|
DRESSING CHANGE, SURGICAL
|
Facility
|
OP
|
$291.00
|
|
| Hospital Charge Code |
2959998
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$84.74 |
| Max. Negotiated Rate |
$278.43 |
| Rate for Payer: Aetna Commercial |
$272.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$260.27
|
| Rate for Payer: Aetna Managed Medicare |
$84.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$196.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$151.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$145.27
|
| 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: Dean Health DHI/DHP/ASO |
$169.36
|
| Rate for Payer: Health EOS Commercial |
$269.35
|
| Rate for Payer: HFN Commercial |
$278.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$226.98
|
| Rate for Payer: Multiplan Commercial |
$242.11
|
| Rate for Payer: NAPHCARE Commercial |
$181.58
|
| Rate for Payer: Preferred Network Access Commercial |
$278.43
|
| Rate for Payer: Quartz Beloit One Network |
$148.29
|
| Rate for Payer: Quartz Commercial |
$196.72
|
| Rate for Payer: Quartz Medicare Advantage |
$181.58
|
| Rate for Payer: The Alliance Commercial |
$151.32
|
| Rate for Payer: WEA Trust Commercial |
$166.45
|
| Rate for Payer: WPS Commercial |
$224.16
|
|
|
DRESSING COBAN 6 X 5 YRD LF UNSTERILE 2086
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS A6455
|
| Hospital Charge Code |
2963675
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$69.85 |
| Rate for Payer: Aetna Commercial |
$68.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.24
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$69.85
|
| Rate for Payer: Health EOS Commercial |
$67.57
|
| Rate for Payer: HFN Commercial |
$69.85
|
| Rate for Payer: Multiplan Commercial |
$60.74
|
| Rate for Payer: Preferred Network Access Commercial |
$69.85
|
| Rate for Payer: Quartz Beloit One Network |
$37.20
|
| Rate for Payer: Quartz Commercial |
$45.55
|
| Rate for Payer: WEA Trust Commercial |
$41.76
|
| Rate for Payer: WPS Commercial |
$56.23
|
|
|
DRESSING COBAN 6 X 5 YRD LF UNSTERILE 2086
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS A6455
|
| Hospital Charge Code |
2963675
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.28 |
| Max. Negotiated Rate |
$69.85 |
| Rate for Payer: Aetna Commercial |
$68.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.29
|
| Rate for Payer: Aetna Managed Medicare |
$21.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.24
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$69.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.49
|
| Rate for Payer: Health EOS Commercial |
$67.57
|
| Rate for Payer: HFN Commercial |
$69.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.94
|
| Rate for Payer: Multiplan Commercial |
$60.74
|
| Rate for Payer: NAPHCARE Commercial |
$45.55
|
| Rate for Payer: Preferred Network Access Commercial |
$69.85
|
| Rate for Payer: Quartz Beloit One Network |
$37.20
|
| Rate for Payer: Quartz Commercial |
$49.35
|
| Rate for Payer: Quartz Medicare Advantage |
$45.55
|
| Rate for Payer: The Alliance Commercial |
$8.28
|
| Rate for Payer: WEA Trust Commercial |
$41.76
|
| Rate for Payer: WPS Commercial |
$56.23
|
|
|
DRESSING DERMATAC DRAPE DTAC10LDP
|
Facility
|
IP
|
$393.00
|
|
| Hospital Charge Code |
5787695
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$200.27 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$245.23
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
DRESSING DERMATAC DRAPE DTAC10LDP
|
Facility
|
OP
|
$393.00
|
|
| Hospital Charge Code |
5787695
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$114.44 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Aetna Managed Medicare |
$114.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$265.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$204.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$196.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$228.73
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$306.54
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: NAPHCARE Commercial |
$245.23
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$265.67
|
| Rate for Payer: Quartz Medicare Advantage |
$245.23
|
| Rate for Payer: The Alliance Commercial |
$204.36
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
DRESSING EXU-DRY 6 X 9 5999006
|
Facility
|
IP
|
$75.00
|
|
| Hospital Charge Code |
2974782
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
DRESSING EXU-DRY 6 X 9 5999006
|
Facility
|
OP
|
$75.00
|
|
| Hospital Charge Code |
2974782
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Aetna Managed Medicare |
$21.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.65
