|
DRESSING TAPE RETENTION MSC4004
|
Facility
IP
|
$146.00
|
|
|
Service Code
|
HCPCS A4452
|
| Hospital Charge Code |
3895342
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.54 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| 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: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| 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 |
$87.60
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
DRESSING TEGADERM 2 3/8X2 3/4 1624W"
|
Facility
OP
|
$9.00
|
|
|
Service Code
|
HCPCS A6258
|
| Hospital Charge Code |
2974460
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$8.28 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Aetna Managed Medicare |
$2.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.77
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.04
|
| Rate for Payer: Health EOS Commercial |
$8.01
|
| Rate for Payer: HFN Commercial |
$8.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.75
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: NAPHCARE Commercial |
$5.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8.28
|
| Rate for Payer: Quartz Beloit One Network |
$4.41
|
| Rate for Payer: Quartz Commercial |
$5.85
|
| Rate for Payer: Quartz Medicare Advantage |
$5.40
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$6.67
|
|
|
DRESSING TEGADERM 2 3/8X2 3/4 1624W"
|
Facility
IP
|
$9.00
|
|
|
Service Code
|
HCPCS A6258
|
| Hospital Charge Code |
2974460
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$8.28 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.77
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: Health EOS Commercial |
$8.01
|
| Rate for Payer: HFN Commercial |
$8.28
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: NAPHCARE Commercial |
$5.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8.28
|
| Rate for Payer: Quartz Beloit One Network |
$4.41
|
| Rate for Payer: Quartz Commercial |
$5.40
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$6.67
|
|
|
DRESSING TEGADERM 3.5 X 4.5 IV
|
Facility
IP
|
$53.00
|
|
| Hospital Charge Code |
2974638
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.97 |
| Max. Negotiated Rate |
$48.76 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$31.80
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
DRESSING TEGADERM 3.5 X 4.5 IV
|
Facility
OP
|
$53.00
|
|
| Hospital Charge Code |
2974638
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$212.00 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Aetna Managed Medicare |
$14.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.75
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$34.45
|
| Rate for Payer: Quartz Medicare Advantage |
$31.80
|
| Rate for Payer: The Alliance Commercial |
$212.00
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
DRESSING TEGADERM 4X4 3/4 1626W
|
Facility
IP
|
$44.00
|
|
| Hospital Charge Code |
2962794
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
DRESSING TEGADERM 4X4 3/4 1626W
|
Facility
OP
|
$44.00
|
|
| Hospital Charge Code |
2962794
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
DRESSING TEGADERM 6 X 8 1628"
|
Facility
OP
|
$96.00
|
|
|
Service Code
|
HCPCS A6258
|
| Hospital Charge Code |
2963843
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.88 |
| Max. Negotiated Rate |
$88.32 |
| Rate for Payer: Aetna Commercial |
$86.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.56
|
| Rate for Payer: Aetna Managed Medicare |
$26.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.88
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$88.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.72
|
| Rate for Payer: Health EOS Commercial |
$85.44
|
| Rate for Payer: HFN Commercial |
$88.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.00
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: NAPHCARE Commercial |
$57.60
|
| Rate for Payer: Preferred Network Access Commercial |
$88.32
|
| Rate for Payer: Quartz Beloit One Network |
$47.04
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: Quartz Medicare Advantage |
$57.60
|
| Rate for Payer: WEA Trust Commercial |
$52.80
|
| Rate for Payer: WPS Commercial |
$71.11
|
|
|
DRESSING TEGADERM 6 X 8 1628"
|
Facility
IP
|
$96.00
|
|
|
Service Code
|
HCPCS A6258
|
| Hospital Charge Code |
2963843
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.04 |
| Max. Negotiated Rate |
$88.32 |
| Rate for Payer: Aetna Commercial |
$86.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.88
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$88.32
|
| Rate for Payer: Health EOS Commercial |
$85.44
|
| Rate for Payer: HFN Commercial |
$88.32
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: NAPHCARE Commercial |
$57.60
|
| Rate for Payer: Preferred Network Access Commercial |
$88.32
|
| Rate for Payer: Quartz Beloit One Network |
$47.04
|
| Rate for Payer: Quartz Commercial |
$57.60
|
| Rate for Payer: WEA Trust Commercial |
$52.80
|
| Rate for Payer: WPS Commercial |
$71.11
|
|
|
DRESSING TEGADERM 8 X 12 1629"
|
Facility
IP
|
$80.00
|
|
| Hospital Charge Code |
2963754
|
|
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 TEGADERM 8 X 12 1629"
|
Facility
OP
|
$80.00
|
|
| Hospital Charge Code |
2963754
|
|
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 TEGADERM IV 2.5 X 2.75 #1683
|
Facility
IP
|
$29.00
|
|
|
Service Code
|
HCPCS A6257
|
| Hospital Charge Code |
4519975
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.21 |
| Max. Negotiated Rate |
$26.68 |
| Rate for Payer: Aetna Commercial |
$26.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.37
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$26.68
|
| Rate for Payer: Health EOS Commercial |
$25.81
|
| Rate for Payer: HFN Commercial |
$26.68
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: NAPHCARE Commercial |
$17.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.68
|
| Rate for Payer: Quartz Beloit One Network |
$14.21
|
| Rate for Payer: Quartz Commercial |
$17.40
