|
DRESSING MEPILEX HEEL 5 X 8 288100
|
Facility
IP
|
$85.00
|
|
| Hospital Charge Code |
2973234
|
|
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 MEPILEX HEEL 5 X 8 288100
|
Facility
OP
|
$85.00
|
|
| Hospital Charge Code |
2973234
|
|
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 MEPITEL NON ADH 3X4 290799
|
Facility
OP
|
$141.00
|
|
|
Service Code
|
HCPCS A6206
|
| Hospital Charge Code |
4063435
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.48 |
| Max. Negotiated Rate |
$129.72 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$121.26
|
| Rate for Payer: Aetna Managed Medicare |
$39.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$91.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$70.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$67.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.73
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$129.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.90
|
| Rate for Payer: Health EOS Commercial |
$125.49
|
| Rate for Payer: HFN Commercial |
$129.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.75
|
| Rate for Payer: Multiplan Commercial |
$112.80
|
| Rate for Payer: NAPHCARE Commercial |
$84.60
|
| Rate for Payer: Preferred Network Access Commercial |
$129.72
|
| Rate for Payer: Quartz Beloit One Network |
$69.09
|
| Rate for Payer: Quartz Commercial |
$91.65
|
| Rate for Payer: Quartz Medicare Advantage |
$84.60
|
| Rate for Payer: WEA Trust Commercial |
$77.55
|
| Rate for Payer: WPS Commercial |
$104.44
|
|
|
DRESSING MEPITEL NON ADH 3X4 290799
|
Facility
IP
|
$141.00
|
|
|
Service Code
|
HCPCS A6206
|
| Hospital Charge Code |
4063435
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.09 |
| Max. Negotiated Rate |
$129.72 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.73
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$129.72
|
| Rate for Payer: Health EOS Commercial |
$125.49
|
| Rate for Payer: HFN Commercial |
$129.72
|
| Rate for Payer: Multiplan Commercial |
$112.80
|
| Rate for Payer: NAPHCARE Commercial |
$84.60
|
| Rate for Payer: Preferred Network Access Commercial |
$129.72
|
| Rate for Payer: Quartz Beloit One Network |
$69.09
|
| Rate for Payer: Quartz Commercial |
$84.60
|
| Rate for Payer: WEA Trust Commercial |
$77.55
|
| Rate for Payer: WPS Commercial |
$104.44
|
|
|
DRESSING MEPITEL ONE 3 X 4
|
Facility
IP
|
$145.00
|
|
| Hospital Charge Code |
2974066
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.05 |
| Max. Negotiated Rate |
$133.40 |
| Rate for Payer: Aetna Commercial |
$130.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.85
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$133.40
|
| Rate for Payer: Health EOS Commercial |
$129.05
|
| Rate for Payer: HFN Commercial |
$133.40
|
| Rate for Payer: Multiplan Commercial |
$116.00
|
| Rate for Payer: NAPHCARE Commercial |
$87.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.40
|
| Rate for Payer: Quartz Beloit One Network |
$71.05
|
| Rate for Payer: Quartz Commercial |
$87.00
|
| Rate for Payer: WEA Trust Commercial |
$79.75
|
| Rate for Payer: WPS Commercial |
$107.40
|
|
|
DRESSING MEPITEL ONE 3 X 4
|
Facility
OP
|
$145.00
|
|
| Hospital Charge Code |
2974066
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$580.00 |
| Rate for Payer: Aetna Commercial |
$130.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.70
|
| Rate for Payer: Aetna Managed Medicare |
$40.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.85
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$133.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.14
|
| Rate for Payer: Health EOS Commercial |
$129.05
|
| Rate for Payer: HFN Commercial |
$133.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.75
|
| Rate for Payer: Multiplan Commercial |
$116.00
|
| Rate for Payer: NAPHCARE Commercial |
$87.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.40
|
| Rate for Payer: Quartz Beloit One Network |
$71.05
|
| Rate for Payer: Quartz Commercial |
$94.25
|
| Rate for Payer: Quartz Medicare Advantage |
$87.00
|
| Rate for Payer: The Alliance Commercial |
$580.00
|
| Rate for Payer: WEA Trust Commercial |
$79.75
|
| Rate for Payer: WPS Commercial |
$107.40
|
|
|
DRESSING MEROGEL 15-17000
|
Facility
OP
|
$1,481.00
|
|
| Hospital Charge Code |
2965320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$414.68 |
| Max. Negotiated Rate |
$5,924.00 |
| Rate for Payer: Aetna Commercial |
$1,332.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,273.66
|
| Rate for Payer: Aetna Managed Medicare |
$414.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$962.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$740.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$710.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$784.93
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cigna Commercial |
