|
DRESSING ABD PAD 9194A
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
HCPCS A6253
|
| Hospital Charge Code |
2974609
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
DRESSING ABD PAD 9194A
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
HCPCS A6253
|
| Hospital Charge Code |
2974609
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$37.56 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Aetna Managed Medicare |
$2.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.82
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.80
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: NAPHCARE Commercial |
$6.24
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.76
|
| Rate for Payer: Quartz Medicare Advantage |
$6.24
|
| Rate for Payer: The Alliance Commercial |
$37.56
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
DRESSING AMD 3X8 TELFA 7663"
|
Facility
|
OP
|
$62.00
|
|
| Hospital Charge Code |
2963151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$59.32 |
| Rate for Payer: Aetna Commercial |
$58.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.45
|
| Rate for Payer: Aetna Managed Medicare |
$18.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.17
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$59.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.08
|
| Rate for Payer: Health EOS Commercial |
$57.39
|
| Rate for Payer: HFN Commercial |
$59.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.36
|
| Rate for Payer: Multiplan Commercial |
$51.58
|
| Rate for Payer: NAPHCARE Commercial |
$38.69
|
| Rate for Payer: Preferred Network Access Commercial |
$59.32
|
| Rate for Payer: Quartz Beloit One Network |
$31.60
|
| Rate for Payer: Quartz Commercial |
$41.91
|
| Rate for Payer: Quartz Medicare Advantage |
$38.69
|
| Rate for Payer: The Alliance Commercial |
$32.24
|
| Rate for Payer: WEA Trust Commercial |
$35.46
|
| Rate for Payer: WPS Commercial |
$47.76
|
|
|
DRESSING AMD 3X8 TELFA 7663"
|
Facility
|
IP
|
$62.00
|
|
| Hospital Charge Code |
2963151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.60 |
| Max. Negotiated Rate |
$59.32 |
| Rate for Payer: Aetna Commercial |
$58.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.17
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$59.32
|
| Rate for Payer: Health EOS Commercial |
$57.39
|
| Rate for Payer: HFN Commercial |
$59.32
|
| Rate for Payer: Multiplan Commercial |
$51.58
|
| Rate for Payer: Preferred Network Access Commercial |
$59.32
|
| Rate for Payer: Quartz Beloit One Network |
$31.60
|
| Rate for Payer: Quartz Commercial |
$38.69
|
| Rate for Payer: WEA Trust Commercial |
$35.46
|
| Rate for Payer: WPS Commercial |
$47.76
|
|
|
DRESSING AQUACEL AG 2X45CM 422300
|
Facility
|
OP
|
$331.00
|
|
| Hospital Charge Code |
2963483
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$96.39 |
| Max. Negotiated Rate |
$316.70 |
| Rate for Payer: Aetna Commercial |
$309.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.05
|
| Rate for Payer: Aetna Managed Medicare |
$96.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$223.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$172.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$165.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.45
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$316.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.64
|
| Rate for Payer: Health EOS Commercial |
$306.37
|
| Rate for Payer: HFN Commercial |
$316.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$258.18
|
| Rate for Payer: Multiplan Commercial |
$275.39
|
| Rate for Payer: NAPHCARE Commercial |
$206.54
|
| Rate for Payer: Preferred Network Access Commercial |
$316.70
|
| Rate for Payer: Quartz Beloit One Network |
$168.68
|
| Rate for Payer: Quartz Commercial |
$223.76
|
| Rate for Payer: Quartz Medicare Advantage |
$206.54
|
| Rate for Payer: The Alliance Commercial |
$172.12
|
| Rate for Payer: WEA Trust Commercial |
$189.33
|
| Rate for Payer: WPS Commercial |
$254.97
|
|
|
DRESSING AQUACEL AG 2X45CM 422300
|
Facility
|
IP
|
$331.00
|
|
| Hospital Charge Code |
2963483
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$168.68 |
| Max. Negotiated Rate |
$316.70 |
| Rate for Payer: Aetna Commercial |
$309.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.45
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$316.70
|
| Rate for Payer: Health EOS Commercial |
$306.37
|
| Rate for Payer: HFN Commercial |
$316.70
|
| Rate for Payer: Multiplan Commercial |
$275.39
|
| Rate for Payer: Preferred Network Access Commercial |
$316.70
|
| Rate for Payer: Quartz Beloit One Network |
$168.68
|
