|
DRAPE V.A.C. STANDARD M6275009/10
|
Facility
IP
|
$208.00
|
|
| Hospital Charge Code |
2974083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.07
|
|
|
DRAPE V.A.C. STANDARD M6275009/10
|
Facility
OP
|
$208.00
|
|
| Hospital Charge Code |
2974083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.24 |
| Max. Negotiated Rate |
$832.00 |
| Rate for Payer: Aetna Managed Medicare |
$58.24
|
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$135.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$99.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$135.20
|
| Rate for Payer: Quartz Medicare Advantage |
$124.80
|
| Rate for Payer: The Alliance Commercial |
$832.00
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.07
|
|
|
Draw Blood From Venous Device
|
Facility
IP
|
$178.00
|
|
|
Service Code
|
CPT 36591
|
| Hospital Charge Code |
5665628
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$87.22 |
| Max. Negotiated Rate |
$163.76 |
| Rate for Payer: Aetna Commercial |
$160.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.34
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$163.76
|
| Rate for Payer: Health EOS Commercial |
$158.42
|
| Rate for Payer: HFN Commercial |
$163.76
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: NAPHCARE Commercial |
$106.80
|
| Rate for Payer: Preferred Network Access Commercial |
$163.76
|
| Rate for Payer: Quartz Beloit One Network |
$87.22
|
| Rate for Payer: Quartz Commercial |
$106.80
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
Draw Blood From Venous Device
|
Facility
OP
|
$178.00
|
|
|
Service Code
|
CPT 36591
|
| Hospital Charge Code |
5665628
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$85.44 |
| Max. Negotiated Rate |
$12,148.04 |
| Rate for Payer: Aetna Commercial |
$160.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$115.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$89.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$85.44
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$163.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$158.42
|
| Rate for Payer: HFN Commercial |
$163.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$163.76
|
| Rate for Payer: Quartz Beloit One Network |
$87.22
|
| Rate for Payer: Quartz Commercial |
$115.70
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$12,148.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
DRBC CPD AS5 500
|
Facility
IP
|
$615.00
|
|
|
Service Code
|
HCPCS P9021
|
| Hospital Charge Code |
1052813
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$301.35 |
| Max. Negotiated Rate |
$565.80 |
| Rate for Payer: Aetna Commercial |
$553.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.95
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$565.80
|
| Rate for Payer: Health EOS Commercial |
$547.35
|
| Rate for Payer: HFN Commercial |
$565.80
|
| Rate for Payer: Multiplan Commercial |
$492.00
|
| Rate for Payer: NAPHCARE Commercial |
$369.00
|
| Rate for Payer: Preferred Network Access Commercial |
$565.80
|
| Rate for Payer: Quartz Beloit One Network |
$301.35
|
| Rate for Payer: Quartz Commercial |
$369.00
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: WPS Commercial |
$455.53
|
|
|
DRBC CPD AS5 500
|
Facility
OP
|
$615.00
|
|
|
Service Code
|
HCPCS P9021
|
| Hospital Charge Code |
1052813
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$141.61 |
| Max. Negotiated Rate |
$2,042.72 |
| Rate for Payer: Aetna Commercial |
$553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.90
|
| Rate for Payer: Aetna Managed Medicare |
$141.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$399.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$295.20
|
| Rate for Payer: Anthem Medicare Advantage |
$141.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$141.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$141.61
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$565.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$141.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$344.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$141.61
|
| Rate for Payer: Health EOS Commercial |
$547.35
|
| Rate for Payer: HFN Commercial |
$565.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$526.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$141.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$141.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$141.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$141.61
