|
DRESSING OPTIFOAM AG 3.5 x14 MSC97314Z
|
Facility
|
IP
|
$600.00
|
|
| Hospital Charge Code |
4414148
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$305.76 |
| Max. Negotiated Rate |
$574.08 |
| Rate for Payer: Aetna Commercial |
$561.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$536.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$330.72
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$574.08
|
| Rate for Payer: Health EOS Commercial |
$555.36
|
| Rate for Payer: HFN Commercial |
$574.08
|
| Rate for Payer: Multiplan Commercial |
$499.20
|
| Rate for Payer: Preferred Network Access Commercial |
$574.08
|
| Rate for Payer: Quartz Beloit One Network |
$305.76
|
| Rate for Payer: Quartz Commercial |
$374.40
|
| Rate for Payer: WEA Trust Commercial |
$343.20
|
| Rate for Payer: WPS Commercial |
$462.18
|
|
|
DRESSING OPTIFOAM AG 3.5X6 MSC9736Z
|
Facility
|
IP
|
$495.00
|
|
| Hospital Charge Code |
4414146
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$252.25 |
| Max. Negotiated Rate |
$473.62 |
| Rate for Payer: Aetna Commercial |
$463.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.84
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$473.62
|
| Rate for Payer: Health EOS Commercial |
$458.17
|
| Rate for Payer: HFN Commercial |
$473.62
|
| Rate for Payer: Multiplan Commercial |
$411.84
|
| Rate for Payer: Preferred Network Access Commercial |
$473.62
|
| Rate for Payer: Quartz Beloit One Network |
$252.25
|
| Rate for Payer: Quartz Commercial |
$308.88
|
| Rate for Payer: WEA Trust Commercial |
$283.14
|
| Rate for Payer: WPS Commercial |
$381.30
|
|
|
DRESSING OPTIFOAM AG 3.5X6 MSC9736Z
|
Facility
|
OP
|
$495.00
|
|
| Hospital Charge Code |
4414146
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$144.14 |
| Max. Negotiated Rate |
$473.62 |
| Rate for Payer: Aetna Commercial |
$463.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.73
|
| Rate for Payer: Aetna Managed Medicare |
$144.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$334.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.84
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$473.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.09
|
| Rate for Payer: Health EOS Commercial |
$458.17
|
| Rate for Payer: HFN Commercial |
$473.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.10
|
| Rate for Payer: Multiplan Commercial |
$411.84
|
| Rate for Payer: NAPHCARE Commercial |
$308.88
|
| Rate for Payer: Preferred Network Access Commercial |
$473.62
|
| Rate for Payer: Quartz Beloit One Network |
$252.25
|
| Rate for Payer: Quartz Commercial |
$334.62
|
| Rate for Payer: Quartz Medicare Advantage |
$308.88
|
| Rate for Payer: The Alliance Commercial |
$257.40
|
| Rate for Payer: WEA Trust Commercial |
$283.14
|
| Rate for Payer: WPS Commercial |
$381.30
|
|
|
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 |
$88.67 |
| Max. Negotiated Rate |
$166.48 |
| Rate for Payer: Aetna Commercial |
$162.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$155.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.91
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$166.48
|
| Rate for Payer: Health EOS Commercial |
$161.05
|
| Rate for Payer: HFN Commercial |
$166.48
|
| Rate for Payer: Multiplan Commercial |
$144.77
|
| Rate for Payer: Preferred Network Access Commercial |
$166.48
|
| Rate for Payer: Quartz Beloit One Network |
$88.67
|
| Rate for Payer: Quartz Commercial |
$108.58
|
| Rate for Payer: WEA Trust Commercial |
$99.53
|
| Rate for Payer: WPS Commercial |
$134.03
|
|
|
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 |
$50.67 |
| Max. Negotiated Rate |
$166.48 |
| Rate for Payer: Aetna Commercial |
$162.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$155.63
|
| Rate for Payer: Aetna Managed Medicare |
$50.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$117.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$90.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$86.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.91
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$166.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.27
|
| Rate for Payer: Health EOS Commercial |
$161.05
|
| Rate for Payer: HFN Commercial |
$166.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.72
|
| Rate for Payer: Multiplan Commercial |
$144.77
|
| Rate for Payer: NAPHCARE Commercial |
$108.58
|
