|
MESH PHASIX 10 X 12 (25.4CM X 30.5CM) 1190500
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5384824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$18.48 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$59.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.76
|
| Rate for Payer: Aetna Managed Medicare |
$18.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.98
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$60.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.93
|
| Rate for Payer: Health EOS Commercial |
$58.74
|
| Rate for Payer: HFN Commercial |
$60.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.50
|
| Rate for Payer: Multiplan Commercial |
$52.80
|
| Rate for Payer: NAPHCARE Commercial |
$39.60
|
| Rate for Payer: Preferred Network Access Commercial |
$60.72
|
| Rate for Payer: Quartz Beloit One Network |
$32.34
|
| Rate for Payer: Quartz Commercial |
$42.90
|
| Rate for Payer: Quartz Medicare Advantage |
$39.60
|
| Rate for Payer: The Alliance Commercial |
$264.00
|
| Rate for Payer: WEA Trust Commercial |
$36.30
|
| Rate for Payer: WPS Commercial |
$48.89
|
|
|
MESH PHASIX 10 X 12 (25.4CM X 30.5CM) 1190500
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5384824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$32.34 |
| Max. Negotiated Rate |
$60.72 |
| Rate for Payer: Aetna Commercial |
$59.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.98
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$60.72
|
| Rate for Payer: Health EOS Commercial |
$58.74
|
| Rate for Payer: HFN Commercial |
$60.72
|
| Rate for Payer: Multiplan Commercial |
$52.80
|
| Rate for Payer: NAPHCARE Commercial |
$39.60
|
| Rate for Payer: Preferred Network Access Commercial |
$60.72
|
| Rate for Payer: Quartz Beloit One Network |
$32.34
|
| Rate for Payer: Quartz Commercial |
$39.60
|
| Rate for Payer: WEA Trust Commercial |
$36.30
|
| Rate for Payer: WPS Commercial |
$48.89
|
|
|
MESH PHASIX 6 X 8 (15.2CM X 20.3CM) 1190300
|
Facility
|
OP
|
$22,978.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5415170
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,433.84 |
| Max. Negotiated Rate |
$91,912.00 |
| Rate for Payer: Aetna Commercial |
$20,680.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,761.08
|
| Rate for Payer: Aetna Managed Medicare |
$6,433.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,935.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,489.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,029.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,178.34
|
| Rate for Payer: Cash Price |
$6,893.40
|
| Rate for Payer: Cigna Commercial |
$21,139.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,858.49
|
| Rate for Payer: Health EOS Commercial |
$20,450.42
|
| Rate for Payer: HFN Commercial |
$21,139.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,233.50
|
| Rate for Payer: Multiplan Commercial |
$18,382.40
|
| Rate for Payer: NAPHCARE Commercial |
$13,786.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21,139.76
|
| Rate for Payer: Quartz Beloit One Network |
$11,259.22
|
| Rate for Payer: Quartz Commercial |
$14,935.70
|
| Rate for Payer: Quartz Medicare Advantage |
$13,786.80
|
| Rate for Payer: The Alliance Commercial |
$91,912.00
|
| Rate for Payer: WEA Trust Commercial |
$12,637.90
|
| Rate for Payer: WPS Commercial |
$17,019.80
|
|
|
MESH PHASIX 6 X 8 (15.2CM X 20.3CM) 1190300
|
Facility
|
IP
|
$22,978.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5415170
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,259.22 |
| Max. Negotiated Rate |
$21,139.76 |
| Rate for Payer: Aetna Commercial |
$20,680.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,761.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,178.34
|
| Rate for Payer: Cash Price |
$6,893.40
|
| Rate for Payer: Cigna Commercial |
$21,139.76
|
| Rate for Payer: Health EOS Commercial |
$20,450.42
|
| Rate for Payer: HFN Commercial |
$21,139.76
|
| Rate for Payer: Multiplan Commercial |
$18,382.40
|
| Rate for Payer: NAPHCARE Commercial |
$13,786.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21,139.76
|
| Rate for Payer: Quartz Beloit One Network |
$11,259.22
|
| Rate for Payer: Quartz Commercial |
$13,786.80
|
| Rate for Payer: WEA Trust Commercial |
$12,637.90
|
| Rate for Payer: WPS Commercial |
$17,019.80
|
|
|
MESH PHASIX 8 X 10 (20.3CM X 25.4CM) 1190400
|
Facility
|
OP
|
$35,505.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5240649
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,941.40 |
| Max. Negotiated Rate |
$142,020.00 |
| Rate for Payer: Aetna Commercial |