|
| Rate for Payer: Multiplan Commercial |
$492.00
|
| Rate for Payer: NAPHCARE Commercial |
$212.42
|
| Rate for Payer: Preferred Network Access Commercial |
$565.80
|
| Rate for Payer: Quartz Beloit One Network |
$301.35
|
| Rate for Payer: Quartz Commercial |
$399.75
|
| Rate for Payer: Quartz Medicare Advantage |
$141.61
|
| Rate for Payer: The Alliance Commercial |
$2,042.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.61
|
| Rate for Payer: United Healthcare PPO |
$461.25
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: Wellcare Medicare |
$141.61
|
| Rate for Payer: WPS Commercial |
$455.53
|
|
|
DREAMWIRE 260CM STIFF 5612
|
Facility
IP
|
$2,280.00
|
|
| Hospital Charge Code |
3072561
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,117.20 |
| Max. Negotiated Rate |
$2,097.60 |
| Rate for Payer: Aetna Commercial |
$2,052.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,208.40
|
| Rate for Payer: Cash Price |
$684.00
|
| Rate for Payer: Cigna Commercial |
$2,097.60
|
| Rate for Payer: Health EOS Commercial |
$2,029.20
|
| Rate for Payer: HFN Commercial |
$2,097.60
|
| Rate for Payer: Multiplan Commercial |
$1,824.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,368.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,097.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,117.20
|
| Rate for Payer: Quartz Commercial |
$1,368.00
|
| Rate for Payer: WEA Trust Commercial |
$1,254.00
|
| Rate for Payer: WPS Commercial |
$1,688.80
|
|
|
DREAMWIRE 260CM STIFF 5612
|
Facility
OP
|
$2,280.00
|
|
| Hospital Charge Code |
3072561
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$638.40 |
| Max. Negotiated Rate |
$9,120.00 |
| Rate for Payer: Aetna Commercial |
$2,052.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,960.80
|
| Rate for Payer: Aetna Managed Medicare |
$638.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,140.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,094.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,208.40
|
| Rate for Payer: Cash Price |
$684.00
|
| Rate for Payer: Cigna Commercial |
$2,097.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,275.89
|
| Rate for Payer: Health EOS Commercial |
$2,029.20
|
| Rate for Payer: HFN Commercial |
$2,097.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,710.00
|
| Rate for Payer: Multiplan Commercial |
$1,824.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,368.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,097.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,117.20
|
| Rate for Payer: Quartz Commercial |
$1,482.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,368.00
|
| Rate for Payer: The Alliance Commercial |
$9,120.00
|
| Rate for Payer: WEA Trust Commercial |
$1,254.00
|
| Rate for Payer: WPS Commercial |
$1,688.80
|
|
|
DREAMWIRE STRAIGHT .035 450CM M00556141
|
Facility
OP
|
$2,281.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
3211485
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$638.68 |
| Max. Negotiated Rate |
$2,098.52 |
| Rate for Payer: Aetna Commercial |
$2,052.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,961.66
|
| Rate for Payer: Aetna Managed Medicare |
$638.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,482.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,140.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,094.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,208.93
|
| Rate for Payer: Cash Price |
$684.30
|
| Rate for Payer: Cigna Commercial |
$2,098.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,276.45
|
| Rate for Payer: Health EOS Commercial |
$2,030.09
|
| Rate for Payer: HFN Commercial |
$2,098.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,710.75
|
| Rate for Payer: Multiplan Commercial |
$1,824.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,368.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,098.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,117.69
|
| Rate for Payer: Quartz Commercial |
$1,482.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,368.60
|
| Rate for Payer: WEA Trust Commercial |
$1,254.55
|
| Rate for Payer: WPS Commercial |
$1,689.54
|
|
|
DREAMWIRE STRAIGHT .035 450CM M00556141
|
Facility
IP
|
$2,281.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
3211485
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,117.69 |
