|
DRESSING FOAM ADHESIVE 3X3 420804
|
Facility
IP
|
$75.00
|
|
| Hospital Charge Code |
4518941
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$67.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.75
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$69.00
|
| Rate for Payer: Health EOS Commercial |
$66.75
|
| Rate for Payer: HFN Commercial |
$69.00
|
| Rate for Payer: Multiplan Commercial |
$60.00
|
| Rate for Payer: NAPHCARE Commercial |
$45.00
|
| Rate for Payer: Preferred Network Access Commercial |
$69.00
|
| Rate for Payer: Quartz Beloit One Network |
$36.75
|
| Rate for Payer: Quartz Commercial |
$45.00
|
| Rate for Payer: WEA Trust Commercial |
$41.25
|
| Rate for Payer: WPS Commercial |
$55.55
|
|
|
DRESSING GAUZE 6X6.75 STERILE 6665
|
Facility
IP
|
$80.00
|
|
| Hospital Charge Code |
2963057
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$73.60 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$48.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
DRESSING GAUZE 6X6.75 STERILE 6665
|
Facility
OP
|
$80.00
|
|
| Hospital Charge Code |
2963057
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$320.00 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Aetna Managed Medicare |
$22.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.77
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$52.00
|
| Rate for Payer: Quartz Medicare Advantage |
$48.00
|
| Rate for Payer: The Alliance Commercial |
$320.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
DRESSING GAUZE VASE. PETROL
|
Facility
OP
|
$62.00
|
|
| Hospital Charge Code |
2963361
|
|
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 GAUZE VASE. PETROL
|
Facility
IP
|
$62.00
|
|
| Hospital Charge Code |
2963361
|
|
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 GRANUFOAM MEDIUM VAC VIAGFM05
|
Facility
OP
|
$891.00
|
|
| Hospital Charge Code |
2973266
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$249.48 |
| Max. Negotiated Rate |
$3,564.00 |
| Rate for Payer: Aetna Commercial |
$801.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$766.26
|
| Rate for Payer: Aetna Managed Medicare |
$249.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$579.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$445.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$427.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$472.23
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna Commercial |
$819.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$498.60
|
| Rate for Payer: Health EOS Commercial |
$792.99
|
| Rate for Payer: HFN Commercial |
$819.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$668.25
|
| Rate for Payer: Multiplan Commercial |
$712.80
|
| Rate for Payer: NAPHCARE Commercial |
$534.60
|
| Rate for Payer: Preferred Network Access Commercial |
$819.72
|
| Rate for Payer: Quartz Beloit One Network |
$436.59
|
| Rate for Payer: Quartz Commercial |
$579.15
|
| Rate for Payer: Quartz Medicare Advantage |
$534.60
|
| Rate for Payer: The Alliance Commercial |
$3,564.00
|
| Rate for Payer: WEA Trust Commercial |
$490.05
|
| Rate for Payer: WPS Commercial |
$659.96
|
|
|
DRESSING GRANUFOAM MEDIUM VAC VIAGFM05
|
Facility
IP
|
$891.00
|
|
| Hospital Charge Code |
2973266
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$436.59 |
| Max. Negotiated Rate |
$819.72 |
| Rate for Payer: Aetna Commercial |
$801.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$472.23
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna Commercial |
$819.72
|
| Rate for Payer: Health EOS Commercial |
$792.99
|
| Rate for Payer: HFN Commercial |
$819.72
|
| Rate for Payer: Multiplan Commercial |
$712.80
|
| Rate for Payer: NAPHCARE Commercial |
$534.60
|
| Rate for Payer: Preferred Network Access Commercial |
$819.72
|
| Rate for Payer: Quartz Beloit One Network |
$436.59
|
| Rate for Payer: Quartz Commercial |
$534.60
|
| Rate for Payer: WEA Trust Commercial |
$490.05
|
| Rate for Payer: WPS Commercial |
$659.96
|
|
|
DRESSING GRANU FOAM SILVER MEDIUM #M6275096
|
Facility
OP
|