$1,362.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$828.77
|
| Rate for Payer: Health EOS Commercial |
$1,318.09
|
| Rate for Payer: HFN Commercial |
$1,362.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,110.75
|
| Rate for Payer: Multiplan Commercial |
$1,184.80
|
| Rate for Payer: NAPHCARE Commercial |
$888.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,362.52
|
| Rate for Payer: Quartz Beloit One Network |
$725.69
|
| Rate for Payer: Quartz Commercial |
$962.65
|
| Rate for Payer: Quartz Medicare Advantage |
$888.60
|
| Rate for Payer: The Alliance Commercial |
$5,924.00
|
| Rate for Payer: WEA Trust Commercial |
$814.55
|
| Rate for Payer: WPS Commercial |
$1,096.98
|
|
|
DRESSING MEROGEL 15-17000
|
Facility
IP
|
$1,481.00
|
|
| Hospital Charge Code |
2965320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$725.69 |
| Max. Negotiated Rate |
$1,362.52 |
| Rate for Payer: Aetna Commercial |
$1,332.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$784.93
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cigna Commercial |
$1,362.52
|
| Rate for Payer: Health EOS Commercial |
$1,318.09
|
| Rate for Payer: HFN Commercial |
$1,362.52
|
| Rate for Payer: Multiplan Commercial |
$1,184.80
|
| Rate for Payer: NAPHCARE Commercial |
$888.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,362.52
|
| Rate for Payer: Quartz Beloit One Network |
$725.69
|
| Rate for Payer: Quartz Commercial |
$888.60
|
| Rate for Payer: WEA Trust Commercial |
$814.55
|
| Rate for Payer: WPS Commercial |
$1,096.98
|
|
|
DRESSING OPTIFOAM AG 3.5X6 MSC9736Z
|
Facility
OP
|
$495.00
|
|
| Hospital Charge Code |
4414146
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$138.60 |
| Max. Negotiated Rate |
$1,980.00 |
| Rate for Payer: Aetna Commercial |
$445.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Aetna Managed Medicare |
$138.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$321.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$247.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$237.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.35
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$455.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$277.00
|
| Rate for Payer: Health EOS Commercial |
$440.55
|
| Rate for Payer: HFN Commercial |
$455.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$371.25
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: NAPHCARE Commercial |
$297.00
|
| Rate for Payer: Preferred Network Access Commercial |
$455.40
|
| Rate for Payer: Quartz Beloit One Network |
$242.55
|
| Rate for Payer: Quartz Commercial |
$321.75
|
| Rate for Payer: Quartz Medicare Advantage |
$297.00
|
| Rate for Payer: The Alliance Commercial |
$1,980.00
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
DRESSING OPTIFOAM AG 3.5X6 MSC9736Z
|
Facility
IP
|
$495.00
|
|
| Hospital Charge Code |
4414146
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$242.55 |
| Max. Negotiated Rate |
$455.40 |
| Rate for Payer: Aetna Commercial |
$445.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.35
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$455.40
|
| Rate for Payer: Health EOS Commercial |
$440.55
|
| Rate for Payer: HFN Commercial |
$455.40
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: NAPHCARE Commercial |
$297.00
|
| Rate for Payer: Preferred Network Access Commercial |
$455.40
|
| Rate for Payer: Quartz Beloit One Network |
$242.55
|
| Rate for Payer: Quartz Commercial |
$297.00
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
DRESSING OPTIFOAM SACRUM 7.9X7.2 MSC2077EP
|
Facility
IP
|
$174.00
|
|
|
Service Code
|
HCPCS A6213
|
| Hospital Charge Code |
3937340
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$160.08 |
| Rate for Payer: Aetna Commercial |
$156.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.22
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$160.08
|
| Rate for Payer: Health EOS Commercial |
$154.86
|
| Rate for Payer: HFN Commercial |
$160.08
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: NAPHCARE Commercial |
$104.40
|
| Rate for Payer: Preferred Network Access Commercial |
$160.08
|
| Rate for Payer: Quartz Beloit One Network |
$85.26
|
| Rate for Payer: Quartz Commercial |
$104.40
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
DRESSING OPTIFOAM SACRUM 7.9X7.2 MSC2077EP
|
Facility
OP
|
$174.00
|
|
|
Service Code
|
HCPCS A6213
|
| Hospital Charge Code |
3937340
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.72 |
| Max. Negotiated Rate |
$160.08 |
| Rate for Payer: Aetna Commercial |
$156.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| Rate for Payer: Aetna Managed Medicare |
$48.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$113.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$87.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$83.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.22