| Max. Negotiated Rate |
$2,098.52 |
| Rate for Payer: Aetna Commercial |
$2,052.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,208.93
|
| Rate for Payer: Cash Price |
$684.30
|
| Rate for Payer: Cigna Commercial |
$2,098.52
|
| Rate for Payer: Health EOS Commercial |
$2,030.09
|
| Rate for Payer: HFN Commercial |
$2,098.52
|
| Rate for Payer: Multiplan Commercial |
$1,824.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,368.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,098.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,117.69
|
| Rate for Payer: Quartz Commercial |
$1,368.60
|
| Rate for Payer: WEA Trust Commercial |
$1,254.55
|
| Rate for Payer: WPS Commercial |
$1,689.54
|
|
|
Dress/Debrid P-Thick Burn 16025
|
Professional
|
$470.00
|
|
|
Service Code
|
CPT 16025
|
| Hospital Charge Code |
4536607
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.10 |
| Max. Negotiated Rate |
$462.24 |
| Rate for Payer: Aetna Commercial |
$446.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.20
|
| Rate for Payer: Aetna Managed Medicare |
$102.72
|
| Rate for Payer: Anthem Medicare Advantage |
$102.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$102.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$102.72
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$446.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$235.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.72
|
| Rate for Payer: Health EOS Commercial |
$427.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$365.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$365.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$102.72
|
| Rate for Payer: Multiplan Commercial |
$376.00
|
| Rate for Payer: Preferred Network Access Commercial |
$446.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.80
|
| Rate for Payer: Quartz Commercial |
$267.90
|
| Rate for Payer: Quartz Medicare Advantage |
$102.72
|
| Rate for Payer: The Alliance Commercial |
$436.56
|
| Rate for Payer: United Healthcare Medicaid |
$43.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$102.72
|
| Rate for Payer: WEA Trust Commercial |
$258.50
|
| Rate for Payer: WPS Commercial |
$462.24
|
|
|
DRESSING 3X3 ADAPTIC AQUAFOR 6112
|
Facility
IP
|
$19.00
|
|
|
Service Code
|
HCPCS A6222
|
| Hospital Charge Code |
2963913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$17.48 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.07
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$17.48
|
| Rate for Payer: Health EOS Commercial |
$16.91
|
| Rate for Payer: HFN Commercial |
$17.48
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: NAPHCARE Commercial |
$11.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17.48
|
| Rate for Payer: Quartz Beloit One Network |
$9.31
|
| Rate for Payer: Quartz Commercial |
$11.40
|
| Rate for Payer: WEA Trust Commercial |
$10.45
|
| Rate for Payer: WPS Commercial |
$14.07
|
|
|
DRESSING 3X3 ADAPTIC AQUAFOR 6112
|
Facility
OP
|
$19.00
|
|
|
Service Code
|
HCPCS A6222
|
| Hospital Charge Code |
2963913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.32 |
| Max. Negotiated Rate |
$17.48 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.34
|
| Rate for Payer: Aetna Managed Medicare |
$5.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.07
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$17.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.63
|
| Rate for Payer: Health EOS Commercial |
$16.91
|
| Rate for Payer: HFN Commercial |
$17.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.25
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: NAPHCARE Commercial |
$11.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17.48
|
| Rate for Payer: Quartz Beloit One Network |
$9.31
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: Quartz Medicare Advantage |
$11.40
|
| Rate for Payer: WEA Trust Commercial |
$10.45
|
| Rate for Payer: WPS Commercial |
$14.07
|
|
|
DRESSING 3X8 ADAPTIC AQUAFOR STRIP 6113
|
Facility
OP
|
$45.00
|
|
| Hospital Charge Code |
2963875
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna Commercial |
$40.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38.70
|
| Rate for Payer: Aetna Managed Medicare |
$12.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.85
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$41.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.18