| Rate for Payer: Quartz Commercial |
$206.54
|
| Rate for Payer: WEA Trust Commercial |
$189.33
|
| Rate for Payer: WPS Commercial |
$254.97
|
|
|
DRESSING AQUACEL AG ADVANTAGE 4X5 422299
|
Facility
|
OP
|
$188.00
|
|
| Hospital Charge Code |
5456957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.75 |
| Max. Negotiated Rate |
$179.88 |
| Rate for Payer: Aetna Commercial |
$175.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.15
|
| Rate for Payer: Aetna Managed Medicare |
$54.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$127.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.63
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$179.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.42
|
| Rate for Payer: Health EOS Commercial |
$174.01
|
| Rate for Payer: HFN Commercial |
$179.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$146.64
|
| Rate for Payer: Multiplan Commercial |
$156.42
|
| Rate for Payer: NAPHCARE Commercial |
$117.31
|
| Rate for Payer: Preferred Network Access Commercial |
$179.88
|
| Rate for Payer: Quartz Beloit One Network |
$95.80
|
| Rate for Payer: Quartz Commercial |
$127.09
|
| Rate for Payer: Quartz Medicare Advantage |
$117.31
|
| Rate for Payer: The Alliance Commercial |
$97.76
|
| Rate for Payer: WEA Trust Commercial |
$107.54
|
| Rate for Payer: WPS Commercial |
$144.82
|
|
|
DRESSING AQUACEL AG ADVANTAGE 4X5 422299
|
Facility
|
IP
|
$188.00
|
|
| Hospital Charge Code |
5456957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$95.80 |
| Max. Negotiated Rate |
$179.88 |
| Rate for Payer: Aetna Commercial |
$175.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.63
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$179.88
|
| Rate for Payer: Health EOS Commercial |
$174.01
|
| Rate for Payer: HFN Commercial |
$179.88
|
| Rate for Payer: Multiplan Commercial |
$156.42
|
| Rate for Payer: Preferred Network Access Commercial |
$179.88
|
| Rate for Payer: Quartz Beloit One Network |
$95.80
|
| Rate for Payer: Quartz Commercial |
$117.31
|
| Rate for Payer: WEA Trust Commercial |
$107.54
|
| Rate for Payer: WPS Commercial |
$144.82
|
|
|
DRESSING AQUACEL FOAM 4X4 ADHESIVE 420680
|
Facility
|
OP
|
$101.00
|
|
| Hospital Charge Code |
2963583
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.41 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Aetna Managed Medicare |
$29.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.78
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.78
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: NAPHCARE Commercial |
$63.02
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$68.28
|
| Rate for Payer: Quartz Medicare Advantage |
$63.02
|
| Rate for Payer: The Alliance Commercial |
$52.52
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
DRESSING AQUACEL FOAM 4X4 ADHESIVE 420680
|
Facility
|
IP
|
$101.00
|
|
| Hospital Charge Code |
2963583
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.47 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$63.02
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
DRESSING ARGLAES 3.25 X 14 MSC9314Z
|
Facility
|
OP
|
$652.00
|
|
| Hospital Charge Code |
2965289
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$189.86 |
| Max. Negotiated Rate |
$623.83 |
| Rate for Payer: Aetna Commercial |
$610.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$583.15
|
| Rate for Payer: Aetna Managed Medicare |
$189.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$440.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$325.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$359.38
|
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$623.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$379.46
|
| Rate for Payer: Health EOS Commercial |
$603.49
|
| Rate for Payer: HFN Commercial |
$623.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$508.56
|
| Rate for Payer: Multiplan Commercial |
$542.46
|
| Rate for Payer: NAPHCARE Commercial |
$406.85
|
| Rate for Payer: Preferred Network Access Commercial |
$623.83
|
| Rate for Payer: Quartz Beloit One Network |
$332.26
|
| Rate for Payer: Quartz Commercial |
$440.75
|
| Rate for Payer: Quartz Medicare Advantage |
$406.85
|
| Rate for Payer: The Alliance Commercial |
$339.04
|
| Rate for Payer: WEA Trust Commercial |
$372.94
|
| Rate for Payer: WPS Commercial |
$502.24
|
|
|
DRESSING ARGLAES 3.25 X 14 MSC9314Z
|
Facility
|
IP
|
$652.00
|
|
| Hospital Charge Code |
2965289
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$332.26 |
| Max. Negotiated Rate |
$623.83 |
| Rate for Payer: Aetna Commercial |
$610.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$583.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$359.38
