|
DRESSING MEDIPORE 5-7/8 X 11 2957
|
Facility
|
IP
|
$85.00
|
|
| Hospital Charge Code |
2963576
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.32 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$53.04
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
DRESSING MEDIPORE 5-7/8 X 11 2957
|
Facility
|
OP
|
$85.00
|
|
| Hospital Charge Code |
2963576
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Aetna Managed Medicare |
$24.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.47
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.30
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: NAPHCARE Commercial |
$53.04
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$57.46
|
| Rate for Payer: Quartz Medicare Advantage |
$53.04
|
| Rate for Payer: The Alliance Commercial |
$44.20
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
DRESSING MEDIPORE 5 7/8X 5 7/8
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
2963313
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.36 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$23.71
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
DRESSING MEDIPORE 5 7/8X 5 7/8
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
2963313
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Aetna Managed Medicare |
$11.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.12
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.64
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: NAPHCARE Commercial |
$23.71
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$25.69
|
| Rate for Payer: Quartz Medicare Advantage |
$23.71
|
| Rate for Payer: The Alliance Commercial |
$19.76
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
DRESSING MEPILEX AG 4X4 287100
|
Facility
|
OP
|
$238.00
|
|
| Hospital Charge Code |
2974587
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.31 |
| Max. Negotiated Rate |
$227.72 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Aetna Managed Medicare |
$69.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$160.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$123.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$118.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$138.52
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$185.64
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: NAPHCARE Commercial |
$148.51
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$160.89
|
| Rate for Payer: Quartz Medicare Advantage |
$148.51
|
| Rate for Payer: The Alliance Commercial |
$123.76
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: WPS Commercial |
$183.33
|
|
|
DRESSING MEPILEX AG 4X4 287100
|
Facility
|
IP
|
$238.00
|
|
| Hospital Charge Code |
2974587
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$121.28 |
| Max. Negotiated Rate |
$227.72 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$148.51
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: WPS Commercial |
$183.33
|
|
|
DRESSING MEPILEX FOAM NONADHESIVE 4x4 294199
|
Facility
|
OP
|
$115.00
|
|
| Hospital Charge Code |
2964025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.49 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Aetna Managed Medicare |
$33.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.93
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.70
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: NAPHCARE Commercial |
$71.76
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$77.74
|
| Rate for Payer: Quartz Medicare Advantage |
$71.76
|
| Rate for Payer: The Alliance Commercial |
$59.80
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
DRESSING MEPILEX FOAM NONADHESIVE 4x4 294199
|
Facility
|
IP
|
$115.00
|
|
| Hospital Charge Code |
2964025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.60 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
DRESSING MEPILEX HEEL 5 X 8 288100
|
Facility
|
OP
|
$85.00
|
|
| Hospital Charge Code |
2973234
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Aetna Managed Medicare |
$24.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.47
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.30
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: NAPHCARE Commercial |
$53.04
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$57.46
|
| Rate for Payer: Quartz Medicare Advantage |
$53.04
|
| Rate for Payer: The Alliance Commercial |
$44.20
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
DRESSING MEPILEX HEEL 5 X 8 288100
|
Facility
|
IP
|
$85.00
|
|
| Hospital Charge Code |
2973234
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.32 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$53.04
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
DRESSING MEPITEL NON ADH 3X4 290799
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
