|
DRESSING TEGADERM IV 2.5 X 2.75 #1683
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
HCPCS A6257
|
| Hospital Charge Code |
4519975
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.98
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.75
|
| Rate for Payer: Health EOS Commercial |
$26.84
|
| Rate for Payer: HFN Commercial |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: Preferred Network Access Commercial |
$27.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.78
|
| Rate for Payer: Quartz Commercial |
$18.10
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$22.34
|
|
|
DRESSING TEGADERM IV 2.5 X 2.75 #1683
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
HCPCS A6257
|
| Hospital Charge Code |
4519975
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Aetna Managed Medicare |
$8.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.98
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.88
|
| Rate for Payer: Health EOS Commercial |
$26.84
|
| Rate for Payer: HFN Commercial |
$27.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.62
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: NAPHCARE Commercial |
$18.10
|
| Rate for Payer: Preferred Network Access Commercial |
$27.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.78
|
| Rate for Payer: Quartz Commercial |
$19.60
|
| Rate for Payer: Quartz Medicare Advantage |
$18.10
|
| Rate for Payer: The Alliance Commercial |
$9.07
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$22.34
|
|
|
DRESSING TELFA 3x4 STERILE AMD 7662
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
2963949
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
DRESSING TELFA 3x4 STERILE AMD 7662
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
2963949
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.49
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: The Alliance Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
DRESSING TELFA MINI ISLAND
|
Facility
|
IP
|
$4.00
|
|
| Hospital Charge Code |
2974550
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: Health EOS Commercial |
$3.70
|
| Rate for Payer: HFN Commercial |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: Preferred Network Access Commercial |
$3.83
|
| Rate for Payer: Quartz Beloit One Network |
$2.04
|
| Rate for Payer: Quartz Commercial |
$2.50
|
| Rate for Payer: WEA Trust Commercial |
$2.29
|
| Rate for Payer: WPS Commercial |
$3.08
|
|
|
DRESSING TELFA MINI ISLAND
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
2974550
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.58
|
| Rate for Payer: Aetna Managed Medicare |
$1.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.33
|
| Rate for Payer: Health EOS Commercial |
$3.70
|
| Rate for Payer: HFN Commercial |
$3.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: NAPHCARE Commercial |
$2.50
|
| Rate for Payer: Preferred Network Access Commercial |
$3.83
|
| Rate for Payer: Quartz Beloit One Network |
$2.04
|
| Rate for Payer: Quartz Commercial |
$2.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2.50
|
| Rate for Payer: The Alliance Commercial |
$2.08
|
| Rate for Payer: WEA Trust Commercial |
$2.29
|
| Rate for Payer: WPS Commercial |
$3.08
|
|
|
DRESSING TRAC LRG CRTN/10 #M6275053-10
|
Facility
|
OP
|
$1,002.00
|
|
| Hospital Charge Code |
2974087
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$291.78 |
| Max. Negotiated Rate |
$958.71 |
| Rate for Payer: Aetna Commercial |
$937.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.19
|
| Rate for Payer: Aetna Managed Medicare |
$291.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$677.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$521.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$500.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.30
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$958.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$583.16
|
| Rate for Payer: Health EOS Commercial |
$927.45
|
| Rate for Payer: HFN Commercial |
$958.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$781.56
|
| Rate for Payer: Multiplan Commercial |
$833.66
|
| Rate for Payer: NAPHCARE Commercial |
$625.25
|
| Rate for Payer: Preferred Network Access Commercial |
$958.71
|
| Rate for Payer: Quartz Beloit One Network |
$510.62
|
| Rate for Payer: Quartz Commercial |
$677.35
|
| Rate for Payer: Quartz Medicare Advantage |
$625.25
|
| Rate for Payer: The Alliance Commercial |
$521.04
|
| Rate for Payer: WEA Trust Commercial |