$31,954.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30,534.30
|
| Rate for Payer: Aetna Managed Medicare |
$9,941.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,078.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,752.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,042.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,817.65
|
| Rate for Payer: Cash Price |
$10,651.50
|
| Rate for Payer: Cigna Commercial |
$32,664.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,868.60
|
| Rate for Payer: Health EOS Commercial |
$31,599.45
|
| Rate for Payer: HFN Commercial |
$32,664.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,628.75
|
| Rate for Payer: Multiplan Commercial |
$28,404.00
|
| Rate for Payer: NAPHCARE Commercial |
$21,303.00
|
| Rate for Payer: Preferred Network Access Commercial |
$32,664.60
|
| Rate for Payer: Quartz Beloit One Network |
$17,397.45
|
| Rate for Payer: Quartz Commercial |
$23,078.25
|
| Rate for Payer: Quartz Medicare Advantage |
$21,303.00
|
| Rate for Payer: The Alliance Commercial |
$142,020.00
|
| Rate for Payer: WEA Trust Commercial |
$19,527.75
|
| Rate for Payer: WPS Commercial |
$26,298.55
|
|
|
MESH PHASIX 8 X 10 (20.3CM X 25.4CM) 1190400
|
Facility
|
IP
|
$35,505.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5240649
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17,397.45 |
| Max. Negotiated Rate |
$32,664.60 |
| Rate for Payer: Aetna Commercial |
$31,954.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30,534.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,817.65
|
| Rate for Payer: Cash Price |
$10,651.50
|
| Rate for Payer: Cigna Commercial |
$32,664.60
|
| Rate for Payer: Health EOS Commercial |
$31,599.45
|
| Rate for Payer: HFN Commercial |
$32,664.60
|
| Rate for Payer: Multiplan Commercial |
$28,404.00
|
| Rate for Payer: NAPHCARE Commercial |
$21,303.00
|
| Rate for Payer: Preferred Network Access Commercial |
$32,664.60
|
| Rate for Payer: Quartz Beloit One Network |
$17,397.45
|
| Rate for Payer: Quartz Commercial |
$21,303.00
|
| Rate for Payer: WEA Trust Commercial |
$19,527.75
|
| Rate for Payer: WPS Commercial |
$26,298.55
|
|
|
MESH PHASIX PLUG & PATCH LARGE 1.5 IN X 1.9 IN 1190602
|
Facility
|
OP
|
$5,373.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5179161
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,504.44 |
| Max. Negotiated Rate |
$21,492.00 |
| Rate for Payer: Aetna Commercial |
$4,835.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,620.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,504.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,492.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,686.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,579.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,847.69
|
| Rate for Payer: Cash Price |
$1,611.90
|
| Rate for Payer: Cigna Commercial |
$4,943.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,006.73
|
| Rate for Payer: Health EOS Commercial |
$4,781.97
|
| Rate for Payer: HFN Commercial |
$4,943.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,029.75
|
| Rate for Payer: Multiplan Commercial |
$4,298.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,223.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,943.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,632.77
|
| Rate for Payer: Quartz Commercial |
$3,492.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,223.80
|
| Rate for Payer: The Alliance Commercial |
$21,492.00
|
| Rate for Payer: WEA Trust Commercial |
$2,955.15
|
| Rate for Payer: WPS Commercial |
$3,979.78
|
|
|
MESH PHASIX PLUG & PATCH LARGE 1.5 IN X 1.9 IN 1190602
|
Facility
|
IP
|
$5,373.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5179161
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,632.77 |
| Max. Negotiated Rate |
$4,943.16 |
| Rate for Payer: Aetna Commercial |
$4,835.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,620.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,847.69
|
| Rate for Payer: Cash Price |
$1,611.90
|
| Rate for Payer: Cigna Commercial |
$4,943.16
|
| Rate for Payer: Health EOS Commercial |
$4,781.97
|
| Rate for Payer: HFN Commercial |
$4,943.16
|
| Rate for Payer: Multiplan Commercial |
$4,298.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,223.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,943.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,632.77
|
| Rate for Payer: Quartz Commercial |
$3,223.80
|
| Rate for Payer: WEA Trust Commercial |
$2,955.15
|
| Rate for Payer: WPS Commercial |
$3,979.78
|
|