|
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$623.83
|
| Rate for Payer: Health EOS Commercial |
$603.49
|
| Rate for Payer: HFN Commercial |
$623.83
|
| Rate for Payer: Multiplan Commercial |
$542.46
|
| Rate for Payer: Preferred Network Access Commercial |
$623.83
|
| Rate for Payer: Quartz Beloit One Network |
$332.26
|
| Rate for Payer: Quartz Commercial |
$406.85
|
| Rate for Payer: WEA Trust Commercial |
$372.94
|
| Rate for Payer: WPS Commercial |
$502.24
|
|
|
DRESSING ARGLAES 4 X 4 MSC9045Z**DEDE 11/19
|
Facility
|
IP
|
$574.00
|
|
| Hospital Charge Code |
3331523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$292.51 |
| Max. Negotiated Rate |
$549.20 |
| Rate for Payer: Aetna Commercial |
$537.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$513.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$316.39
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cigna Commercial |
$549.20
|
| Rate for Payer: Health EOS Commercial |
$531.29
|
| Rate for Payer: HFN Commercial |
$549.20
|
| Rate for Payer: Multiplan Commercial |
$477.57
|
| Rate for Payer: Preferred Network Access Commercial |
$549.20
|
| Rate for Payer: Quartz Beloit One Network |
$292.51
|
| Rate for Payer: Quartz Commercial |
$358.18
|
| Rate for Payer: WEA Trust Commercial |
$328.33
|
| Rate for Payer: WPS Commercial |
$442.15
|
|
|
DRESSING ARGLAES 4 X 4 MSC9045Z**DEDE 11/19
|
Facility
|
OP
|
$574.00
|
|
| Hospital Charge Code |
3331523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$167.15 |
| Max. Negotiated Rate |
$549.20 |
| Rate for Payer: Aetna Commercial |
$537.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$513.39
|
| Rate for Payer: Aetna Managed Medicare |
$167.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$388.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$286.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$316.39
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cigna Commercial |
$549.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$334.07
|
| Rate for Payer: Health EOS Commercial |
$531.29
|
| Rate for Payer: HFN Commercial |
$549.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$447.72
|
| Rate for Payer: Multiplan Commercial |
$477.57
|
| Rate for Payer: NAPHCARE Commercial |
$358.18
|
| Rate for Payer: Preferred Network Access Commercial |
$549.20
|
| Rate for Payer: Quartz Beloit One Network |
$292.51
|
| Rate for Payer: Quartz Commercial |
$388.02
|
| Rate for Payer: Quartz Medicare Advantage |
$358.18
|
| Rate for Payer: The Alliance Commercial |
$298.48
|
| Rate for Payer: WEA Trust Commercial |
$328.33
|
| Rate for Payer: WPS Commercial |
$442.15
|
|
|
DRESSING BANDAGE ROLL GAUZE 3331 STERILE
|
Facility
|
OP
|
$76.00
|
|
| Hospital Charge Code |
2963145
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.13 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Aetna Managed Medicare |
$22.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.23
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.28
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: NAPHCARE Commercial |
$47.42
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$51.38
|
| Rate for Payer: Quartz Medicare Advantage |
$47.42
|
| Rate for Payer: The Alliance Commercial |
$39.52
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$58.54
|
|
|
DRESSING BANDAGE ROLL GAUZE 3331 STERILE
|
Facility
|
IP
|
$76.00
|
|
| Hospital Charge Code |
2963145
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$47.42
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$58.54
|
|
|
DRESSING BARRIER FLEXTEND CTF 4X4 8800
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS A4385
|
| Hospital Charge Code |
4063434
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$57.41
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
DRESSING BARRIER FLEXTEND CTF 4X4 8800
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS A4385
|
| Hospital Charge Code |
4063434
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.79 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Aetna Managed Medicare |
$26.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$47.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.54
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: NAPHCARE Commercial |
$57.41
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$62.19
|
| Rate for Payer: Quartz Medicare Advantage |
$57.41
|
| Rate for Payer: The Alliance Commercial |
$30.20
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
DRESSING BIOPATCH 1X7MM HOLE 4152
|
Facility
|
OP
|
$175.00
|
|
| Hospital Charge Code |
2963970
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Aetna Managed Medicare |