$573.14
|
| Rate for Payer: WPS Commercial |
$771.84
|
|
|
DRESSING TRAC LRG CRTN/10 #M6275053-10
|
Facility
|
IP
|
$1,002.00
|
|
| Hospital Charge Code |
2974087
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$510.62 |
| Max. Negotiated Rate |
$958.71 |
| Rate for Payer: Aetna Commercial |
$937.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.30
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$958.71
|
| Rate for Payer: Health EOS Commercial |
$927.45
|
| Rate for Payer: HFN Commercial |
$958.71
|
| Rate for Payer: Multiplan Commercial |
$833.66
|
| Rate for Payer: Preferred Network Access Commercial |
$958.71
|
| Rate for Payer: Quartz Beloit One Network |
$510.62
|
| Rate for Payer: Quartz Commercial |
$625.25
|
| Rate for Payer: WEA Trust Commercial |
$573.14
|
| Rate for Payer: WPS Commercial |
$771.84
|
|
|
DRESSING TRAC LRG CRTN/5 #M6275053-5
|
Facility
|
OP
|
$1,566.00
|
|
| Hospital Charge Code |
2974088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.02 |
| Max. Negotiated Rate |
$1,498.35 |
| Rate for Payer: Aetna Commercial |
$1,465.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,400.63
|
| Rate for Payer: Aetna Managed Medicare |
$456.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,058.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$814.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$781.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$863.18
|
| Rate for Payer: Cash Price |
$469.80
|
| Rate for Payer: Cigna Commercial |
$1,498.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$911.41
|
| Rate for Payer: Health EOS Commercial |
$1,449.49
|
| Rate for Payer: HFN Commercial |
$1,498.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,221.48
|
| Rate for Payer: Multiplan Commercial |
$1,302.91
|
| Rate for Payer: NAPHCARE Commercial |
$977.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,498.35
|
| Rate for Payer: Quartz Beloit One Network |
$798.03
|
| Rate for Payer: Quartz Commercial |
$1,058.62
|
| Rate for Payer: Quartz Medicare Advantage |
$977.18
|
| Rate for Payer: The Alliance Commercial |
$814.32
|
| Rate for Payer: WEA Trust Commercial |
$895.75
|
| Rate for Payer: WPS Commercial |
$1,206.29
|
|
|
DRESSING TRAC LRG CRTN/5 #M6275053-5
|
Facility
|
IP
|
$1,566.00
|
|
| Hospital Charge Code |
2974088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$798.03 |
| Max. Negotiated Rate |
$1,498.35 |
| Rate for Payer: Aetna Commercial |
$1,465.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,400.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$863.18
|
| Rate for Payer: Cash Price |
$469.80
|
| Rate for Payer: Cigna Commercial |
$1,498.35
|
| Rate for Payer: Health EOS Commercial |
$1,449.49
|
| Rate for Payer: HFN Commercial |
$1,498.35
|
| Rate for Payer: Multiplan Commercial |
$1,302.91
|
| Rate for Payer: Preferred Network Access Commercial |
$1,498.35
|
| Rate for Payer: Quartz Beloit One Network |
$798.03
|
| Rate for Payer: Quartz Commercial |
$977.18
|
| Rate for Payer: WEA Trust Commercial |
$895.75
|
| Rate for Payer: WPS Commercial |
$1,206.29
|
|
|
Dressing - Trauma
|
Facility
|
IP
|
$3.00
|
|
| Hospital Charge Code |
3040322
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.65
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.87
|
| Rate for Payer: Health EOS Commercial |
$2.78
|
| Rate for Payer: HFN Commercial |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2.87
|
| Rate for Payer: Quartz Beloit One Network |
$1.53
|
| Rate for Payer: Quartz Commercial |
$1.87
|
| Rate for Payer: WEA Trust Commercial |
$1.72
|
| Rate for Payer: WPS Commercial |
$2.31
|
|
|
Dressing - Trauma
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
3040322
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.68
|
| Rate for Payer: Aetna Managed Medicare |
$0.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.65
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.75
|
| Rate for Payer: Health EOS Commercial |
$2.78
|
| Rate for Payer: HFN Commercial |
$2.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: NAPHCARE Commercial |
$1.87
|
| Rate for Payer: Preferred Network Access Commercial |
$2.87
|
| Rate for Payer: Quartz Beloit One Network |
$1.53
|
| Rate for Payer: Quartz Commercial |
$2.03
|
| Rate for Payer: Quartz Medicare Advantage |
$1.87
|
| Rate for Payer: The Alliance Commercial |
$1.56
|
| Rate for Payer: WEA Trust Commercial |
$1.72
|
| Rate for Payer: WPS Commercial |
$2.31
|
|
|
DRESSING UNNA BOOT DRSG.PK 650944
|
