|
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 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: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| 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 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: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$861.72
|
| 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 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/5 #M6275053-5
|
Facility
|
OP
|
$1,566.00
|
|
| Hospital Charge Code |
2974088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$438.48 |
| Max. Negotiated Rate |
$6,264.00 |
| Rate for Payer: Aetna Commercial |
$1,409.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,346.76
|
| Rate for Payer: Aetna Managed Medicare |
$438.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,017.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$783.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$751.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$829.98
|
| Rate for Payer: Cash Price |
$469.80
|
| Rate for Payer: Cigna Commercial |
$1,440.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$876.33
|
| Rate for Payer: Health EOS Commercial |
$1,393.74
|
| Rate for Payer: HFN Commercial |
$1,440.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,174.50
|
| Rate for Payer: Multiplan Commercial |
$1,252.80
|
| Rate for Payer: NAPHCARE Commercial |
$939.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,440.72
|
| Rate for Payer: Quartz Beloit One Network |
$767.34
|
| Rate for Payer: Quartz Commercial |
$1,017.90
|
| Rate for Payer: Quartz Medicare Advantage |
$939.60
|
| Rate for Payer: The Alliance Commercial |
$6,264.00
|
| Rate for Payer: WEA Trust Commercial |
$861.30
|
| Rate for Payer: WPS Commercial |
$1,159.94
|
|
|
DRESSING TRAC LRG CRTN/5 #M6275053-5
|
Facility
|
IP
|
$1,566.00
|
|
| Hospital Charge Code |
2974088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$767.34 |
| Max. Negotiated Rate |
$1,440.72 |
| Rate for Payer: Aetna Commercial |
$1,409.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,346.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$829.98
|
| Rate for Payer: Cash Price |
$469.80
|
| Rate for Payer: Cigna Commercial |
$1,440.72
|
| Rate for Payer: Health EOS Commercial |
$1,393.74
|
| Rate for Payer: HFN Commercial |
$1,440.72
|
| Rate for Payer: Multiplan Commercial |
$1,252.80
|
| Rate for Payer: NAPHCARE Commercial |
$939.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,440.72
|
| Rate for Payer: Quartz Beloit One Network |
$767.34
|
| Rate for Payer: Quartz Commercial |
$939.60
|
| Rate for Payer: WEA Trust Commercial |
$861.30
|
| Rate for Payer: WPS Commercial |
$1,159.94
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| 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: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| 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
|
|
|
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 |
$4,024.00 |
| 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: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
DRESSING V.A.C. VERAFLO CLEANSE CHOICE MEDIUM ULTVCC05MD
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
5583409
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$882.00 |
| Max. Negotiated Rate |
$1,656.00 |
| Rate for Payer: Aetna Commercial |
$1,620.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,548.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.00
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cigna Commercial |
$1,656.00
|
| Rate for Payer: Health EOS Commercial |
$1,602.00
|
| Rate for Payer: HFN Commercial |
$1,656.00
|
| Rate for Payer: Multiplan Commercial |
$1,440.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,080.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,656.00
|
| Rate for Payer: Quartz Beloit One Network |
$882.00
|
| Rate for Payer: Quartz Commercial |
$1,080.00
|
| Rate for Payer: WEA Trust Commercial |
$990.00
|
| Rate for Payer: WPS Commercial |
$1,333.26
|
|
|
DRESSING V.A.C. VERAFLO CLEANSE CHOICE MEDIUM ULTVCC05MD
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
5583409
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$7,200.00 |
| Rate for Payer: Aetna Commercial |
$1,620.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,548.00
|
| Rate for Payer: Aetna Managed Medicare |
$504.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,170.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$900.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$864.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.00
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cigna Commercial |
$1,656.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,007.28
|
| Rate for Payer: Health EOS Commercial |
$1,602.00
|
| Rate for Payer: HFN Commercial |
$1,656.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,350.00
|
| Rate for Payer: Multiplan Commercial |