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
DRESSING TEGADERM IV 2.5 X 2.75 #1683
|
Facility
OP
|
$29.00
|
|
|
Service Code
|
HCPCS A6257
|
| Hospital Charge Code |
4519975
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.12 |
| Max. Negotiated Rate |
$26.68 |
| Rate for Payer: Aetna Commercial |
$26.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| Rate for Payer: Aetna Managed Medicare |
$8.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.37
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$26.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.23
|
| Rate for Payer: Health EOS Commercial |
$25.81
|
| Rate for Payer: HFN Commercial |
$26.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.75
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: NAPHCARE Commercial |
$17.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.68
|
| Rate for Payer: Quartz Beloit One Network |
$14.21
|
| Rate for Payer: Quartz Commercial |
$18.85
|
| Rate for Payer: Quartz Medicare Advantage |
$17.40
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
DRESSING TELFA 3x4 STERILE AMD 7662
|
Facility
IP
|
$6.00
|
|
| Hospital Charge Code |
2963949
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
DRESSING TELFA 3x4 STERILE AMD 7662
|
Facility
OP
|
$6.00
|
|
| Hospital Charge Code |
2963949
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.36
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
DRESSING TELFA MINI ISLAND
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
2974550
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| Rate for Payer: Aetna Managed Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.24
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2.40
|
| Rate for Payer: The Alliance Commercial |
$16.00
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
DRESSING TELFA MINI ISLAND
|
Facility
IP
|
$4.00
|
|
| Hospital Charge Code |
2974550
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.40
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
DRESSING TRAC LRG CRTN/10 #M6275053-10
|
Facility
OP
|
$1,002.00
|
|
| Hospital Charge Code |
2974087
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$280.56 |
| Max. Negotiated Rate |
$4,008.00 |
| Rate for Payer: Aetna Commercial |
$901.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$861.72
|
| Rate for Payer: Aetna Managed Medicare |
$280.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$651.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$501.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$480.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$531.06
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$921.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$560.72
|
| Rate for Payer: Health EOS Commercial |
$891.78
|
| Rate for Payer: HFN Commercial |
$921.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$751.50
|
| Rate for Payer: Multiplan Commercial |
$801.60
|
| Rate for Payer: NAPHCARE Commercial |
$601.20
|
| Rate for Payer: Preferred Network Access Commercial |
$921.84
|
| Rate for Payer: Quartz Beloit One Network |
$490.98
|
| Rate for Payer: Quartz Commercial |
$651.30
|
| Rate for Payer: Quartz Medicare Advantage |
$601.20
|
| Rate for Payer: The Alliance Commercial |
$4,008.00
|
| Rate for Payer: WEA Trust Commercial |
$551.10
|
| Rate for Payer: WPS Commercial |
$742.18
|
|
|
DRESSING TRAC LRG CRTN/10 #M6275053-10
|
Facility
IP
|
$1,002.00
|
|
| Hospital Charge Code |
2974087
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$490.98 |
| Max. Negotiated Rate |
$921.84 |
| Rate for Payer: Aetna Commercial |
$901.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$531.06
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$921.84
|
| Rate for Payer: Health EOS Commercial |
$891.78
|
| Rate for Payer: HFN Commercial |
$921.84
|
| Rate for Payer: Multiplan Commercial |
$801.60
|
| Rate for Payer: NAPHCARE Commercial |
$601.20
|
| Rate for Payer: Preferred Network Access Commercial |
$921.84
|
| Rate for Payer: Quartz Beloit One Network |
$490.98
|
| Rate for Payer: Quartz Commercial |
$601.20
|
| Rate for Payer: WEA Trust Commercial |
$551.10
|
| Rate for Payer: WPS Commercial |
$742.18
|
|
|
Dressing - Trauma
|
Facility
IP
|
$3.00
|
|
| Hospital Charge Code |
3040322
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.80
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
Dressing - Trauma
|
Facility
OP
|
$3.00
|
|
| Hospital Charge Code |
3040322
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Aetna Managed Medicare |
$0.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.68
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1.80
|
| Rate for Payer: The Alliance Commercial |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
DRESSING UNNA BOOT DRSG.PK 650944
|
Facility
IP
|
$159.00
|
|
| Hospital Charge Code |
2963876
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$77.91 |
| Max. Negotiated Rate |
$146.28 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$95.40
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
DRESSING UNNA BOOT DRSG.PK 650944
|
Facility
OP
|
$159.00
|
|
| Hospital Charge Code |
2963876
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.52 |
| Max. Negotiated Rate |
$636.00 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Aetna Managed Medicare |
$44.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.25
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$103.35
|
| Rate for Payer: Quartz Medicare Advantage |
$95.40
|
| Rate for Payer: The Alliance Commercial |
$636.00
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
DRESSING V.A.C. GRANUFOAM MED 18 X 12.5 X 3.2CM M8275052/10 (CS INV)
|
Facility
OP
|
$1,006.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
3785555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
DRESSING V.A.C. GRANUFOAM MED 18 X 12.5 X 3.2CM M8275052/10 (CS INV)
|
Facility
IP
|
$1,006.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
3785555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