|
MESH PHASIX PLUG & PATCH MEDIUM 1.3 IN X 1.6 IN 1190601
|
Facility
|
IP
|
$4,454.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
6172832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,182.46 |
| Max. Negotiated Rate |
$4,097.68 |
| Rate for Payer: Aetna Commercial |
$4,008.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,830.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,360.62
|
| Rate for Payer: Cash Price |
$1,336.20
|
| Rate for Payer: Cigna Commercial |
$4,097.68
|
| Rate for Payer: Health EOS Commercial |
$3,964.06
|
| Rate for Payer: HFN Commercial |
$4,097.68
|
| Rate for Payer: Multiplan Commercial |
$3,563.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,672.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,097.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,182.46
|
| Rate for Payer: Quartz Commercial |
$2,672.40
|
| Rate for Payer: WEA Trust Commercial |
$2,449.70
|
| Rate for Payer: WPS Commercial |
$3,299.08
|
|
|
MESH PHASIX PLUG & PATCH MEDIUM 1.3 IN X 1.6 IN 1190601
|
Facility
|
OP
|
$4,454.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
6172832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,247.12 |
| Max. Negotiated Rate |
$17,816.00 |
| Rate for Payer: Aetna Commercial |
$4,008.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,830.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,247.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,895.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,227.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,137.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,360.62
|
| Rate for Payer: Cash Price |
$1,336.20
|
| Rate for Payer: Cigna Commercial |
$4,097.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,492.46
|
| Rate for Payer: Health EOS Commercial |
$3,964.06
|
| Rate for Payer: HFN Commercial |
$4,097.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,340.50
|
| Rate for Payer: Multiplan Commercial |
$3,563.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,672.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,097.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,182.46
|
| Rate for Payer: Quartz Commercial |
$2,895.10
|
| Rate for Payer: Quartz Medicare Advantage |
$2,672.40
|
| Rate for Payer: The Alliance Commercial |
$17,816.00
|
| Rate for Payer: WEA Trust Commercial |
$2,449.70
|
| Rate for Payer: WPS Commercial |
$3,299.08
|
|
|
MESH PHASIX PLUG & PATCH SMALL 1.0 IN X 1.4 IN 1190600
|
Facility
|
OP
|
$4,352.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
6172833
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.56 |
| Max. Negotiated Rate |
$17,408.00 |
| Rate for Payer: Aetna Commercial |
$3,916.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,742.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,218.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,828.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,176.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,088.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,306.56
|
| Rate for Payer: Cash Price |
$1,305.60
|
| Rate for Payer: Cigna Commercial |
$4,003.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,435.38
|
| Rate for Payer: Health EOS Commercial |
$3,873.28
|
| Rate for Payer: HFN Commercial |
$4,003.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,264.00
|
| Rate for Payer: Multiplan Commercial |
$3,481.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,611.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,003.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,132.48
|
| Rate for Payer: Quartz Commercial |
$2,828.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,611.20
|
| Rate for Payer: The Alliance Commercial |
$17,408.00
|
| Rate for Payer: WEA Trust Commercial |
$2,393.60
|
| Rate for Payer: WPS Commercial |
$3,223.53
|
|
|
MESH PHASIX PLUG & PATCH SMALL 1.0 IN X 1.4 IN 1190600
|
Facility
|
IP
|
$4,352.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
6172833
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,132.48 |
| Max. Negotiated Rate |
$4,003.84 |
| Rate for Payer: Aetna Commercial |
$3,916.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,742.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,306.56
|
| Rate for Payer: Cash Price |
$1,305.60
|
| Rate for Payer: Cigna Commercial |
$4,003.84
|
| Rate for Payer: Health EOS Commercial |
$3,873.28
|
| Rate for Payer: HFN Commercial |
$4,003.84
|
| Rate for Payer: Multiplan Commercial |
$3,481.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,611.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,003.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,132.48