|
| Rate for Payer: Health EOS Commercial |
$40.05
|
| Rate for Payer: HFN Commercial |
$41.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.75
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: NAPHCARE Commercial |
$27.00
|
| Rate for Payer: Preferred Network Access Commercial |
$41.40
|
| Rate for Payer: Quartz Beloit One Network |
$22.05
|
| Rate for Payer: Quartz Commercial |
$29.25
|
| Rate for Payer: Quartz Medicare Advantage |
$27.00
|
| Rate for Payer: The Alliance Commercial |
$180.00
|
| Rate for Payer: WEA Trust Commercial |
$24.75
|
| Rate for Payer: WPS Commercial |
$33.33
|
|
|
DRESSING 3X8 ADAPTIC AQUAFOR STRIP 6113
|
Facility
IP
|
$45.00
|
|
| Hospital Charge Code |
2963875
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna Commercial |
$40.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.85
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$41.40
|
| Rate for Payer: Health EOS Commercial |
$40.05
|
| Rate for Payer: HFN Commercial |
$41.40
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: NAPHCARE Commercial |
$27.00
|
| Rate for Payer: Preferred Network Access Commercial |
$41.40
|
| Rate for Payer: Quartz Beloit One Network |
$22.05
|
| Rate for Payer: Quartz Commercial |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$24.75
|
| Rate for Payer: WPS Commercial |
$33.33
|
|
|
DRESSING ABD HEAVY DRAINAGE 3913
|
Facility
OP
|
$72.00
|
|
| Hospital Charge Code |
2963422
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Aetna Managed Medicare |
$20.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.29
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: Quartz Medicare Advantage |
$43.20
|
| Rate for Payer: The Alliance Commercial |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
DRESSING ABD HEAVY DRAINAGE 3913
|
Facility
IP
|
$72.00
|
|
| Hospital Charge Code |
2963422
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.28 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$43.20
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
DRESSING ABD PAD 9194A
|
Facility
IP
|
$10.00
|
|
|
Service Code
|
HCPCS A6253
|
| Hospital Charge Code |
2974609
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$9.20 |
| Rate for Payer: Aetna Commercial |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.30
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: Health EOS Commercial |
$8.90
|
| Rate for Payer: HFN Commercial |
$9.20
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: NAPHCARE Commercial |
$6.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9.20
|
| Rate for Payer: Quartz Beloit One Network |
$4.90
|
| Rate for Payer: Quartz Commercial |
$6.00
|
| Rate for Payer: WEA Trust Commercial |
$5.50
|
| Rate for Payer: WPS Commercial |
$7.41
|
|
|
DRESSING ABD PAD 9194A
|
Facility
OP
|
$10.00
|
|
|
Service Code
|
HCPCS A6253
|
| Hospital Charge Code |
2974609
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$9.20 |
| Rate for Payer: Aetna Commercial |
$9.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.60
|
| Rate for Payer: Aetna Managed Medicare |
$2.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.30
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.60
|
| Rate for Payer: Health EOS Commercial |
$8.90
|
| Rate for Payer: HFN Commercial |
$9.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: NAPHCARE Commercial |
$6.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9.20
|
| Rate for Payer: Quartz Beloit One Network |
$4.90
|
| Rate for Payer: Quartz Commercial |
$6.50
|
| Rate for Payer: Quartz Medicare Advantage |
$6.00
|
| Rate for Payer: WEA Trust Commercial |
$5.50
|
| Rate for Payer: WPS Commercial |
$7.41
|
|
|
DRESSING AMD 3X8 TELFA 7663"
|
Facility
OP
|
$62.00
|
|
| Hospital Charge Code |
2963151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.36 |
| Max. Negotiated Rate |
$248.00 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Aetna Managed Medicare |
$17.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.70
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.50
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$40.30
|
| Rate for Payer: Quartz Medicare Advantage |
$37.20
|
| Rate for Payer: The Alliance Commercial |
$248.00
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
DRESSING AMD 3X8 TELFA 7663"
|
Facility
IP
|
$62.00
|
|
| Hospital Charge Code |
2963151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.38 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$37.20