$50.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$118.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$87.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.85
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.50
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$118.30
|
| Rate for Payer: Quartz Medicare Advantage |
$109.20
|
| Rate for Payer: The Alliance Commercial |
$91.00
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.80
|
|
|
DRESSING BIOPATCH 1X7MM HOLE 4152
|
Facility
|
IP
|
$175.00
|
|
| Hospital Charge Code |
2963970
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.18 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.80
|
|
|
DRESSING BRIDGE XG #M827504415
|
Facility
|
OP
|
$1,549.00
|
|
| Hospital Charge Code |
2974092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$451.07 |
| Max. Negotiated Rate |
$1,482.08 |
| Rate for Payer: Aetna Commercial |
$1,449.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,385.43
|
| Rate for Payer: Aetna Managed Medicare |
$451.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,047.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$805.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$773.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$853.81
|
| Rate for Payer: Cash Price |
$464.70
|
| Rate for Payer: Cigna Commercial |
$1,482.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$901.52
|
| Rate for Payer: Health EOS Commercial |
$1,433.75
|
| Rate for Payer: HFN Commercial |
$1,482.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,208.22
|
| Rate for Payer: Multiplan Commercial |
$1,288.77
|
| Rate for Payer: NAPHCARE Commercial |
$966.58
|
| Rate for Payer: Preferred Network Access Commercial |
$1,482.08
|
| Rate for Payer: Quartz Beloit One Network |
$789.37
|
| Rate for Payer: Quartz Commercial |
$1,047.12
|
| Rate for Payer: Quartz Medicare Advantage |
$966.58
|
| Rate for Payer: The Alliance Commercial |
$805.48
|
| Rate for Payer: WEA Trust Commercial |
$886.03
|
| Rate for Payer: WPS Commercial |
$1,193.19
|
|
|
DRESSING BRIDGE XG #M827504415
|
Facility
|
IP
|
$1,549.00
|
|
| Hospital Charge Code |
2974092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$789.37 |
| Max. Negotiated Rate |
$1,482.08 |
| Rate for Payer: Aetna Commercial |
$1,449.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,385.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$853.81
|
| Rate for Payer: Cash Price |
$464.70
|
| Rate for Payer: Cigna Commercial |
$1,482.08
|
| Rate for Payer: Health EOS Commercial |
$1,433.75
|
| Rate for Payer: HFN Commercial |
$1,482.08
|
| Rate for Payer: Multiplan Commercial |
$1,288.77
|
| Rate for Payer: Preferred Network Access Commercial |
$1,482.08
|
| Rate for Payer: Quartz Beloit One Network |
$789.37
|
| Rate for Payer: Quartz Commercial |
$966.58
|
| Rate for Payer: WEA Trust Commercial |
$886.03
|
| Rate for Payer: WPS Commercial |
$1,193.19
|
|
|
DRESSING CALCIUM ALGINATE 4X4 MSC7344EPZ
|
Facility
|
IP
|
$87.00
|
|
| Hospital Charge Code |
5553372
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$54.29
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
DRESSING CALCIUM ALGINATE 4X4 MSC7344EPZ
|
Facility
|
OP
|
$87.00
|
|
| Hospital Charge Code |
5553372
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.33 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Aetna Managed Medicare |
$25.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.63
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.86
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: NAPHCARE Commercial |
$54.29
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$58.81
|
| Rate for Payer: Quartz Medicare Advantage |
$54.29
|
| Rate for Payer: The Alliance Commercial |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
DRESSING CHANGE, SURGICAL
|
Facility
|
IP
|
$291.00
|
|
| Hospital Charge Code |
2959998
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$148.29 |
| Max. Negotiated Rate |
$278.43 |
| Rate for Payer: Aetna Commercial |
$272.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$260.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.40
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$278.43
|
| Rate for Payer: Health EOS Commercial |
$269.35
|
| Rate for Payer: HFN Commercial |
$278.43
|
| Rate for Payer: Multiplan Commercial |
$242.11
|
| Rate for Payer: Preferred Network Access Commercial |
$278.43
|
| Rate for Payer: Quartz Beloit One Network |
$148.29
|
| Rate for Payer: Quartz Commercial |
$181.58
|
| Rate for Payer: WEA Trust Commercial |
$166.45
|
| Rate for Payer: WPS Commercial |
$224.16
|
|