| Rate for Payer: Preferred Network Access Commercial |
$166.48
|
| Rate for Payer: Quartz Beloit One Network |
$88.67
|
| Rate for Payer: Quartz Commercial |
$117.62
|
| Rate for Payer: Quartz Medicare Advantage |
$108.58
|
| Rate for Payer: The Alliance Commercial |
$90.48
|
| Rate for Payer: WEA Trust Commercial |
$99.53
|
| Rate for Payer: WPS Commercial |
$134.03
|
|
|
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 |
$132.79 |
| Max. Negotiated Rate |
$3,576.52 |
| Rate for Payer: Aetna Commercial |
$3,498.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,343.27
|
| Rate for Payer: Aetna Managed Medicare |
$1,088.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,526.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,943.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,866.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,060.39
|
| Rate for Payer: Cash Price |
$1,121.40
|
| Rate for Payer: Cash Price |
$1,121.40
|
| Rate for Payer: Cigna Commercial |
$3,576.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,175.52
|
| Rate for Payer: Health EOS Commercial |
$3,459.89
|
| Rate for Payer: HFN Commercial |
$3,576.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,915.64
|
| Rate for Payer: Multiplan Commercial |
$3,110.02
|
| Rate for Payer: NAPHCARE Commercial |
$2,332.51
|
| Rate for Payer: Preferred Network Access Commercial |
$3,576.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,904.88
|
| Rate for Payer: Quartz Commercial |
$2,526.89
|
| Rate for Payer: Quartz Medicare Advantage |
$2,332.51
|
| Rate for Payer: The Alliance Commercial |
$132.79
|
| Rate for Payer: WEA Trust Commercial |
$2,138.14
|
| Rate for Payer: WPS Commercial |
$2,879.38
|
|
|
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 |
$1,904.88 |
| Max. Negotiated Rate |
$3,576.52 |
| Rate for Payer: Aetna Commercial |
$3,498.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,343.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,060.39
|
| Rate for Payer: Cash Price |
$1,121.40
|
| Rate for Payer: Cigna Commercial |
$3,576.52
|
| Rate for Payer: Health EOS Commercial |
$3,459.89
|
| Rate for Payer: HFN Commercial |
$3,576.52
|
| Rate for Payer: Multiplan Commercial |
$3,110.02
|
| Rate for Payer: Preferred Network Access Commercial |
$3,576.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,904.88
|
| Rate for Payer: Quartz Commercial |
$2,332.51
|
| Rate for Payer: WEA Trust Commercial |
$2,138.14
|
| Rate for Payer: WPS Commercial |
$2,879.38
|
|
|
DRESSING PROWICK PACK
|
Facility
|
OP
|
$4,882.00
|
|
| Hospital Charge Code |
2964678
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,421.64 |
| Max. Negotiated Rate |
$4,671.10 |
| Rate for Payer: Aetna Commercial |
$4,569.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,366.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,421.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,300.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,538.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,437.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,690.96
|
| Rate for Payer: Cash Price |
$1,464.60
|
| Rate for Payer: Cigna Commercial |
$4,671.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,841.32
|
| Rate for Payer: Health EOS Commercial |
$4,518.78
|
| Rate for Payer: HFN Commercial |
$4,671.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,807.96
|
| Rate for Payer: Multiplan Commercial |
$4,061.82
|
| Rate for Payer: NAPHCARE Commercial |
$3,046.37
|
| Rate for Payer: Preferred Network Access Commercial |
$4,671.10
|
| Rate for Payer: Quartz Beloit One Network |
$2,487.87
|
| Rate for Payer: Quartz Commercial |
$3,300.23
|
| Rate for Payer: Quartz Medicare Advantage |
$3,046.37
|
| Rate for Payer: The Alliance Commercial |
$2,538.64
|
| Rate for Payer: WEA Trust Commercial |
$2,792.50
|
| Rate for Payer: WPS Commercial |
$3,760.60
|
|
|
DRESSING PROWICK PACK
|
Facility
|
IP
|
$4,882.00
|
|
| Hospital Charge Code |
2964678
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,487.87 |
| Max. Negotiated Rate |
$4,671.10 |
| Rate for Payer: Aetna Commercial |
$4,569.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,366.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,690.96
|
| Rate for Payer: Cash Price |
$1,464.60
|
| Rate for Payer: Cigna Commercial |
$4,671.10
|
| Rate for Payer: Health EOS Commercial |
$4,518.78
|
| Rate for Payer: HFN Commercial |
$4,671.10
|