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
DRESSING AQUACEL AG 2X45CM 422300
|
Facility
IP
|
$331.00
|
|
| Hospital Charge Code |
2963483
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$162.19 |
| Max. Negotiated Rate |
$304.52 |
| Rate for Payer: Aetna Commercial |
$297.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$175.43
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$304.52
|
| Rate for Payer: Health EOS Commercial |
$294.59
|
| Rate for Payer: HFN Commercial |
$304.52
|
| Rate for Payer: Multiplan Commercial |
$264.80
|
| Rate for Payer: NAPHCARE Commercial |
$198.60
|
| Rate for Payer: Preferred Network Access Commercial |
$304.52
|
| Rate for Payer: Quartz Beloit One Network |
$162.19
|
| Rate for Payer: Quartz Commercial |
$198.60
|
| Rate for Payer: WEA Trust Commercial |
$182.05
|
| Rate for Payer: WPS Commercial |
$245.17
|
|
|
DRESSING AQUACEL AG 2X45CM 422300
|
Facility
OP
|
$331.00
|
|
| Hospital Charge Code |
2963483
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$92.68 |
| Max. Negotiated Rate |
$1,324.00 |
| Rate for Payer: Aetna Commercial |
$297.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$284.66
|
| Rate for Payer: Aetna Managed Medicare |
$92.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$215.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$165.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$158.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$175.43
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$304.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$185.23
|
| Rate for Payer: Health EOS Commercial |
$294.59
|
| Rate for Payer: HFN Commercial |
$304.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$248.25
|
| Rate for Payer: Multiplan Commercial |
$264.80
|
| Rate for Payer: NAPHCARE Commercial |
$198.60
|
| Rate for Payer: Preferred Network Access Commercial |
$304.52
|
| Rate for Payer: Quartz Beloit One Network |
$162.19
|
| Rate for Payer: Quartz Commercial |
$215.15
|
| Rate for Payer: Quartz Medicare Advantage |
$198.60
|
| Rate for Payer: The Alliance Commercial |
$1,324.00
|
| Rate for Payer: WEA Trust Commercial |
$182.05
|
| Rate for Payer: WPS Commercial |
$245.17
|
|
|
DRESSING AQUACEL AG ADVANTAGE 4X5 422299
|
Facility
IP
|
$188.00
|
|
| Hospital Charge Code |
5456957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$92.12 |
| Max. Negotiated Rate |
$172.96 |
| Rate for Payer: Aetna Commercial |
$169.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.64
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$172.96
|
| Rate for Payer: Health EOS Commercial |
$167.32
|
| Rate for Payer: HFN Commercial |
$172.96
|
| Rate for Payer: Multiplan Commercial |
$150.40
|
| Rate for Payer: NAPHCARE Commercial |
$112.80
|
| Rate for Payer: Preferred Network Access Commercial |
$172.96
|
| Rate for Payer: Quartz Beloit One Network |
$92.12
|
| Rate for Payer: Quartz Commercial |
$112.80
|
| Rate for Payer: WEA Trust Commercial |
$103.40
|
| Rate for Payer: WPS Commercial |
$139.25
|
|
|
DRESSING AQUACEL AG ADVANTAGE 4X5 422299
|
Facility
OP
|
$188.00
|
|
| Hospital Charge Code |
5456957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.64 |
| Max. Negotiated Rate |
$752.00 |
| Rate for Payer: Aetna Commercial |
$169.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.68
|
| Rate for Payer: Aetna Managed Medicare |
$52.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$122.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$94.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$90.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.64
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$172.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.20
|
| Rate for Payer: Health EOS Commercial |
$167.32
|
| Rate for Payer: HFN Commercial |
$172.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.00
|
| Rate for Payer: Multiplan Commercial |
$150.40
|
| Rate for Payer: NAPHCARE Commercial |
$112.80
|
| Rate for Payer: Preferred Network Access Commercial |
$172.96
|
| Rate for Payer: Quartz Beloit One Network |
$92.12
|
| Rate for Payer: Quartz Commercial |
$122.20
|
| Rate for Payer: Quartz Medicare Advantage |
$112.80
|
| Rate for Payer: The Alliance Commercial |
$752.00
|
| Rate for Payer: WEA Trust Commercial |
$103.40
|
| Rate for Payer: WPS Commercial |
$139.25
|
|