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.50
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$50.70
|
| Rate for Payer: Quartz Medicare Advantage |
$46.80
|
| Rate for Payer: The Alliance Commercial |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
DRESSING FOAM ADHESIVE 3X3 420804
|
Facility
|
OP
|
$75.00
|
|
| Hospital Charge Code |
4518941
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Aetna Managed Medicare |
$21.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.65
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.50
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$50.70
|
| Rate for Payer: Quartz Medicare Advantage |
$46.80
|
| Rate for Payer: The Alliance Commercial |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
DRESSING FOAM ADHESIVE 3X3 420804
|
Facility
|
IP
|
$75.00
|
|
| Hospital Charge Code |
4518941
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
DRESSING GAUZE 6X6.75 STERILE 6665
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
2963057
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.77 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
DRESSING GAUZE 6X6.75 STERILE 6665
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
2963057
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.30 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Aetna Managed Medicare |
$23.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.56
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: NAPHCARE Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$54.08
|
| Rate for Payer: Quartz Medicare Advantage |
$49.92
|
| Rate for Payer: The Alliance Commercial |
$41.60
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
DRESSING GAUZE VASE. PETROL
|
Facility
|
IP
|
$62.00
|
|
| Hospital Charge Code |
2963361
|
|
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 GAUZE VASE. PETROL
|
Facility
|
OP
|
$62.00
|
|
| Hospital Charge Code |
2963361
|
|
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 GRANUFOAM MEDIUM VAC VIAGFM05
|
Facility
|
OP
|
$891.00
|
|
| Hospital Charge Code |
2973266
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$259.46 |
| Max. Negotiated Rate |
$852.51 |
| Rate for Payer: Aetna Commercial |
$833.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$796.91
|
| Rate for Payer: Aetna Managed Medicare |
$259.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$602.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$463.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$444.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$491.12
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna Commercial |
$852.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$518.56
|
| Rate for Payer: Health EOS Commercial |
$824.71
|
| Rate for Payer: HFN Commercial |
$852.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$694.98
|
| Rate for Payer: Multiplan Commercial |
$741.31
|
| Rate for Payer: NAPHCARE Commercial |
$555.98
|
| Rate for Payer: Preferred Network Access Commercial |
$852.51
|
| Rate for Payer: Quartz Beloit One Network |
$454.05
|
| Rate for Payer: Quartz Commercial |
$602.32
|
| Rate for Payer: Quartz Medicare Advantage |
$555.98
|
| Rate for Payer: The Alliance Commercial |
$463.32
|
| Rate for Payer: WEA Trust Commercial |
$509.65
|
| Rate for Payer: WPS Commercial |
$686.34
|
|
|
DRESSING GRANUFOAM MEDIUM VAC VIAGFM05
|
Facility
|
IP
|
$891.00
|
|
| Hospital Charge Code |
2973266
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$454.05 |
| Max. Negotiated Rate |
$852.51 |
| Rate for Payer: Aetna Commercial |
$833.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$796.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$491.12
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna Commercial |
$852.51
|
| Rate for Payer: Health EOS Commercial |
$824.71
|
| Rate for Payer: HFN Commercial |
$852.51
|
| Rate for Payer: Multiplan Commercial |
$741.31
|
| Rate for Payer: Preferred Network Access Commercial |
$852.51
|
| Rate for Payer: Quartz Beloit One Network |
$454.05
|
| Rate for Payer: Quartz Commercial |
$555.98
|
| Rate for Payer: WEA Trust Commercial |
$509.65
|
| Rate for Payer: WPS Commercial |
$686.34
|
|
|
DRESSING GRANU FOAM SILVER MEDIUM #M6275096
|
Facility
|
IP
|
$1,156.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
2974090
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$589.10 |
| Max. Negotiated Rate |
$1,106.06 |
| Rate for Payer: Aetna Commercial |
$1,082.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,033.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$637.19
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,106.06