$1,156.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
2974090
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$323.68 |
| Max. Negotiated Rate |
$1,063.52 |
| Rate for Payer: Aetna Commercial |
$1,040.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$994.16
|
| Rate for Payer: Aetna Managed Medicare |
$323.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$751.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$578.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$554.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$612.68
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,063.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$646.90
|
| Rate for Payer: Health EOS Commercial |
$1,028.84
|
| Rate for Payer: HFN Commercial |
$1,063.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$867.00
|
| Rate for Payer: Multiplan Commercial |
$924.80
|
| Rate for Payer: NAPHCARE Commercial |
$693.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,063.52
|
| Rate for Payer: Quartz Beloit One Network |
$566.44
|
| Rate for Payer: Quartz Commercial |
$751.40
|
| Rate for Payer: Quartz Medicare Advantage |
$693.60
|
| Rate for Payer: WEA Trust Commercial |
$635.80
|
| Rate for Payer: WPS Commercial |
$856.25
|
|
|
DRESSING GRANU FOAM SILVER MEDIUM #M6275096
|
Facility
IP
|
$1,156.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
2974090
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.44 |
| Max. Negotiated Rate |
$1,063.52 |
| Rate for Payer: Aetna Commercial |
$1,040.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$612.68
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,063.52
|
| Rate for Payer: Health EOS Commercial |
$1,028.84
|
| Rate for Payer: HFN Commercial |
$1,063.52
|
| Rate for Payer: Multiplan Commercial |
$924.80
|
| Rate for Payer: NAPHCARE Commercial |
$693.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,063.52
|
| Rate for Payer: Quartz Beloit One Network |
$566.44
|
| Rate for Payer: Quartz Commercial |
$693.60
|
| Rate for Payer: WEA Trust Commercial |
$635.80
|
| Rate for Payer: WPS Commercial |
$856.25
|
|
|
DRESSING GRANUFOAM SMALL VAC VIAGFS05
|
Facility
IP
|
$589.00
|
|
| Hospital Charge Code |
5415580
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$288.61 |
| Max. Negotiated Rate |
$541.88 |
| Rate for Payer: Aetna Commercial |
$530.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$312.17
|
| Rate for Payer: Cash Price |
$176.70
|
| Rate for Payer: Cigna Commercial |
$541.88
|
| Rate for Payer: Health EOS Commercial |
$524.21
|
| Rate for Payer: HFN Commercial |
$541.88
|
| Rate for Payer: Multiplan Commercial |
$471.20
|
| Rate for Payer: NAPHCARE Commercial |
$353.40
|
| Rate for Payer: Preferred Network Access Commercial |
$541.88
|
| Rate for Payer: Quartz Beloit One Network |
$288.61
|
| Rate for Payer: Quartz Commercial |
$353.40
|
| Rate for Payer: WEA Trust Commercial |
$323.95
|
| Rate for Payer: WPS Commercial |
$436.27
|
|
|
DRESSING GRANUFOAM SMALL VAC VIAGFS05
|
Facility
OP
|
$589.00
|
|
| Hospital Charge Code |
5415580
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$164.92 |
| Max. Negotiated Rate |
$2,356.00 |
| Rate for Payer: Aetna Commercial |
$530.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$506.54
|
| Rate for Payer: Aetna Managed Medicare |
$164.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$382.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$294.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$312.17
|
| Rate for Payer: Cash Price |
$176.70
|
| Rate for Payer: Cigna Commercial |
$541.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$329.60
|
| Rate for Payer: Health EOS Commercial |
$524.21
|
| Rate for Payer: HFN Commercial |
$541.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$441.75
|
| Rate for Payer: Multiplan Commercial |
$471.20
|
| Rate for Payer: NAPHCARE Commercial |
$353.40
|
| Rate for Payer: Preferred Network Access Commercial |
$541.88
|
| Rate for Payer: Quartz Beloit One Network |
$288.61
|
| Rate for Payer: Quartz Commercial |
$382.85
|