Facility
|
IP
|
$159.00
|
|
| Hospital Charge Code |
2963876
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.03 |
| Max. Negotiated Rate |
$152.13 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$99.22
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
DRESSING UNNA BOOT DRSG.PK 650944
|
Facility
|
OP
|
$159.00
|
|
| Hospital Charge Code |
2963876
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.30 |
| Max. Negotiated Rate |
$152.13 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Aetna Managed Medicare |
$46.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$107.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.54
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$124.02
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: NAPHCARE Commercial |
$99.22
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$107.48
|
| Rate for Payer: Quartz Medicare Advantage |
$99.22
|
| Rate for Payer: The Alliance Commercial |
$82.68
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
DRESSING V.A.C. GRANUFOAM MED 18 X 12.5 X 3.2CM M8275052/10 (CS INV)
|
Facility
|
OP
|
$1,006.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
3785555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.79 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$132.79
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
DRESSING V.A.C. GRANUFOAM MED 18 X 12.5 X 3.2CM M8275052/10 (CS INV)
|
Facility
|
IP
|
$1,006.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
3785555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
DRESSING V.A.C. VERAFLO CLEANSE CHOICE MEDIUM ULTVCC05MD
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
5583409
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.79 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,684.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,609.92
|
| Rate for Payer: Aetna Managed Medicare |
$524.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,216.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$936.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$898.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$992.16
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cigna Commercial |
$1,722.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,047.60
|
| Rate for Payer: Health EOS Commercial |
$1,666.08
|
| Rate for Payer: HFN Commercial |
$1,722.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,404.00
|
| Rate for Payer: Multiplan Commercial |
$1,497.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,123.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,722.24
|
| Rate for Payer: Quartz Beloit One Network |
$917.28
|
| Rate for Payer: Quartz Commercial |
$1,216.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,123.20
|
| Rate for Payer: The Alliance Commercial |
$132.79
|
| Rate for Payer: WEA Trust Commercial |
$1,029.60
|
| Rate for Payer: WPS Commercial |
$1,386.54
|
|
|
DRESSING V.A.C. VERAFLO CLEANSE CHOICE MEDIUM ULTVCC05MD
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
5583409
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$917.28 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,684.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,609.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$992.16
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cigna Commercial |
$1,722.24
|
| Rate for Payer: Health EOS Commercial |
$1,666.08
|
| Rate for Payer: HFN Commercial |
$1,722.24
|
| Rate for Payer: Multiplan Commercial |
$1,497.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,722.24
|
| Rate for Payer: Quartz Beloit One Network |
$917.28
|
| Rate for Payer: Quartz Commercial |
$1,123.20
|
| Rate for Payer: WEA Trust Commercial |
$1,029.60
|
| Rate for Payer: WPS Commercial |
$1,386.54
|
|
|
DRESSING V.A.C. WHITEFOAM SMALL 10 X 7.5 X 1CM M6275033/10
|
Facility
|
OP
|
$272.00
|
|
| Hospital Charge Code |
2974084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$79.21 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Aetna Managed Medicare |
$79.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$183.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$141.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$135.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$158.30
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$212.16
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: NAPHCARE Commercial |
$169.73
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$183.87
|