|
| Rate for Payer: Health EOS Commercial |
$1,069.99
|
| Rate for Payer: HFN Commercial |
$1,106.06
|
| Rate for Payer: Multiplan Commercial |
$961.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,106.06
|
| Rate for Payer: Quartz Beloit One Network |
$589.10
|
| Rate for Payer: Quartz Commercial |
$721.34
|
| Rate for Payer: WEA Trust Commercial |
$661.23
|
| Rate for Payer: WPS Commercial |
$890.47
|
|
|
DRESSING GRANU FOAM SILVER MEDIUM #M6275096
|
Facility
|
OP
|
$1,156.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
2974090
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.79 |
| Max. Negotiated Rate |
$1,106.06 |
| Rate for Payer: Aetna Commercial |
$1,082.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,033.93
|
| Rate for Payer: Aetna Managed Medicare |
$336.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$781.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$601.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$577.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$637.19
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,106.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$672.79
|
| Rate for Payer: Health EOS Commercial |
$1,069.99
|
| Rate for Payer: HFN Commercial |
$1,106.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$901.68
|
| Rate for Payer: Multiplan Commercial |
$961.79
|
| Rate for Payer: NAPHCARE Commercial |
$721.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,106.06
|
| Rate for Payer: Quartz Beloit One Network |
$589.10
|
| Rate for Payer: Quartz Commercial |
$781.46
|
| Rate for Payer: Quartz Medicare Advantage |
$721.34
|
| Rate for Payer: The Alliance Commercial |
$132.79
|
| Rate for Payer: WEA Trust Commercial |
$661.23
|
| Rate for Payer: WPS Commercial |
$890.47
|
|
|
DRESSING GRANUFOAM SMALL VAC VIAGFS05
|
Facility
|
IP
|
$589.00
|
|
| Hospital Charge Code |
5415580
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$300.15 |
| Max. Negotiated Rate |
$563.56 |
| Rate for Payer: Aetna Commercial |
$551.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$526.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$324.66
|
| Rate for Payer: Cash Price |
$176.70
|
| Rate for Payer: Cigna Commercial |
$563.56
|
| Rate for Payer: Health EOS Commercial |
$545.18
|
| Rate for Payer: HFN Commercial |
$563.56
|
| Rate for Payer: Multiplan Commercial |
$490.05
|
| Rate for Payer: Preferred Network Access Commercial |
$563.56
|
| Rate for Payer: Quartz Beloit One Network |
$300.15
|
| Rate for Payer: Quartz Commercial |
$367.54
|
| Rate for Payer: WEA Trust Commercial |
$336.91
|
| Rate for Payer: WPS Commercial |
$453.71
|
|
|
DRESSING GRANUFOAM SMALL VAC VIAGFS05
|
Facility
|
OP
|
$589.00
|
|
| Hospital Charge Code |
5415580
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$171.52 |
| Max. Negotiated Rate |
$563.56 |
| Rate for Payer: Aetna Commercial |
$551.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$526.80
|
| Rate for Payer: Aetna Managed Medicare |
$171.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$398.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$306.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$294.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$324.66
|
| Rate for Payer: Cash Price |
$176.70
|
| Rate for Payer: Cigna Commercial |
$563.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$342.80
|
| Rate for Payer: Health EOS Commercial |
$545.18
|
| Rate for Payer: HFN Commercial |
$563.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$459.42
|
| Rate for Payer: Multiplan Commercial |
$490.05
|
| Rate for Payer: NAPHCARE Commercial |
$367.54
|
| Rate for Payer: Preferred Network Access Commercial |
$563.56
|
| Rate for Payer: Quartz Beloit One Network |
$300.15
|
| Rate for Payer: Quartz Commercial |
$398.16
|
| Rate for Payer: Quartz Medicare Advantage |
$367.54
|
| Rate for Payer: The Alliance Commercial |
$306.28
|
| Rate for Payer: WEA Trust Commercial |
$336.91
|
| Rate for Payer: WPS Commercial |
$453.71
|
|
|
DRESSING KIT TRAC MED CTN/10 #M6275052-10
|
Facility
|
IP
|
$969.00
|
|
| Hospital Charge Code |
2974086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$493.80 |
| Max. Negotiated Rate |
$927.14 |
| Rate for Payer: Aetna Commercial |
$906.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$866.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$534.11
|
| Rate for Payer: Cash Price |
$290.70
|
| Rate for Payer: Cigna Commercial |
$927.14
|
| Rate for Payer: Health EOS Commercial |
$896.91
|
| Rate for Payer: HFN Commercial |
$927.14
|
| Rate for Payer: Multiplan Commercial |
$806.21
|
| Rate for Payer: Preferred Network Access Commercial |