| Rate for Payer: Multiplan Commercial |
$4,061.82
|
| Rate for Payer: Preferred Network Access Commercial |
$4,671.10
|
| Rate for Payer: Quartz Beloit One Network |
$2,487.87
|
| Rate for Payer: Quartz Commercial |
$3,046.37
|
| Rate for Payer: WEA Trust Commercial |
$2,792.50
|
| Rate for Payer: WPS Commercial |
$3,760.60
|
|
|
DRESSING SENSATRAC MED M8275052/5.S
|
Facility
|
OP
|
$952.00
|
|
| Hospital Charge Code |
4858667
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.22 |
| Max. Negotiated Rate |
$910.87 |
| Rate for Payer: Aetna Commercial |
$891.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$851.47
|
| Rate for Payer: Aetna Managed Medicare |
$277.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$643.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$495.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$475.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$524.74
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$910.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$554.06
|
| Rate for Payer: Health EOS Commercial |
$881.17
|
| Rate for Payer: HFN Commercial |
$910.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$742.56
|
| Rate for Payer: Multiplan Commercial |
$792.06
|
| Rate for Payer: NAPHCARE Commercial |
$594.05
|
| Rate for Payer: Preferred Network Access Commercial |
$910.87
|
| Rate for Payer: Quartz Beloit One Network |
$485.14
|
| Rate for Payer: Quartz Commercial |
$643.55
|
| Rate for Payer: Quartz Medicare Advantage |
$594.05
|
| Rate for Payer: The Alliance Commercial |
$495.04
|
| Rate for Payer: WEA Trust Commercial |
$544.54
|
| Rate for Payer: WPS Commercial |
$733.33
|
|
|
DRESSING SENSATRAC MED M8275052/5.S
|
Facility
|
IP
|
$952.00
|
|
| Hospital Charge Code |
4858667
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$485.14 |
| Max. Negotiated Rate |
$910.87 |
| Rate for Payer: Aetna Commercial |
$891.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$851.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$524.74
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$910.87
|
| Rate for Payer: Health EOS Commercial |
$881.17
|
| Rate for Payer: HFN Commercial |
$910.87
|
| Rate for Payer: Multiplan Commercial |
$792.06
|
| Rate for Payer: Preferred Network Access Commercial |
$910.87
|
| Rate for Payer: Quartz Beloit One Network |
$485.14
|
| Rate for Payer: Quartz Commercial |
$594.05
|
| Rate for Payer: WEA Trust Commercial |
$544.54
|
| Rate for Payer: WPS Commercial |
$733.33
|
|
|
DRESSING SINU-FOAM STAMMBERGER RR650
|
Facility
|
IP
|
$1,273.00
|
|
| Hospital Charge Code |
3439508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$648.72 |
| Max. Negotiated Rate |
$1,218.01 |
| Rate for Payer: Aetna Commercial |
$1,191.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,138.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$701.68
|
| Rate for Payer: Cash Price |
$381.90
|
| Rate for Payer: Cigna Commercial |
$1,218.01
|
| Rate for Payer: Health EOS Commercial |
$1,178.29
|
| Rate for Payer: HFN Commercial |
$1,218.01
|
| Rate for Payer: Multiplan Commercial |
$1,059.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.01
|
| Rate for Payer: Quartz Beloit One Network |
$648.72
|
| Rate for Payer: Quartz Commercial |
$794.35
|
| Rate for Payer: WEA Trust Commercial |
$728.16
|
| Rate for Payer: WPS Commercial |
$980.59
|
|
|
DRESSING SINU-FOAM STAMMBERGER RR650
|
Facility
|
OP
|
$1,273.00
|
|
| Hospital Charge Code |
3439508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$370.70 |
| Max. Negotiated Rate |
$1,218.01 |
| Rate for Payer: Aetna Commercial |
$1,191.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,138.57
|
| Rate for Payer: Aetna Managed Medicare |
$370.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$860.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$661.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$635.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$701.68
|
| Rate for Payer: Cash Price |
$381.90
|
| Rate for Payer: Cigna Commercial |
$1,218.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$740.89
|
| Rate for Payer: Health EOS Commercial |
$1,178.29
|
| Rate for Payer: HFN Commercial |
$1,218.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$992.94
|
| Rate for Payer: Multiplan Commercial |
$1,059.14
|
| Rate for Payer: NAPHCARE Commercial |
$794.35
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.01
|