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$160.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.37
|
| Rate for Payer: Health EOS Commercial |
$154.86
|
| Rate for Payer: HFN Commercial |
$160.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.50
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: NAPHCARE Commercial |
$104.40
|
| Rate for Payer: Preferred Network Access Commercial |
$160.08
|
| Rate for Payer: Quartz Beloit One Network |
$85.26
|
| Rate for Payer: Quartz Commercial |
$113.10
|
| Rate for Payer: Quartz Medicare Advantage |
$104.40
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
DRESSING PREVENA VAC 20CM PRE1055US
|
Facility
IP
|
$3,738.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
2975060
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$1,831.62 |
| Max. Negotiated Rate |
$3,438.96 |
| Rate for Payer: Aetna Commercial |
$3,364.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,981.14
|
| Rate for Payer: Cash Price |
$1,121.40
|
| Rate for Payer: Cigna Commercial |
$3,438.96
|
| Rate for Payer: Health EOS Commercial |
$3,326.82
|
| Rate for Payer: HFN Commercial |
$3,438.96
|
| Rate for Payer: Multiplan Commercial |
$2,990.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,242.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,438.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,831.62
|
| Rate for Payer: Quartz Commercial |
$2,242.80
|
| Rate for Payer: WEA Trust Commercial |
$2,055.90
|
| Rate for Payer: WPS Commercial |
$2,768.74
|
|
|
DRESSING PREVENA VAC 20CM PRE1055US
|
Facility
OP
|
$3,738.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
2975060
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$1,046.64 |
| Max. Negotiated Rate |
$3,438.96 |
| Rate for Payer: Aetna Commercial |
$3,364.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,214.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,046.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,429.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,869.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,794.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,981.14
|
| Rate for Payer: Cash Price |
$1,121.40
|
| Rate for Payer: Cigna Commercial |
$3,438.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,091.78
|
| Rate for Payer: Health EOS Commercial |
$3,326.82
|
| Rate for Payer: HFN Commercial |
$3,438.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,803.50
|
| Rate for Payer: Multiplan Commercial |
$2,990.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,242.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,438.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,831.62
|
| Rate for Payer: Quartz Commercial |
$2,429.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,242.80
|
| Rate for Payer: WEA Trust Commercial |
$2,055.90
|
| Rate for Payer: WPS Commercial |
$2,768.74
|
|
|
DRESSING PROWICK PACK
|
Facility
OP
|
$4,882.00
|
|
| Hospital Charge Code |
2964678
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,366.96 |
| Max. Negotiated Rate |
$19,528.00 |
| Rate for Payer: Aetna Commercial |
$4,393.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,198.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,366.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,173.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,441.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,343.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,587.46
|
| Rate for Payer: Cash Price |
$1,464.60
|
| Rate for Payer: Cigna Commercial |
$4,491.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,731.97
|
| Rate for Payer: Health EOS Commercial |
$4,344.98
|
| Rate for Payer: HFN Commercial |
$4,491.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,661.50
|
| Rate for Payer: Multiplan Commercial |
$3,905.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,929.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,491.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,392.18
|
| Rate for Payer: Quartz Commercial |
$3,173.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,929.20
|
| Rate for Payer: The Alliance Commercial |
$19,528.00
|
| Rate for Payer: WEA Trust Commercial |
$2,685.10
|
| Rate for Payer: WPS Commercial |
$3,616.10
|
|
|
DRESSING PROWICK PACK
|
Facility
IP
|
$4,882.00
|
|
| Hospital Charge Code |
2964678
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,392.18 |
| Max. Negotiated Rate |
$4,491.44 |
| Rate for Payer: Aetna Commercial |
$4,393.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,587.46
|
| Rate for Payer: Cash Price |
$1,464.60
|
| Rate for Payer: Cigna Commercial |
$4,491.44
|
| Rate for Payer: Health EOS Commercial |
$4,344.98
|
| Rate for Payer: HFN Commercial |
