commercial |
$173.89
|
| Rate for Payer: NAPHCARE Commercial |
$130.42
|
| Rate for Payer: Preferred Network Access Commercial |
$199.97
|
| Rate for Payer: Quartz Beloit One Network |
$106.51
|
| Rate for Payer: Quartz Commercial |
$141.28
|
| Rate for Payer: Quartz Medicare Advantage |
$130.42
|
| Rate for Payer: The Alliance Commercial |
$1.66
|
| Rate for Payer: WEA Trust Commercial |
$119.55
|
| Rate for Payer: WPS Commercial |
$160.99
|
|
|
BANDAGE COMPRILAN 10cm x 5m 4.5 #01029000
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
HCPCS A6443
|
| Hospital Charge Code |
2969554
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$106.51 |
| Max. Negotiated Rate |
$199.97 |
| Rate for Payer: Aetna Commercial |
$195.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.20
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$199.97
|
| Rate for Payer: Health EOS Commercial |
$193.45
|
| Rate for Payer: HFN Commercial |
$199.97
|
| Rate for Payer: Multiplan Commercial |
$173.89
|
| Rate for Payer: Preferred Network Access Commercial |
$199.97
|
| Rate for Payer: Quartz Beloit One Network |
$106.51
|
| Rate for Payer: Quartz Commercial |
$130.42
|
| Rate for Payer: WEA Trust Commercial |
$119.55
|
| Rate for Payer: WPS Commercial |
$160.99
|
|
|
BANDAGE COMPRILAN 12cm x 5m #590008
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS A6443
|
| Hospital Charge Code |
2973473
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$382.72 |
| Rate for Payer: Aetna Commercial |
$374.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$357.76
|
| Rate for Payer: Aetna Managed Medicare |
$116.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$270.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$199.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$220.48
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$382.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$232.80
|
| Rate for Payer: Health EOS Commercial |
$370.24
|
| Rate for Payer: HFN Commercial |
$382.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.00
|
| Rate for Payer: Multiplan Commercial |
$332.80
|
| Rate for Payer: NAPHCARE Commercial |
$249.60
|
| Rate for Payer: Preferred Network Access Commercial |
$382.72
|
| Rate for Payer: Quartz Beloit One Network |
$203.84
|
| Rate for Payer: Quartz Commercial |
$270.40
|
| Rate for Payer: Quartz Medicare Advantage |
$249.60
|
| Rate for Payer: The Alliance Commercial |
$1.66
|
| Rate for Payer: WEA Trust Commercial |
$228.80
|
| Rate for Payer: WPS Commercial |
$308.12
|
|
|
BANDAGE COMPRILAN 12cm x 5m #590008
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS A6443
|
| Hospital Charge Code |
2973473
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$203.84 |
| Max. Negotiated Rate |
$382.72 |
| Rate for Payer: Aetna Commercial |
$374.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$357.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$220.48
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$382.72
|
| Rate for Payer: Health EOS Commercial |
$370.24
|
| Rate for Payer: HFN Commercial |
$382.72
|
| Rate for Payer: Multiplan Commercial |
$332.80
|
| Rate for Payer: Preferred Network Access Commercial |
$382.72
|
| Rate for Payer: Quartz Beloit One Network |
$203.84
|
| Rate for Payer: Quartz Commercial |
$249.60
|
| Rate for Payer: WEA Trust Commercial |
$228.80
|
| Rate for Payer: WPS Commercial |
$308.12
|
|
|
BANDAGE COMPRILAN 6cm X 5m #01026000
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
HCPCS A6442
|
| Hospital Charge Code |
2970154
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$66.76 |
| Max. Negotiated Rate |
$125.34 |
| Rate for Payer: Aetna Commercial |
$122.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.21
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$125.34
|
| Rate for Payer: Health EOS Commercial |
$121.25
|
| Rate for Payer: HFN Commercial |
$125.34
|
| Rate for Payer: Multiplan Commercial |
$108.99
|
| Rate for Payer: Preferred Network Access Commercial |
$125.34
|
| Rate for Payer: Quartz Beloit One Network |
$66.76
|
| Rate for Payer: Quartz Commercial |
$81.74
|
| Rate for Payer: WEA Trust Commercial |
$74.93
|
| Rate for Payer: WPS Commercial |
$100.91
|
|
|
BANDAGE COMPRILAN 6cm X 5m #01026000
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
HCPCS A6442
|
| Hospital Charge Code |
2970154
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$125.34 |
| Rate for Payer: Aetna Commercial |
$122.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.17
|
| Rate for Payer: Aetna Managed Medicare |
$38.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$88.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$68.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$65.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.21
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$125.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.24
|
| Rate for Payer: Health EOS Commercial |
$121.25
|
| Rate for Payer: HFN Commercial |
$125.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.18
|
| Rate for Payer: Multiplan Commercial |
$108.99
|
| Rate for Payer: NAPHCARE Commercial |
$81.74
|
| Rate for Payer: Preferred Network Access Commercial |
$125.34
|
| Rate for Payer: Quartz Beloit One Network |
$66.76
|
| Rate for Payer: Quartz Commercial |
$88.56
|
| Rate for Payer: Quartz Medicare Advantage |
$81.74
|
| Rate for Payer: The Alliance Commercial |
$0.96
|
| Rate for Payer: WEA Trust Commercial |
$74.93
|
| Rate for Payer: WPS Commercial |
$100.91
|
|
|
BANDAGE COMPRILAN 8cm X 5m #590006
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
HCPCS A6443
|
| Hospital Charge Code |
2969552
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$1.66
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
BANDAGE COMPRILAN 8cm X 5m #590006
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