| Rate for Payer: Quartz Beloit One Network |
$648.72
|
| Rate for Payer: Quartz Commercial |
$860.55
|
| Rate for Payer: Quartz Medicare Advantage |
$794.35
|
| Rate for Payer: The Alliance Commercial |
$661.96
|
| Rate for Payer: WEA Trust Commercial |
$728.16
|
| Rate for Payer: WPS Commercial |
$980.59
|
|
|
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 |
$132.79 |
| Max. Negotiated Rate |
$996.99 |
| Rate for Payer: Aetna Commercial |
$975.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$931.96
|
| Rate for Payer: Aetna Managed Medicare |
$303.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$541.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.35
|
| Rate for Payer: Cash Price |
$312.60
|
| Rate for Payer: Cash Price |
$312.60
|
| Rate for Payer: Cigna Commercial |
$996.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.44
|
| Rate for Payer: Health EOS Commercial |
$964.48
|
| Rate for Payer: HFN Commercial |
$996.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$812.76
|
| Rate for Payer: Multiplan Commercial |
$866.94
|
| Rate for Payer: NAPHCARE Commercial |
$650.21
|
| Rate for Payer: Preferred Network Access Commercial |
$996.99
|
| Rate for Payer: Quartz Beloit One Network |
$531.00
|
| Rate for Payer: Quartz Commercial |
$704.39
|
| Rate for Payer: Quartz Medicare Advantage |
$650.21
|
| Rate for Payer: The Alliance Commercial |
$132.79
|
| Rate for Payer: WEA Trust Commercial |
$596.02
|
| Rate for Payer: WPS Commercial |
$802.65
|
|
|
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 |
$531.00 |
| Max. Negotiated Rate |
$996.99 |
| Rate for Payer: Aetna Commercial |
$975.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$931.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.35
|
| Rate for Payer: Cash Price |
$312.60
|
| Rate for Payer: Cigna Commercial |
$996.99
|
| Rate for Payer: Health EOS Commercial |
$964.48
|
| Rate for Payer: HFN Commercial |
$996.99
|
| Rate for Payer: Multiplan Commercial |
$866.94
|
| Rate for Payer: Preferred Network Access Commercial |
$996.99
|
| Rate for Payer: Quartz Beloit One Network |
$531.00
|
| Rate for Payer: Quartz Commercial |
$650.21
|
| Rate for Payer: WEA Trust Commercial |
$596.02
|
| Rate for Payer: WPS Commercial |
$802.65
|
|
|
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 |
$779.18 |
| Max. Negotiated Rate |
$1,462.95 |
| Rate for Payer: Aetna Commercial |
$1,431.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,367.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$842.78
|
| Rate for Payer: Cash Price |
$458.70
|
| Rate for Payer: Cigna Commercial |
$1,462.95
|
| Rate for Payer: Health EOS Commercial |
$1,415.24
|
| Rate for Payer: HFN Commercial |
$1,462.95
|
| Rate for Payer: Multiplan Commercial |
$1,272.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,462.95
|
| Rate for Payer: Quartz Beloit One Network |
$779.18
|
| Rate for Payer: Quartz Commercial |
$954.10
|
| Rate for Payer: WEA Trust Commercial |
$874.59
|
| Rate for Payer: WPS Commercial |
$1,177.79
|
|
|
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 |
$132.79 |
| Max. Negotiated Rate |
$1,462.95 |
| Rate for Payer: Aetna Commercial |
$1,431.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,367.54
|
| Rate for Payer: Aetna Managed Medicare |
$445.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,033.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$795.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$763.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$842.78
|
| Rate for Payer: Cash Price |
$458.70
|
| Rate for Payer: Cash Price |
$458.70
|
| Rate for Payer: Cigna Commercial |
$1,462.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$889.88
|
| Rate for Payer: Health EOS Commercial |
$1,415.24
|
| Rate for Payer: HFN Commercial |
$1,462.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,192.62
|
| Rate for Payer: Multiplan Commercial |
$1,272.13
|
| Rate for Payer: NAPHCARE Commercial |
$954.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,462.95
|
| Rate for Payer: Quartz Beloit One Network |
$779.18
|
| Rate for Payer: Quartz Commercial |
$1,033.60
|
| Rate for Payer: Quartz Medicare Advantage |
$954.10
|
| Rate for Payer: The Alliance Commercial |
$132.79
|
| Rate for Payer: WEA Trust Commercial |
$874.59
|
| Rate for Payer: WPS Commercial |
$1,177.79
|
|
|
DRESSING TAPE RETENTION MSC4004
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS A4452
|