| Rate for Payer: Quartz Medicare Advantage |
$353.40
|
| Rate for Payer: The Alliance Commercial |
$2,356.00
|
| Rate for Payer: WEA Trust Commercial |
$323.95
|
| Rate for Payer: WPS Commercial |
$436.27
|
|
|
DRESSING KIT TRAC MED CTN/10 #M6275052-10
|
Facility
IP
|
$969.00
|
|
| Hospital Charge Code |
2974086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$474.81 |
| Max. Negotiated Rate |
$891.48 |
| Rate for Payer: Aetna Commercial |
$872.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$513.57
|
| Rate for Payer: Cash Price |
$290.70
|
| Rate for Payer: Cigna Commercial |
$891.48
|
| Rate for Payer: Health EOS Commercial |
$862.41
|
| Rate for Payer: HFN Commercial |
$891.48
|
| Rate for Payer: Multiplan Commercial |
$775.20
|
| Rate for Payer: NAPHCARE Commercial |
$581.40
|
| Rate for Payer: Preferred Network Access Commercial |
$891.48
|
| Rate for Payer: Quartz Beloit One Network |
$474.81
|
| Rate for Payer: Quartz Commercial |
$581.40
|
| Rate for Payer: WEA Trust Commercial |
$532.95
|
| Rate for Payer: WPS Commercial |
$717.74
|
|
|
DRESSING KIT TRAC MED CTN/10 #M6275052-10
|
Facility
OP
|
$969.00
|
|
| Hospital Charge Code |
2974086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.32 |
| Max. Negotiated Rate |
$3,876.00 |
| Rate for Payer: Aetna Commercial |
$872.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$833.34
|
| Rate for Payer: Aetna Managed Medicare |
$271.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$629.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$484.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$465.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$513.57
|
| Rate for Payer: Cash Price |
$290.70
|
| Rate for Payer: Cigna Commercial |
$891.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$542.25
|
| Rate for Payer: Health EOS Commercial |
$862.41
|
| Rate for Payer: HFN Commercial |
$891.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$726.75
|
| Rate for Payer: Multiplan Commercial |
$775.20
|
| Rate for Payer: NAPHCARE Commercial |
$581.40
|
| Rate for Payer: Preferred Network Access Commercial |
$891.48
|
| Rate for Payer: Quartz Beloit One Network |
$474.81
|
| Rate for Payer: Quartz Commercial |
$629.85
|
| Rate for Payer: Quartz Medicare Advantage |
$581.40
|
| Rate for Payer: The Alliance Commercial |
$3,876.00
|
| Rate for Payer: WEA Trust Commercial |
$532.95
|
| Rate for Payer: WPS Commercial |
$717.74
|
|
|
DRESSING KIT TRAC SMALL CTN/10 #M6275051-10
|
Facility
OP
|
$768.00
|
|
| Hospital Charge Code |
2974085
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$215.04 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$691.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$660.48
|
| Rate for Payer: Aetna Managed Medicare |
$215.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$499.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$384.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$368.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$407.04
|
| Rate for Payer: Cash Price |
$230.40
|
| Rate for Payer: Cigna Commercial |
$706.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$429.77
|
| Rate for Payer: Health EOS Commercial |
$683.52
|
| Rate for Payer: HFN Commercial |
$706.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$576.00
|
| Rate for Payer: Multiplan Commercial |
$614.40
|
| Rate for Payer: NAPHCARE Commercial |
$460.80
|
| Rate for Payer: Preferred Network Access Commercial |
$706.56
|
| Rate for Payer: Quartz Beloit One Network |
$376.32
|
| Rate for Payer: Quartz Commercial |
$499.20
|
| Rate for Payer: Quartz Medicare Advantage |
$460.80
|
| Rate for Payer: The Alliance Commercial |
$3,072.00
|
| Rate for Payer: WEA Trust Commercial |
$422.40
|
| Rate for Payer: WPS Commercial |
$568.86
|
|
|
DRESSING KIT TRAC SMALL CTN/10 #M6275051-10
|
Facility
IP
|
$768.00
|
|
| Hospital Charge Code |
2974085
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$376.32 |
| Max. Negotiated Rate |
$706.56 |
| Rate for Payer: Aetna Commercial |
$691.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$407.04