|
| Rate for Payer: Quartz Commercial |
$2,611.20
|
| Rate for Payer: WEA Trust Commercial |
$2,393.60
|
| Rate for Payer: WPS Commercial |
$3,223.53
|
|
|
MESH PHASIX PLUG & PATCH X-LARGE 1.4 IN X 2.0 IN 1190603
|
Facility
|
IP
|
$4,648.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5179163
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,277.52 |
| Max. Negotiated Rate |
$4,276.16 |
| Rate for Payer: Aetna Commercial |
$4,183.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,997.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,463.44
|
| Rate for Payer: Cash Price |
$1,394.40
|
| Rate for Payer: Cigna Commercial |
$4,276.16
|
| Rate for Payer: Health EOS Commercial |
$4,136.72
|
| Rate for Payer: HFN Commercial |
$4,276.16
|
| Rate for Payer: Multiplan Commercial |
$3,718.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,788.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,276.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,277.52
|
| Rate for Payer: Quartz Commercial |
$2,788.80
|
| Rate for Payer: WEA Trust Commercial |
$2,556.40
|
| Rate for Payer: WPS Commercial |
$3,442.77
|
|
|
MESH PHASIX PLUG & PATCH X-LARGE 1.4 IN X 2.0 IN 1190603
|
Facility
|
OP
|
$4,648.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5179163
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,301.44 |
| Max. Negotiated Rate |
$18,592.00 |
| Rate for Payer: Aetna Commercial |
$4,183.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,997.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,301.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,021.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,324.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,231.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,463.44
|
| Rate for Payer: Cash Price |
$1,394.40
|
| Rate for Payer: Cigna Commercial |
$4,276.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,601.02
|
| Rate for Payer: Health EOS Commercial |
$4,136.72
|
| Rate for Payer: HFN Commercial |
$4,276.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,486.00
|
| Rate for Payer: Multiplan Commercial |
$3,718.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,788.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,276.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,277.52
|
| Rate for Payer: Quartz Commercial |
$3,021.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,788.80
|
| Rate for Payer: The Alliance Commercial |
$18,592.00
|
| Rate for Payer: WEA Trust Commercial |
$2,556.40
|
| Rate for Payer: WPS Commercial |
$3,442.77
|
|
|
MESH PHASIX ST 10 X 15 WITH ECHO 2.0 1211015
|
Facility
|
OP
|
$13,425.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5947630
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,759.00 |
| Max. Negotiated Rate |
$53,700.00 |
| Rate for Payer: Aetna Commercial |
$12,082.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,545.50
|
| Rate for Payer: Aetna Managed Medicare |
$3,759.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,726.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,712.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,444.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,115.25
|
| Rate for Payer: Cash Price |
$4,027.50
|
| Rate for Payer: Cigna Commercial |
$12,351.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,512.63
|
| Rate for Payer: Health EOS Commercial |
$11,948.25
|
| Rate for Payer: HFN Commercial |
$12,351.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,068.75
|
| Rate for Payer: Multiplan Commercial |
$10,740.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,055.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,351.00
|
| Rate for Payer: Quartz Beloit One Network |
$6,578.25
|
| Rate for Payer: Quartz Commercial |
$8,726.25
|
| Rate for Payer: Quartz Medicare Advantage |
$8,055.00
|
| Rate for Payer: The Alliance Commercial |
$53,700.00
|
| Rate for Payer: WEA Trust Commercial |
$7,383.75
|
| Rate for Payer: WPS Commercial |
$9,943.90
|
|
|
MESH PHASIX ST 10 X 15 WITH ECHO 2.0 1211015
|
Facility
|
IP
|
$13,425.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5947630
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,578.25 |
| Max. Negotiated Rate |
$12,351.00 |
| Rate for Payer: Aetna Commercial |
$12,082.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,545.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,115.25
|
| Rate for Payer: Cash Price |
$4,027.50
|
| Rate for Payer: Cigna Commercial |
$12,351.00
|
| Rate for Payer: Health EOS Commercial |