| Rate for Payer: Quartz Medicare Advantage |
$169.73
|
| Rate for Payer: The Alliance Commercial |
$141.44
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$209.52
|
|
|
DRESSING V.A.C. WHITEFOAM SMALL 10 X 7.5 X 1CM M6275033/10
|
Facility
|
IP
|
$272.00
|
|
| Hospital Charge Code |
2974084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$138.61 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$169.73
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$209.52
|
|
|
Dressing Vaseline
|
Facility
|
IP
|
$1.00
|
|
| Hospital Charge Code |
3040320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna Commercial |
$0.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.55
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.96
|
| Rate for Payer: Health EOS Commercial |
$0.93
|
| Rate for Payer: HFN Commercial |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Preferred Network Access Commercial |
$0.96
|
| Rate for Payer: Quartz Beloit One Network |
$0.51
|
| Rate for Payer: Quartz Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$0.57
|
| Rate for Payer: WPS Commercial |
$0.77
|
|
|
Dressing Vaseline
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
3040320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna Commercial |
$0.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.89
|
| Rate for Payer: Aetna Managed Medicare |
$0.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.55
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.58
|
| Rate for Payer: Health EOS Commercial |
$0.93
|
| Rate for Payer: HFN Commercial |
$0.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: NAPHCARE Commercial |
$0.62
|
| Rate for Payer: Preferred Network Access Commercial |
$0.96
|
| Rate for Payer: Quartz Beloit One Network |
$0.51
|
| Rate for Payer: Quartz Commercial |
$0.68
|
| Rate for Payer: Quartz Medicare Advantage |
$0.62
|
| Rate for Payer: The Alliance Commercial |
$0.52
|
| Rate for Payer: WEA Trust Commercial |
$0.57
|
| Rate for Payer: WPS Commercial |
$0.77
|
|
|
DRESSING VASELINE GAUZE 1X8 8884417601
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
2963746
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.82 |
| Max. Negotiated Rate |
$19.14 |
| Rate for Payer: Aetna Commercial |
$18.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.89
|
| Rate for Payer: Aetna Managed Medicare |
$5.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.02
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$19.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.64
|
| Rate for Payer: Health EOS Commercial |
$18.51
|
| Rate for Payer: HFN Commercial |
$19.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.60
|
| Rate for Payer: Multiplan Commercial |
$16.64
|
| Rate for Payer: NAPHCARE Commercial |
$12.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19.14
|
| Rate for Payer: Quartz Beloit One Network |
$10.19
|
| Rate for Payer: Quartz Commercial |
$13.52
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$10.40
|
| Rate for Payer: WEA Trust Commercial |
$11.44
|
| Rate for Payer: WPS Commercial |
$15.41
|
|
|
DRESSING VASELINE GAUZE 1X8 8884417601
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
2963746
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$19.14 |
| Rate for Payer: Aetna Commercial |
$18.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.02
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$18.51
|
| Rate for Payer: HFN Commercial |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$16.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19.14
|
| Rate for Payer: Quartz Beloit One Network |
$10.19
|
| Rate for Payer: Quartz Commercial |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$11.44
|
| Rate for Payer: WPS Commercial |
$15.41
|
|
|
DRESSING VASELINE GAUZE 3X9
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS A6223
|
| Hospital Charge Code |
2963775
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$24.88 |
| Rate for Payer: Aetna Commercial |
$24.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.33
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$24.88
|
| Rate for Payer: Health EOS Commercial |
$24.07
|
| Rate for Payer: HFN Commercial |
$24.88
|
| Rate for Payer: Multiplan Commercial |
$21.63
|
| Rate for Payer: Preferred Network Access Commercial |
$24.88
|
| Rate for Payer: Quartz Beloit One Network |
$13.25
|
| Rate for Payer: Quartz Commercial |
$16.22
|
| Rate for Payer: WEA Trust Commercial |
$14.87
|
| Rate for Payer: WPS Commercial |
$20.03
|
|