HCPCS A6443
|
| Hospital Charge Code |
2969552
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
BANDAGE CONFORM 1 2230"
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
HCPCS A6445
|
| Hospital Charge Code |
2965833
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$44.97 |
| Rate for Payer: Aetna Commercial |
$43.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.04
|
| Rate for Payer: Aetna Managed Medicare |
$13.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.91
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$44.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.35
|
| Rate for Payer: Health EOS Commercial |
$43.50
|
| Rate for Payer: HFN Commercial |
$44.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.66
|
| Rate for Payer: Multiplan Commercial |
$39.10
|
| Rate for Payer: NAPHCARE Commercial |
$29.33
|
| Rate for Payer: Preferred Network Access Commercial |
$44.97
|
| Rate for Payer: Quartz Beloit One Network |
$23.95
|
| Rate for Payer: Quartz Commercial |
$31.77
|
| Rate for Payer: Quartz Medicare Advantage |
$29.33
|
| Rate for Payer: The Alliance Commercial |
$1.87
|
| Rate for Payer: WEA Trust Commercial |
$26.88
|
| Rate for Payer: WPS Commercial |
$36.20
|
|
|
BANDAGE CONFORM 1 2230"
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
HCPCS A6445
|
| Hospital Charge Code |
2965833
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.95 |
| Max. Negotiated Rate |
$44.97 |
| Rate for Payer: Aetna Commercial |
$43.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.91
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$44.97
|
| Rate for Payer: Health EOS Commercial |
$43.50
|
| Rate for Payer: HFN Commercial |
$44.97
|
| Rate for Payer: Multiplan Commercial |
$39.10
|
| Rate for Payer: Preferred Network Access Commercial |
$44.97
|
| Rate for Payer: Quartz Beloit One Network |
$23.95
|
| Rate for Payer: Quartz Commercial |
$29.33
|
| Rate for Payer: WEA Trust Commercial |
$26.88
|
| Rate for Payer: WPS Commercial |
$36.20
|
|
|
BANDAGE CONFORM 2IN 2242
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS A6448
|
| Hospital Charge Code |
2974403
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
BANDAGE CONFORM 2IN 2242
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS A6448
|
| Hospital Charge Code |
2974403
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.82 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.49
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: The Alliance Commercial |
$6.82
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
BANDAGE CONFORM 4 LATEX FREE 2236
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
HCPCS A6449
|
| Hospital Charge Code |
2963664
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$6.86
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
BANDAGE CONFORM 4 LATEX FREE 2236
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS A6449
|
| Hospital Charge Code |
2963664
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Aetna Managed Medicare |
$3.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.40
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.58
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: NAPHCARE Commercial |
$6.86
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$7.44
|
| Rate for Payer: Quartz Medicare Advantage |
$6.86
|
| Rate for Payer: The Alliance Commercial |
$10.40
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
BANDAGE CONFORM 6 PT READY
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS A6450
|
| Hospital Charge Code |
2963669
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
BANDAGE CONFORM 6 PT READY
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
HCPCS A6450
|
| Hospital Charge Code |
2963669
|
|
Hospital Revenue Code
|
272
|
| 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 |
$10.40
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
BANDAGE COVER ROLL 4X2 STRETCH 45548
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
HCPCS A6449
|
| Hospital Charge Code |
5264862
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.84 |
| Max. Negotiated Rate |
$84.20 |
| Rate for Payer: Aetna Commercial |
$82.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.51
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$84.20
|
| Rate for Payer: Health EOS Commercial |
$81.45
|
| Rate for Payer: HFN Commercial |
$84.20
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: Preferred Network Access Commercial |
$84.20
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$54.91
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: WPS Commercial |
$67.79
|
|
|
BANDAGE COVER ROLL 4X2 STRETCH 45548
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
HCPCS A6449
|
| Hospital Charge Code |
5264862
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$84.20 |
| Rate for Payer: Aetna Commercial |
$82.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Aetna Managed Medicare |
$25.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.51
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$84.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.22
|
| Rate for Payer: Health EOS Commercial |
$81.45
|
| Rate for Payer: HFN Commercial |
$84.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.64
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: NAPHCARE Commercial |
$54.91
|
| Rate for Payer: Preferred Network Access Commercial |
$84.20
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$59.49
|
| Rate for Payer: Quartz Medicare Advantage |
$54.91
|
| Rate for Payer: The Alliance Commercial |
$10.40
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: WPS Commercial |
$67.79
|
|
|
BANDAGE ECONO-PASTE 47300000
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS A6456
|
| Hospital Charge Code |
2974620
|
|
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
|
|