$4,491.44
|
| Rate for Payer: Multiplan Commercial |
$3,905.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,929.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,491.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,392.18
|
| Rate for Payer: Quartz Commercial |
$2,929.20
|
| Rate for Payer: WEA Trust Commercial |
$2,685.10
|
| Rate for Payer: WPS Commercial |
$3,616.10
|
|
|
DRESSING SENSATRAC MED M8275052/5.S
|
Facility
OP
|
$952.00
|
|
| Hospital Charge Code |
4858667
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.56 |
| Max. Negotiated Rate |
$3,808.00 |
| Rate for Payer: Aetna Commercial |
$856.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.72
|
| Rate for Payer: Aetna Managed Medicare |
$266.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$476.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.56
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$875.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.74
|
| Rate for Payer: Health EOS Commercial |
$847.28
|
| Rate for Payer: HFN Commercial |
$875.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$714.00
|
| Rate for Payer: Multiplan Commercial |
$761.60
|
| Rate for Payer: NAPHCARE Commercial |
$571.20
|
| Rate for Payer: Preferred Network Access Commercial |
$875.84
|
| Rate for Payer: Quartz Beloit One Network |
$466.48
|
| Rate for Payer: Quartz Commercial |
$618.80
|
| Rate for Payer: Quartz Medicare Advantage |
$571.20
|
| Rate for Payer: The Alliance Commercial |
$3,808.00
|
| Rate for Payer: WEA Trust Commercial |
$523.60
|
| Rate for Payer: WPS Commercial |
$705.15
|
|
|
DRESSING SENSATRAC MED M8275052/5.S
|
Facility
IP
|
$952.00
|
|
| Hospital Charge Code |
4858667
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$466.48 |
| Max. Negotiated Rate |
$875.84 |
| Rate for Payer: Aetna Commercial |
$856.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.56
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$875.84
|
| Rate for Payer: Health EOS Commercial |
$847.28
|
| Rate for Payer: HFN Commercial |
$875.84
|
| Rate for Payer: Multiplan Commercial |
$761.60
|
| Rate for Payer: NAPHCARE Commercial |
$571.20
|
| Rate for Payer: Preferred Network Access Commercial |
$875.84
|
| Rate for Payer: Quartz Beloit One Network |
$466.48
|
| Rate for Payer: Quartz Commercial |
$571.20
|
| Rate for Payer: WEA Trust Commercial |
$523.60
|
| Rate for Payer: WPS Commercial |
$705.15
|
|
|
DRESSING SINU-FOAM STAMMBERGER RR650
|
Facility
OP
|
$1,273.00
|
|
| Hospital Charge Code |
3439508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$356.44 |
| Max. Negotiated Rate |
$5,092.00 |
| Rate for Payer: Aetna Commercial |
$1,145.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,094.78
|
| Rate for Payer: Aetna Managed Medicare |
$356.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$827.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$636.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$611.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$674.69
|
| Rate for Payer: Cash Price |
$381.90
|
| Rate for Payer: Cigna Commercial |
$1,171.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$712.37
|
| Rate for Payer: Health EOS Commercial |
$1,132.97
|
| Rate for Payer: HFN Commercial |
$1,171.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$954.75
|
| Rate for Payer: Multiplan Commercial |
$1,018.40
|
| Rate for Payer: NAPHCARE Commercial |
$763.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,171.16
|
| Rate for Payer: Quartz Beloit One Network |
$623.77
|
| Rate for Payer: Quartz Commercial |
$827.45
|
| Rate for Payer: Quartz Medicare Advantage |
$763.80
|
| Rate for Payer: The Alliance Commercial |
$5,092.00
|
| Rate for Payer: WEA Trust Commercial |
$700.15
|
| Rate for Payer: WPS Commercial |
$942.91
|
|
|
DRESSING SINU-FOAM STAMMBERGER RR650
|
Facility
IP
|
$1,273.00
|
|
| Hospital Charge Code |
3439508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$623.77 |
| Max. Negotiated Rate |
$1,171.16 |
| Rate for Payer: Aetna Commercial |
$1,145.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$674.69
|
| Rate for Payer: Cash Price |
$381.90
|
| Rate for Payer: Cigna Commercial |
$1,171.16
|
| Rate for Payer: Health EOS Commercial |
$1,132.97
|
| Rate for Payer: HFN Commercial |
$1,171.16
|
| Rate for Payer: Multiplan Commercial |
$1,018.40
|
| Rate for Payer: NAPHCARE Commercial |
$763.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,171.16
|
| Rate for Payer: Quartz Beloit One Network |
$623.77
|
| Rate for Payer: Quartz Commercial |
$763.80
|
| Rate for Payer: WEA Trust Commercial |
$700.15
|
| Rate for Payer: WPS Commercial |
$942.91
|
|
|
DRESSINGS V.A.C. GRANUFOAM LARGE 26 X 15 X 3.2CM M8275053/10
|
Facility
IP
|
$1,042.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
4519918