|
| Rate for Payer: Cash Price |
$230.40
|
| Rate for Payer: Cigna Commercial |
$706.56
|
| Rate for Payer: Health EOS Commercial |
$683.52
|
| Rate for Payer: HFN Commercial |
$706.56
|
| Rate for Payer: Multiplan Commercial |
$614.40
|
| Rate for Payer: NAPHCARE Commercial |
$460.80
|
| Rate for Payer: Preferred Network Access Commercial |
$706.56
|
| Rate for Payer: Quartz Beloit One Network |
$376.32
|
| Rate for Payer: Quartz Commercial |
$460.80
|
| Rate for Payer: WEA Trust Commercial |
$422.40
|
| Rate for Payer: WPS Commercial |
$568.86
|
|
|
DRESSING MEDIPORE 3 7/8X 4 5/8 2954
|
Facility
IP
|
$18.00
|
|
| Hospital Charge Code |
2963510
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$16.56 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.54
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$16.56
|
| Rate for Payer: Health EOS Commercial |
$16.02
|
| Rate for Payer: HFN Commercial |
$16.56
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: NAPHCARE Commercial |
$10.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16.56
|
| Rate for Payer: Quartz Beloit One Network |
$8.82
|
| Rate for Payer: Quartz Commercial |
$10.80
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: WPS Commercial |
$13.33
|
|
|
DRESSING MEDIPORE 3 7/8X 4 5/8 2954
|
Facility
OP
|
$18.00
|
|
| Hospital Charge Code |
2963510
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.48
|
| Rate for Payer: Aetna Managed Medicare |
$5.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.54
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$16.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.07
|
| Rate for Payer: Health EOS Commercial |
$16.02
|
| Rate for Payer: HFN Commercial |
$16.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: NAPHCARE Commercial |
$10.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16.56
|
| Rate for Payer: Quartz Beloit One Network |
$8.82
|
| Rate for Payer: Quartz Commercial |
$11.70
|
| Rate for Payer: Quartz Medicare Advantage |
$10.80
|
| Rate for Payer: The Alliance Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: WPS Commercial |
$13.33
|
|
|
DRESSING MEDIPORE 5-7/8 X 11 2957
|
Facility
IP
|
$85.00
|
|
| Hospital Charge Code |
2963576
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$78.20 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.05
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: Health EOS Commercial |
$75.65
|
| Rate for Payer: HFN Commercial |
$78.20
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: NAPHCARE Commercial |
$51.00
|
| Rate for Payer: Preferred Network Access Commercial |
$78.20
|
| Rate for Payer: Quartz Beloit One Network |
$41.65
|
| Rate for Payer: Quartz Commercial |
$51.00
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: WPS Commercial |
$62.96
|
|
|
DRESSING MEDIPORE 5-7/8 X 11 2957
|
Facility
OP
|
$85.00
|
|
| Hospital Charge Code |
2963576
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.10
|
| Rate for Payer: Aetna Managed Medicare |
$23.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.05
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.57
|
| Rate for Payer: Health EOS Commercial |
$75.65
|
| Rate for Payer: HFN Commercial |
$78.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.75
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: NAPHCARE Commercial |
$51.00
|
| Rate for Payer: Preferred Network Access Commercial |
$78.20
|
| Rate for Payer: Quartz Beloit One Network |
$41.65
|
| Rate for Payer: Quartz Commercial |
$55.25
|
| Rate for Payer: Quartz Medicare Advantage |
$51.00
|
| Rate for Payer: The Alliance Commercial |
$340.00
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: WPS Commercial |
$62.96
|
|
|
DRESSING MEDIPORE 5 7/8X 5 7/8
|
Facility
IP
|
$38.00
|
|
| Hospital Charge Code |
2963313
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.62 |
| Max. Negotiated Rate |
$34.96 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.14
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$34.96
|
| Rate for Payer: Health EOS Commercial |