$927.14
|
| Rate for Payer: Quartz Beloit One Network |
$493.80
|
| Rate for Payer: Quartz Commercial |
$604.66
|
| Rate for Payer: WEA Trust Commercial |
$554.27
|
| Rate for Payer: WPS Commercial |
$746.42
|
|
|
DRESSING KIT TRAC MED CTN/10 #M6275052-10
|
Facility
|
OP
|
$969.00
|
|
| Hospital Charge Code |
2974086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$282.17 |
| Max. Negotiated Rate |
$927.14 |
| Rate for Payer: Aetna Commercial |
$906.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$866.67
|
| Rate for Payer: Aetna Managed Medicare |
$282.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$655.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$483.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$534.11
|
| Rate for Payer: Cash Price |
$290.70
|
| Rate for Payer: Cigna Commercial |
$927.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$563.96
|
| Rate for Payer: Health EOS Commercial |
$896.91
|
| Rate for Payer: HFN Commercial |
$927.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$755.82
|
| Rate for Payer: Multiplan Commercial |
$806.21
|
| Rate for Payer: NAPHCARE Commercial |
$604.66
|
| Rate for Payer: Preferred Network Access Commercial |
$927.14
|
| Rate for Payer: Quartz Beloit One Network |
$493.80
|
| Rate for Payer: Quartz Commercial |
$655.04
|
| Rate for Payer: Quartz Medicare Advantage |
$604.66
|
| Rate for Payer: The Alliance Commercial |
$503.88
|
| Rate for Payer: WEA Trust Commercial |
$554.27
|
| Rate for Payer: WPS Commercial |
$746.42
|
|
|
DRESSING KIT TRAC SMALL CTN/10 #M6275051-10
|
Facility
|
IP
|
$768.00
|
|
| Hospital Charge Code |
2974085
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$391.37 |
| Max. Negotiated Rate |
$734.82 |
| Rate for Payer: Aetna Commercial |
$718.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$686.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$423.32
|
| Rate for Payer: Cash Price |
$230.40
|
| Rate for Payer: Cigna Commercial |
$734.82
|
| Rate for Payer: Health EOS Commercial |
$710.86
|
| Rate for Payer: HFN Commercial |
$734.82
|
| Rate for Payer: Multiplan Commercial |
$638.98
|
| Rate for Payer: Preferred Network Access Commercial |
$734.82
|
| Rate for Payer: Quartz Beloit One Network |
$391.37
|
| Rate for Payer: Quartz Commercial |
$479.23
|
| Rate for Payer: WEA Trust Commercial |
$439.30
|
| Rate for Payer: WPS Commercial |
$591.59
|
|
|
DRESSING KIT TRAC SMALL CTN/10 #M6275051-10
|
Facility
|
OP
|
$768.00
|
|
| Hospital Charge Code |
2974085
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$223.64 |
| Max. Negotiated Rate |
$734.82 |
| Rate for Payer: Aetna Commercial |
$718.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$686.90
|
| Rate for Payer: Aetna Managed Medicare |
$223.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$519.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$399.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$383.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$423.32
|
| Rate for Payer: Cash Price |
$230.40
|
| Rate for Payer: Cigna Commercial |
$734.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$446.98
|
| Rate for Payer: Health EOS Commercial |
$710.86
|
| Rate for Payer: HFN Commercial |
$734.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$599.04
|
| Rate for Payer: Multiplan Commercial |
$638.98
|
| Rate for Payer: NAPHCARE Commercial |
$479.23
|
| Rate for Payer: Preferred Network Access Commercial |
$734.82
|
| Rate for Payer: Quartz Beloit One Network |
$391.37
|
| Rate for Payer: Quartz Commercial |
$519.17
|
| Rate for Payer: Quartz Medicare Advantage |
$479.23
|
| Rate for Payer: The Alliance Commercial |
$399.36
|
| Rate for Payer: WEA Trust Commercial |
$439.30
|
| Rate for Payer: WPS Commercial |
$591.59
|
|
|
DRESSING MEDIPORE 3 7/8X 4 5/8 2954
|
Facility
|
OP
|
$18.00
|
|
| Hospital Charge Code |
2963510
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.24 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Aetna Managed Medicare |
$5.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.48
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.04
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: NAPHCARE Commercial |
$11.23
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$12.17
|
| Rate for Payer: Quartz Medicare Advantage |
$11.23
|
| Rate for Payer: The Alliance Commercial |
$9.36
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
DRESSING MEDIPORE 3 7/8X 4 5/8 2954
|
Facility
|
IP
|
$18.00
|
|
| Hospital Charge Code |
2963510
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.23
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