| Hospital Charge Code |
3895342
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.52 |
| Max. Negotiated Rate |
$139.69 |
| Rate for Payer: Aetna Commercial |
$136.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.58
|
| Rate for Payer: Aetna Managed Medicare |
$42.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.48
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$139.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.97
|
| Rate for Payer: Health EOS Commercial |
$135.14
|
| Rate for Payer: HFN Commercial |
$139.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.88
|
| Rate for Payer: Multiplan Commercial |
$121.47
|
| Rate for Payer: NAPHCARE Commercial |
$91.10
|
| Rate for Payer: Preferred Network Access Commercial |
$139.69
|
| Rate for Payer: Quartz Beloit One Network |
$74.40
|
| Rate for Payer: Quartz Commercial |
$98.70
|
| Rate for Payer: Quartz Medicare Advantage |
$91.10
|
| Rate for Payer: The Alliance Commercial |
$75.92
|
| Rate for Payer: WEA Trust Commercial |
$83.51
|
| Rate for Payer: WPS Commercial |
$112.46
|
|
|
DRESSING TAPE RETENTION MSC4004
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS A4452
|
| Hospital Charge Code |
3895342
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$74.40 |
| Max. Negotiated Rate |
$139.69 |
| Rate for Payer: Aetna Commercial |
$136.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.48
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$139.69
|
| Rate for Payer: Health EOS Commercial |
$135.14
|
| Rate for Payer: HFN Commercial |
$139.69
|
| Rate for Payer: Multiplan Commercial |
$121.47
|
| Rate for Payer: Preferred Network Access Commercial |
$139.69
|
| Rate for Payer: Quartz Beloit One Network |
$74.40
|
| Rate for Payer: Quartz Commercial |
$91.10
|
| Rate for Payer: WEA Trust Commercial |
$83.51
|
| Rate for Payer: WPS Commercial |
$112.46
|
|
|
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 |
$2.62 |
| Max. Negotiated Rate |
$25.54 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Aetna Managed Medicare |
$2.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.24
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.02
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: NAPHCARE Commercial |
$5.62
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$6.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5.62
|
| Rate for Payer: The Alliance Commercial |
$25.54
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$6.93
|
|
|
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 |
$4.59 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$5.62
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$6.93
|
|
|
DRESSING TEGADERM 3.5 X 4.5 IV
|
Facility
|
OP
|
$53.00
|
|
| Hospital Charge Code |
2974638
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.43 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Aetna Managed Medicare |
$15.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.85
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.34
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: NAPHCARE Commercial |
$33.07
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$35.83
|
| Rate for Payer: Quartz Medicare Advantage |
$33.07
|
| Rate for Payer: The Alliance Commercial |
$27.56
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$40.83
|
|
|
DRESSING TEGADERM 3.5 X 4.5 IV
|
Facility
|
IP
|
$53.00
|
|
| Hospital Charge Code |
2974638
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.01 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$33.07
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$40.83
|
|
|
DRESSING TEGADERM 4X4 3/4 1626W
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2962794
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$27.46
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
DRESSING TEGADERM 4X4 3/4 1626W
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2962794
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.81 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Aetna Managed Medicare |
$12.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.61
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.32
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: NAPHCARE Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$29.74
|
| Rate for Payer: Quartz Medicare Advantage |
$27.46
|
| Rate for Payer: The Alliance Commercial |
$22.88
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