$33.82
|
| Rate for Payer: HFN Commercial |
$34.96
|
| Rate for Payer: Multiplan Commercial |
$30.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34.96
|
| Rate for Payer: Quartz Beloit One Network |
$18.62
|
| Rate for Payer: Quartz Commercial |
$22.80
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
DRESSING MEDIPORE 5 7/8X 5 7/8
|
Facility
OP
|
$38.00
|
|
| Hospital Charge Code |
2963313
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.64 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| Rate for Payer: Aetna Managed Medicare |
$10.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.14
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$34.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.26
|
| Rate for Payer: Health EOS Commercial |
$33.82
|
| Rate for Payer: HFN Commercial |
$34.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.50
|
| Rate for Payer: Multiplan Commercial |
$30.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34.96
|
| Rate for Payer: Quartz Beloit One Network |
$18.62
|
| Rate for Payer: Quartz Commercial |
$24.70
|
| Rate for Payer: Quartz Medicare Advantage |
$22.80
|
| Rate for Payer: The Alliance Commercial |
$152.00
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
DRESSING MEPILEX AG 4X4 287100
|
Facility
IP
|
$238.00
|
|
| Hospital Charge Code |
2974587
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.62 |
| Max. Negotiated Rate |
$218.96 |
| Rate for Payer: Aetna Commercial |
$214.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.14
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$218.96
|
| Rate for Payer: Health EOS Commercial |
$211.82
|
| Rate for Payer: HFN Commercial |
$218.96
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: NAPHCARE Commercial |
$142.80
|
| Rate for Payer: Preferred Network Access Commercial |
$218.96
|
| Rate for Payer: Quartz Beloit One Network |
$116.62
|
| Rate for Payer: Quartz Commercial |
$142.80
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: WPS Commercial |
$176.29
|
|
|
DRESSING MEPILEX AG 4X4 287100
|
Facility
OP
|
$238.00
|
|
| Hospital Charge Code |
2974587
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.64 |
| Max. Negotiated Rate |
$952.00 |
| Rate for Payer: Aetna Commercial |
$214.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.68
|
| Rate for Payer: Aetna Managed Medicare |
$66.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$154.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$119.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$114.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.14
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$218.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.18
|
| Rate for Payer: Health EOS Commercial |
$211.82
|
| Rate for Payer: HFN Commercial |
$218.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$178.50
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: NAPHCARE Commercial |
$142.80
|
| Rate for Payer: Preferred Network Access Commercial |
$218.96
|
| Rate for Payer: Quartz Beloit One Network |
$116.62
|
| Rate for Payer: Quartz Commercial |
$154.70
|
| Rate for Payer: Quartz Medicare Advantage |
$142.80
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: WPS Commercial |
$176.29
|
|
|
DRESSING MEPILEX FOAM NONADHESIVE 4x4 294199
|
Facility
IP
|
$115.00
|
|
| Hospital Charge Code |
2964025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$105.80 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
DRESSING MEPILEX FOAM NONADHESIVE 4x4 294199
|
Facility
OP
|
$115.00
|
|
| Hospital Charge Code |
2964025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$460.00 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Aetna Managed Medicare |
$32.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.35
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.25
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$74.75
|
| Rate for Payer: Quartz Medicare Advantage |
$69.00
|
| Rate for Payer: The Alliance Commercial |
$460.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