HCPCS A6206
|
| Hospital Charge Code |
4063435
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.85 |
| Max. Negotiated Rate |
$134.91 |
| Rate for Payer: Aetna Commercial |
$131.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.72
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$134.91
|
| Rate for Payer: Health EOS Commercial |
$130.51
|
| Rate for Payer: HFN Commercial |
$134.91
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: Preferred Network Access Commercial |
$134.91
|
| Rate for Payer: Quartz Beloit One Network |
$71.85
|
| Rate for Payer: Quartz Commercial |
$87.98
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: WPS Commercial |
$108.61
|
|
|
DRESSING MEPITEL NON ADH 3X4 290799
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
HCPCS A6206
|
| Hospital Charge Code |
4063435
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.06 |
| Max. Negotiated Rate |
$134.91 |
| Rate for Payer: Aetna Commercial |
$131.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Aetna Managed Medicare |
$41.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.72
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$134.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.06
|
| Rate for Payer: Health EOS Commercial |
$130.51
|
| Rate for Payer: HFN Commercial |
$134.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.98
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: NAPHCARE Commercial |
$87.98
|
| Rate for Payer: Preferred Network Access Commercial |
$134.91
|
| Rate for Payer: Quartz Beloit One Network |
$71.85
|
| Rate for Payer: Quartz Commercial |
$95.32
|
| Rate for Payer: Quartz Medicare Advantage |
$87.98
|
| Rate for Payer: The Alliance Commercial |
$73.32
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: WPS Commercial |
$108.61
|
|
|
DRESSING MEPITEL ONE 3 X 4
|
Facility
|
IP
|
$145.00
|
|
| Hospital Charge Code |
2974066
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.89 |
| Max. Negotiated Rate |
$138.74 |
| Rate for Payer: Aetna Commercial |
$135.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.92
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$138.74
|
| Rate for Payer: Health EOS Commercial |
$134.21
|
| Rate for Payer: HFN Commercial |
$138.74
|
| Rate for Payer: Multiplan Commercial |
$120.64
|
| Rate for Payer: Preferred Network Access Commercial |
$138.74
|
| Rate for Payer: Quartz Beloit One Network |
$73.89
|
| Rate for Payer: Quartz Commercial |
$90.48
|
| Rate for Payer: WEA Trust Commercial |
$82.94
|
| Rate for Payer: WPS Commercial |
$111.69
|
|
|
DRESSING MEPITEL ONE 3 X 4
|
Facility
|
OP
|
$145.00
|
|
| Hospital Charge Code |
2974066
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.22 |
| Max. Negotiated Rate |
$138.74 |
| Rate for Payer: Aetna Commercial |
$135.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.69
|
| Rate for Payer: Aetna Managed Medicare |
$42.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.92
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$138.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.39
|
| Rate for Payer: Health EOS Commercial |
$134.21
|
| Rate for Payer: HFN Commercial |
$138.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.10
|
| Rate for Payer: Multiplan Commercial |
$120.64
|
| Rate for Payer: NAPHCARE Commercial |
$90.48
|
| Rate for Payer: Preferred Network Access Commercial |
$138.74
|
| Rate for Payer: Quartz Beloit One Network |
$73.89
|
| Rate for Payer: Quartz Commercial |
$98.02
|
| Rate for Payer: Quartz Medicare Advantage |
$90.48
|
| Rate for Payer: The Alliance Commercial |
$75.40
|
| Rate for Payer: WEA Trust Commercial |
$82.94
|
| Rate for Payer: WPS Commercial |
$111.69
|
|
|
DRESSING MEROGEL 15-17000
|
Facility
|
OP
|
$1,481.00
|
|
| Hospital Charge Code |
2965320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$431.27 |
| Max. Negotiated Rate |
$1,417.02 |
| Rate for Payer: Aetna Commercial |
$1,386.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,324.61
|
| Rate for Payer: Aetna Managed Medicare |
$431.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,001.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$770.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$739.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$816.33
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cigna Commercial |
$1,417.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$861.94
|
| Rate for Payer: Health EOS Commercial |
$1,370.81
|
| Rate for Payer: HFN Commercial |
$1,417.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,155.18
|
| Rate for Payer: Multiplan Commercial |
$1,232.19
|
| Rate for Payer: NAPHCARE Commercial |
$924.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,417.02
|
| Rate for Payer: Quartz Beloit One Network |
