|
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: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| 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: Aetna Gatekeeper/Not Gatekeeper |
$204.68
|
| 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
|
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
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| 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 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 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: Aetna Gatekeeper/Not Gatekeeper |
$73.10
|
| 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 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 |
$564.00 |
| 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: The Alliance Commercial |
$564.00
|
| 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: Aetna Gatekeeper/Not Gatekeeper |
$121.26
|
| 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
|
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 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: Aetna Gatekeeper/Not Gatekeeper |
$124.70
|
| 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 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: Aetna Gatekeeper/Not Gatekeeper |
$1,273.66
|
| 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 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 OPTIFOAM AG 3.5x10 MSC97310Z
|
Facility
|
OP
|
$514.00
|
|
| Hospital Charge Code |
4414147
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$143.92 |
| Max. Negotiated Rate |
$2,056.00 |
| Rate for Payer: Aetna Commercial |
$462.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.04
|
| Rate for Payer: Aetna Managed Medicare |
$143.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$334.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.42
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$472.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$287.63
|
| Rate for Payer: Health EOS Commercial |
$457.46
|
| Rate for Payer: HFN Commercial |
$472.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$385.50
|
| Rate for Payer: Multiplan Commercial |
$411.20
|
| Rate for Payer: NAPHCARE Commercial |
$308.40
|
| Rate for Payer: Preferred Network Access Commercial |
$472.88
|
| Rate for Payer: Quartz Beloit One Network |
$251.86
|
| Rate for Payer: Quartz Commercial |
$334.10
|
| Rate for Payer: Quartz Medicare Advantage |
$308.40
|
| Rate for Payer: The Alliance Commercial |
$2,056.00
|
| Rate for Payer: WEA Trust Commercial |
$282.70
|
| Rate for Payer: WPS Commercial |
$380.72
|
|
|
DRESSING OPTIFOAM AG 3.5x10 MSC97310Z
|
Facility
|
IP
|
$514.00
|
|
| Hospital Charge Code |
4414147
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.86 |
| Max. Negotiated Rate |
$472.88 |
| Rate for Payer: Aetna Commercial |
$462.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.42
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$472.88
|
| Rate for Payer: Health EOS Commercial |
$457.46
|
| Rate for Payer: HFN Commercial |
$472.88
|
| Rate for Payer: Multiplan Commercial |
$411.20
|
| Rate for Payer: NAPHCARE Commercial |
$308.40
|
| Rate for Payer: Preferred Network Access Commercial |
$472.88
|
| Rate for Payer: Quartz Beloit One Network |
$251.86
|
| Rate for Payer: Quartz Commercial |
$308.40
|
| Rate for Payer: WEA Trust Commercial |
$282.70
|
| Rate for Payer: WPS Commercial |
$380.72
|
|
|
DRESSING OPTIFOAM AG 3.5 x14 MSC97314Z
|
Facility
|
OP
|
$600.00
|
|
| Hospital Charge Code |
4414148
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$168.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$540.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.00
|
| Rate for Payer: Aetna Managed Medicare |
$168.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$390.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$300.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$288.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$552.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$335.76
|
| Rate for Payer: Health EOS Commercial |
$534.00
|
| Rate for Payer: HFN Commercial |
$552.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$450.00
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
| Rate for Payer: NAPHCARE Commercial |
$360.00
|
| Rate for Payer: Preferred Network Access Commercial |
$552.00
|
| Rate for Payer: Quartz Beloit One Network |
$294.00
|
| Rate for Payer: Quartz Commercial |
$390.00
|
| Rate for Payer: Quartz Medicare Advantage |
$360.00
|
| Rate for Payer: The Alliance Commercial |
$2,400.00
|
| Rate for Payer: WEA Trust Commercial |
$330.00
|
| Rate for Payer: WPS Commercial |
$444.42
|
|
|
DRESSING OPTIFOAM AG 3.5 x14 MSC97314Z
|
Facility
|
IP
|
$600.00
|
|
| Hospital Charge Code |
4414148
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$294.00 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$540.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$552.00
|
| Rate for Payer: Health EOS Commercial |
$534.00
|
| Rate for Payer: HFN Commercial |
$552.00
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
| Rate for Payer: NAPHCARE Commercial |
$360.00
|
| Rate for Payer: Preferred Network Access Commercial |
$552.00
|
| Rate for Payer: Quartz Beloit One Network |
$294.00
|
| Rate for Payer: Quartz Commercial |
$360.00
|
| Rate for Payer: WEA Trust Commercial |
$330.00
|
| Rate for Payer: WPS Commercial |
$444.42
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| 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
|
OP
|
$174.00
|
|
|
Service Code
|
HCPCS A6213
|
| Hospital Charge Code |
3937340
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.72 |
| Max. Negotiated Rate |
$696.00 |
| 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: The Alliance Commercial |
$696.00
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| 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 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: Aetna Gatekeeper/Not Gatekeeper |
$3,214.68
|
| 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 |
$14,952.00 |
| 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: The Alliance Commercial |
$14,952.00
|
| 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
|
|