$11,948.25
|
| Rate for Payer: HFN Commercial |
$12,351.00
|
| Rate for Payer: Multiplan Commercial |
$10,740.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,055.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,351.00
|
| Rate for Payer: Quartz Beloit One Network |
$6,578.25
|
| Rate for Payer: Quartz Commercial |
$8,055.00
|
| Rate for Payer: WEA Trust Commercial |
$7,383.75
|
| Rate for Payer: WPS Commercial |
$9,943.90
|
|
|
MESH PHASIX ST 15 X 20 WITH ECHO 2.0 1211520
|
Facility
|
OP
|
$26,569.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5563519
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,439.32 |
| Max. Negotiated Rate |
$106,276.00 |
| Rate for Payer: Aetna Commercial |
$23,912.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,849.34
|
| Rate for Payer: Aetna Managed Medicare |
$7,439.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,269.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,284.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,753.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,081.57
|
| Rate for Payer: Cash Price |
$7,970.70
|
| Rate for Payer: Cigna Commercial |
$24,443.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,868.01
|
| Rate for Payer: Health EOS Commercial |
$23,646.41
|
| Rate for Payer: HFN Commercial |
$24,443.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,926.75
|
| Rate for Payer: Multiplan Commercial |
$21,255.20
|
| Rate for Payer: NAPHCARE Commercial |
$15,941.40
|
| Rate for Payer: Preferred Network Access Commercial |
$24,443.48
|
| Rate for Payer: Quartz Beloit One Network |
$13,018.81
|
| Rate for Payer: Quartz Commercial |
$17,269.85
|
| Rate for Payer: Quartz Medicare Advantage |
$15,941.40
|
| Rate for Payer: The Alliance Commercial |
$106,276.00
|
| Rate for Payer: WEA Trust Commercial |
$14,612.95
|
| Rate for Payer: WPS Commercial |
$19,679.66
|
|
|
MESH PHASIX ST 15 X 20 WITH ECHO 2.0 1211520
|
Facility
|
IP
|
$26,569.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5563519
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,018.81 |
| Max. Negotiated Rate |
$24,443.48 |
| Rate for Payer: Aetna Commercial |
$23,912.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,849.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,081.57
|
| Rate for Payer: Cash Price |
$7,970.70
|
| Rate for Payer: Cigna Commercial |
$24,443.48
|
| Rate for Payer: Health EOS Commercial |
$23,646.41
|
| Rate for Payer: HFN Commercial |
$24,443.48
|
| Rate for Payer: Multiplan Commercial |
$21,255.20
|
| Rate for Payer: NAPHCARE Commercial |
$15,941.40
|
| Rate for Payer: Preferred Network Access Commercial |
$24,443.48
|
| Rate for Payer: Quartz Beloit One Network |
$13,018.81
|
| Rate for Payer: Quartz Commercial |
$15,941.40
|
| Rate for Payer: WEA Trust Commercial |
$14,612.95
|
| Rate for Payer: WPS Commercial |
$19,679.66
|
|
|
MESH PHASIX ST 4.5 IN (11CM) WITH ECHO 2 1210011
|
Facility
|
OP
|
$13,710.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
6199027
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.80 |
| Max. Negotiated Rate |
$54,840.00 |
| Rate for Payer: Aetna Commercial |
$12,339.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,790.60
|
| Rate for Payer: Aetna Managed Medicare |
$3,838.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,911.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,855.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,580.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,266.30
|
| Rate for Payer: Cash Price |
$4,113.00
|
| Rate for Payer: Cigna Commercial |
$12,613.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,672.12
|
| Rate for Payer: Health EOS Commercial |
$12,201.90
|
| Rate for Payer: HFN Commercial |
$12,613.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,282.50
|
| Rate for Payer: Multiplan Commercial |
$10,968.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,226.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,613.20
|
| Rate for Payer: Quartz Beloit One Network |
$6,717.90
|
| Rate for Payer: Quartz Commercial |
$8,911.50
|
| Rate for Payer: Quartz Medicare Advantage |
$8,226.00
|
| Rate for Payer: The Alliance Commercial |
$54,840.00
|
| Rate for Payer: WEA Trust Commercial |
$7,540.50
|
| Rate for Payer: WPS Commercial |
$10,155.00
|
|
|
MESH PHASIX ST 4.5 IN (11CM) WITH ECHO 2 1210011
|
Facility
|
IP
|
$13,710.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
6199027
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,717.90 |
| Max. Negotiated Rate |
$12,613.20 |
| Rate for Payer: Aetna Commercial |