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$510.58 |
| Max. Negotiated Rate |
$958.64 |
| Rate for Payer: Aetna Commercial |
$937.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.26
|
| Rate for Payer: Cash Price |
$312.60
|
| Rate for Payer: Cigna Commercial |
$958.64
|
| Rate for Payer: Health EOS Commercial |
$927.38
|
| Rate for Payer: HFN Commercial |
$958.64
|
| Rate for Payer: Multiplan Commercial |
$833.60
|
| Rate for Payer: NAPHCARE Commercial |
$625.20
|
| Rate for Payer: Preferred Network Access Commercial |
$958.64
|
| Rate for Payer: Quartz Beloit One Network |
$510.58
|
| Rate for Payer: Quartz Commercial |
$625.20
|
| Rate for Payer: WEA Trust Commercial |
$573.10
|
| Rate for Payer: WPS Commercial |
$771.81
|
|
|
DRESSINGS V.A.C. GRANUFOAM LARGE 26 X 15 X 3.2CM M8275053/10
|
Facility
OP
|
$1,042.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
4519918
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$291.76 |
| Max. Negotiated Rate |
$958.64 |
| Rate for Payer: Aetna Commercial |
$937.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.12
|
| Rate for Payer: Aetna Managed Medicare |
$291.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$677.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$521.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$500.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.26
|
| Rate for Payer: Cash Price |
$312.60
|
| Rate for Payer: Cigna Commercial |
$958.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$583.10
|
| Rate for Payer: Health EOS Commercial |
$927.38
|
| Rate for Payer: HFN Commercial |
$958.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$781.50
|
| Rate for Payer: Multiplan Commercial |
$833.60
|
| Rate for Payer: NAPHCARE Commercial |
$625.20
|
| Rate for Payer: Preferred Network Access Commercial |
$958.64
|
| Rate for Payer: Quartz Beloit One Network |
$510.58
|
| Rate for Payer: Quartz Commercial |
$677.30
|
| Rate for Payer: Quartz Medicare Advantage |
$625.20
|
| Rate for Payer: WEA Trust Commercial |
$573.10
|
| Rate for Payer: WPS Commercial |
$771.81
|
|
|
DRESSINGS V.A.C. GRANUFOAM X-LARGE 60 X 30 X 1.5CM M8275065/5
|
Facility
IP
|
$1,529.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
5917641
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$749.21 |
| Max. Negotiated Rate |
$1,406.68 |
| Rate for Payer: Aetna Commercial |
$1,376.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$810.37
|
| Rate for Payer: Cash Price |
$458.70
|
| Rate for Payer: Cigna Commercial |
$1,406.68
|
| Rate for Payer: Health EOS Commercial |
$1,360.81
|
| Rate for Payer: HFN Commercial |
$1,406.68
|
| Rate for Payer: Multiplan Commercial |
$1,223.20
|
| Rate for Payer: NAPHCARE Commercial |
$917.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,406.68
|
| Rate for Payer: Quartz Beloit One Network |
$749.21
|
| Rate for Payer: Quartz Commercial |
$917.40
|
| Rate for Payer: WEA Trust Commercial |
$840.95
|
| Rate for Payer: WPS Commercial |
$1,132.53
|
|
|
DRESSINGS V.A.C. GRANUFOAM X-LARGE 60 X 30 X 1.5CM M8275065/5
|
Facility
OP
|
$1,529.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
5917641
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$428.12 |
| Max. Negotiated Rate |
$1,406.68 |
| Rate for Payer: Aetna Commercial |
$1,376.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,314.94
|
| Rate for Payer: Aetna Managed Medicare |
$428.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$993.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$764.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$733.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$810.37
|
| Rate for Payer: Cash Price |
$458.70
|
| Rate for Payer: Cigna Commercial |
$1,406.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$855.63
|
| Rate for Payer: Health EOS Commercial |
$1,360.81
|
| Rate for Payer: HFN Commercial |
$1,406.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,146.75
|
| Rate for Payer: Multiplan Commercial |
$1,223.20
|
| Rate for Payer: NAPHCARE Commercial |
$917.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,406.68
|
| Rate for Payer: Quartz Beloit One Network |
$749.21
|
| Rate for Payer: Quartz Commercial |
$993.85
|
| Rate for Payer: Quartz Medicare Advantage |
$917.40
|
| Rate for Payer: WEA Trust Commercial |
$840.95
|
| Rate for Payer: WPS Commercial |
$1,132.53
|
|
|
DRESSING TAPE RETENTION MSC4004
|
Facility
OP
|
$146.00
|
|
|
Service Code
|
HCPCS A4452
|
| Hospital Charge Code |
3895342
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Aetna Managed Medicare |
$40.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.70
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.50
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$94.90
|
| Rate for Payer: Quartz Medicare Advantage |
$87.60
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