$754.72
|
| Rate for Payer: Quartz Commercial |
$1,001.16
|
| Rate for Payer: Quartz Medicare Advantage |
$924.14
|
| Rate for Payer: The Alliance Commercial |
$770.12
|
| Rate for Payer: WEA Trust Commercial |
$847.13
|
| Rate for Payer: WPS Commercial |
$1,140.81
|
|
|
DRESSING MEROGEL 15-17000
|
Facility
|
IP
|
$1,481.00
|
|
| Hospital Charge Code |
2965320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$754.72 |
| Max. Negotiated Rate |
$1,417.02 |
| Rate for Payer: Aetna Commercial |
$1,386.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,324.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$816.33
|
| Rate for Payer: Cash Price |
$444.30
|
| Rate for Payer: Cigna Commercial |
$1,417.02
|
| Rate for Payer: Health EOS Commercial |
$1,370.81
|
| Rate for Payer: HFN Commercial |
$1,417.02
|
| Rate for Payer: Multiplan Commercial |
$1,232.19
|
| Rate for Payer: Preferred Network Access Commercial |
$1,417.02
|
| Rate for Payer: Quartz Beloit One Network |
$754.72
|
| Rate for Payer: Quartz Commercial |
$924.14
|
| Rate for Payer: WEA Trust Commercial |
$847.13
|
| Rate for Payer: WPS Commercial |
$1,140.81
|
|
|
DRESSING OPTIFOAM AG 3.5x10 MSC97310Z
|
Facility
|
OP
|
$514.00
|
|
| Hospital Charge Code |
4414147
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.68 |
| Max. Negotiated Rate |
$491.80 |
| Rate for Payer: Aetna Commercial |
$481.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$459.72
|
| Rate for Payer: Aetna Managed Medicare |
$149.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$347.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$267.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$256.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.32
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$491.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$299.15
|
| Rate for Payer: Health EOS Commercial |
$475.76
|
| Rate for Payer: HFN Commercial |
$491.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$400.92
|
| Rate for Payer: Multiplan Commercial |
$427.65
|
| Rate for Payer: NAPHCARE Commercial |
$320.74
|
| Rate for Payer: Preferred Network Access Commercial |
$491.80
|
| Rate for Payer: Quartz Beloit One Network |
$261.93
|
| Rate for Payer: Quartz Commercial |
$347.46
|
| Rate for Payer: Quartz Medicare Advantage |
$320.74
|
| Rate for Payer: The Alliance Commercial |
$267.28
|
| Rate for Payer: WEA Trust Commercial |
$294.01
|
| Rate for Payer: WPS Commercial |
$395.93
|
|
|
DRESSING OPTIFOAM AG 3.5x10 MSC97310Z
|
Facility
|
IP
|
$514.00
|
|
| Hospital Charge Code |
4414147
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.93 |
| Max. Negotiated Rate |
$491.80 |
| Rate for Payer: Aetna Commercial |
$481.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$459.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.32
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$491.80
|
| Rate for Payer: Health EOS Commercial |
$475.76
|
| Rate for Payer: HFN Commercial |
$491.80
|
| Rate for Payer: Multiplan Commercial |
$427.65
|
| Rate for Payer: Preferred Network Access Commercial |
$491.80
|
| Rate for Payer: Quartz Beloit One Network |
$261.93
|
| Rate for Payer: Quartz Commercial |
$320.74
|
| Rate for Payer: WEA Trust Commercial |
$294.01
|
| Rate for Payer: WPS Commercial |
$395.93
|
|
|
DRESSING OPTIFOAM AG 3.5 x14 MSC97314Z
|
Facility
|
OP
|
$600.00
|
|
| Hospital Charge Code |
4414148
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$174.72 |
| Max. Negotiated Rate |
$574.08 |
| Rate for Payer: Aetna Commercial |
$561.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$536.64
|
| Rate for Payer: Aetna Managed Medicare |
$174.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$405.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$312.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$299.52
|
| 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: Dean Health DHI/DHP/ASO |
$349.20
|
| Rate for Payer: Health EOS Commercial |
$555.36
|
| Rate for Payer: HFN Commercial |
$574.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$468.00
|
| Rate for Payer: Multiplan Commercial |
$499.20
|
| Rate for Payer: NAPHCARE Commercial |
$374.40
|
| Rate for Payer: Preferred Network Access Commercial |
$574.08
|
| Rate for Payer: Quartz Beloit One Network |
$305.76
|
| Rate for Payer: Quartz Commercial |
$405.60
|
| Rate for Payer: Quartz Medicare Advantage |
$374.40
|
| Rate for Payer: The Alliance Commercial |
$312.00
|
| Rate for Payer: WEA Trust Commercial |
$343.20
|
| Rate for Payer: WPS Commercial |
$462.18
|
|
|
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
|
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 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 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
|
|
