|
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 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: Aetna Gatekeeper/Not Gatekeeper |
$818.72
|
| 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 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 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: Aetna Gatekeeper/Not Gatekeeper |
$1,094.78
|
| 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
|
OP
|
$1,042.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
4519918
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$291.76 |
| Max. Negotiated Rate |
$4,168.00 |
| 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: The Alliance Commercial |
$4,168.00
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$896.12
|
| 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 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 |
$6,116.00 |
| 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: The Alliance Commercial |
$6,116.00
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$1,314.94
|
| 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
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| 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 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 |
$584.00 |
| 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: The Alliance Commercial |
$584.00
|
| 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 |
$36.00 |
| 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: The Alliance Commercial |
$36.00
|
| 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: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| 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
|
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 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: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| 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 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: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$82.56
|
| 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 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 |
$384.00 |
| 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: The Alliance Commercial |
$384.00
|
| Rate for Payer: WEA Trust Commercial |
$52.80
|
| Rate for Payer: WPS Commercial |
$71.11
|
|
|
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 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: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| 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 CHG IV 3.5 IN X 4.5 IN (8.5CM X 11.5CM) 1657
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
HCPCS A6257
|
| Hospital Charge Code |
4858934
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.28 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$42.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.50
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.25
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$98.15
|
| Rate for Payer: Quartz Medicare Advantage |
$90.60
|
| Rate for Payer: The Alliance Commercial |
$604.00
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
DRESSING TEGADERM CHG IV 3.5 IN X 4.5 IN (8.5CM X 11.5CM) 1657
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
HCPCS A6257
|
| Hospital Charge Code |
4858934
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$138.92 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$90.60
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| 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 |
$116.00 |
| 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: The Alliance Commercial |
$116.00
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