$1,440.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,080.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,656.00
|
| Rate for Payer: Quartz Beloit One Network |
$882.00
|
| Rate for Payer: Quartz Commercial |
$1,170.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,080.00
|
| Rate for Payer: The Alliance Commercial |
$7,200.00
|
| Rate for Payer: WEA Trust Commercial |
$990.00
|
| Rate for Payer: WPS Commercial |
$1,333.26
|
|
|
DRESSING V.A.C. WHITEFOAM SMALL 10 X 7.5 X 1CM M6275033/10
|
Facility
|
OP
|
$272.00
|
|
| Hospital Charge Code |
2974084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.16 |
| Max. Negotiated Rate |
$1,088.00 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Aetna Managed Medicare |
$76.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$136.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.21
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.00
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$176.80
|
| Rate for Payer: Quartz Medicare Advantage |
$163.20
|
| Rate for Payer: The Alliance Commercial |
$1,088.00
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
DRESSING V.A.C. WHITEFOAM SMALL 10 X 7.5 X 1CM M6275033/10
|
Facility
|
IP
|
$272.00
|
|
| Hospital Charge Code |
2974084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.28 |
| Max. Negotiated Rate |
$250.24 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$163.20
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Dressing Vaseline
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
3040320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Aetna Managed Medicare |
$0.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.56
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.65
|
| Rate for Payer: Quartz Medicare Advantage |
$0.60
|
| Rate for Payer: The Alliance Commercial |
$4.00
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
Dressing Vaseline
|
Facility
|
IP
|
$1.00
|
|
| Hospital Charge Code |
3040320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.60
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
DRESSING VASELINE GAUZE 1X8 8884417601
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
2963746
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$18.40 |
| Rate for Payer: Aetna Commercial |
$18.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.60
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$18.40
|
| Rate for Payer: Health EOS Commercial |
$17.80
|
| Rate for Payer: HFN Commercial |
$18.40
|
| Rate for Payer: Multiplan Commercial |
$16.00
|
| Rate for Payer: NAPHCARE Commercial |
$12.00
|
| Rate for Payer: Preferred Network Access Commercial |
$18.40
|
| Rate for Payer: Quartz Beloit One Network |
$9.80
|
| Rate for Payer: Quartz Commercial |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$11.00
|
| Rate for Payer: WPS Commercial |
$14.81
|
|
|
DRESSING VASELINE GAUZE 1X8 8884417601
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
2963746
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Aetna Commercial |
$18.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.20
|
| Rate for Payer: Aetna Managed Medicare |
$5.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.60
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$18.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.19
|
| Rate for Payer: Health EOS Commercial |
$17.80
|
| Rate for Payer: HFN Commercial |
$18.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.00
|
| Rate for Payer: Multiplan Commercial |
$16.00
|
| Rate for Payer: NAPHCARE Commercial |
$12.00
|
| Rate for Payer: Preferred Network Access Commercial |
$18.40
|
| Rate for Payer: Quartz Beloit One Network |
$9.80
|
| Rate for Payer: Quartz Commercial |
$13.00
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$80.00
|
| Rate for Payer: WEA Trust Commercial |
$11.00
|
| Rate for Payer: WPS Commercial |
$14.81
|
|
|
DRESSING VASELINE GAUZE 3X9
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS A6223
|
| Hospital Charge Code |
2963775
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.55
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.60
|
| Rate for Payer: The Alliance Commercial |
$104.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
DRESSING VASELINE GAUZE 3X9
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS A6223
|
| Hospital Charge Code |
2963775
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
DRESSING XEROFORM 1 X 8 IN OCCLUSICE GAUZE STRIP 8884433301
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
HCPCS A6222
|
| Hospital Charge Code |
2963792
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Aetna Managed Medicare |
$7.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.11
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.25
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$17.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.20
|
| Rate for Payer: The Alliance Commercial |
$108.00
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