$12,339.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,790.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,266.30
|
| Rate for Payer: Cash Price |
$4,113.00
|
| Rate for Payer: Cigna Commercial |
$12,613.20
|
| Rate for Payer: Health EOS Commercial |
$12,201.90
|
| Rate for Payer: HFN Commercial |
$12,613.20
|
| Rate for Payer: Multiplan Commercial |
$10,968.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,226.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,613.20
|
| Rate for Payer: Quartz Beloit One Network |
$6,717.90
|
| Rate for Payer: Quartz Commercial |
$8,226.00
|
| Rate for Payer: WEA Trust Commercial |
$7,540.50
|
| Rate for Payer: WPS Commercial |
$10,155.00
|
|
|
MESH PHASIX ST 6 X 8 (15CM X 20CM) 1201520
|
Facility
|
IP
|
$24,406.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4594987
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,958.94 |
| Max. Negotiated Rate |
$22,453.52 |
| Rate for Payer: Aetna Commercial |
$21,965.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,989.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,935.18
|
| Rate for Payer: Cash Price |
$7,321.80
|
| Rate for Payer: Cigna Commercial |
$22,453.52
|
| Rate for Payer: Health EOS Commercial |
$21,721.34
|
| Rate for Payer: HFN Commercial |
$22,453.52
|
| Rate for Payer: Multiplan Commercial |
$19,524.80
|
| Rate for Payer: NAPHCARE Commercial |
$14,643.60
|
| Rate for Payer: Preferred Network Access Commercial |
$22,453.52
|
| Rate for Payer: Quartz Beloit One Network |
$11,958.94
|
| Rate for Payer: Quartz Commercial |
$14,643.60
|
| Rate for Payer: WEA Trust Commercial |
$13,423.30
|
| Rate for Payer: WPS Commercial |
$18,077.52
|
|
|
MESH PHASIX ST 6 X 8 (15CM X 20CM) 1201520
|
Facility
|
OP
|
$24,406.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4594987
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,833.68 |
| Max. Negotiated Rate |
$97,624.00 |
| Rate for Payer: Aetna Commercial |
$21,965.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,989.16
|
| Rate for Payer: Aetna Managed Medicare |
$6,833.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,863.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,203.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,714.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,935.18
|
| Rate for Payer: Cash Price |
$7,321.80
|
| Rate for Payer: Cigna Commercial |
$22,453.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,657.60
|
| Rate for Payer: Health EOS Commercial |
$21,721.34
|
| Rate for Payer: HFN Commercial |
$22,453.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,304.50
|
| Rate for Payer: Multiplan Commercial |
$19,524.80
|
| Rate for Payer: NAPHCARE Commercial |
$14,643.60
|
| Rate for Payer: Preferred Network Access Commercial |
$22,453.52
|
| Rate for Payer: Quartz Beloit One Network |
$11,958.94
|
| Rate for Payer: Quartz Commercial |
$15,863.90
|
| Rate for Payer: Quartz Medicare Advantage |
$14,643.60
|
| Rate for Payer: The Alliance Commercial |
$97,624.00
|
| Rate for Payer: WEA Trust Commercial |
$13,423.30
|
| Rate for Payer: WPS Commercial |
$18,077.52
|
|
|
MESH PHASIX ST 8 X 10 (20CM X 25CM) 1202025
|
Facility
|
OP
|
$51,873.00
|
|
| Hospital Charge Code |
5179114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14,524.44 |
| Max. Negotiated Rate |
$207,492.00 |
| Rate for Payer: Aetna Commercial |
$46,685.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44,610.78
|
| Rate for Payer: Aetna Managed Medicare |
$14,524.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33,717.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,936.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,899.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27,492.69
|
| Rate for Payer: Cash Price |
$15,561.90
|
| Rate for Payer: Cigna Commercial |
$47,723.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29,028.13
|
| Rate for Payer: Health EOS Commercial |
$46,166.97
|
| Rate for Payer: HFN Commercial |
$47,723.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38,904.75
|
| Rate for Payer: Multiplan Commercial |
$41,498.40
|
| Rate for Payer: NAPHCARE Commercial |
$31,123.80
|
| Rate for Payer: Preferred Network Access Commercial |
$47,723.16
|
| Rate for Payer: Quartz Beloit One Network |
$25,417.77
|
| Rate for Payer: Quartz Commercial |
$33,717.45
|
| Rate for Payer: Quartz Medicare Advantage |
$31,123.80
|
| Rate for Payer: The Alliance Commercial |
$207,492.00
|
| Rate for Payer: WEA Trust Commercial |
$28,530.15
|
| Rate for Payer: WPS Commercial |
$38,422.33
|
|
|
MESH PHASIX ST 8 X 10 (20CM X 25CM) 1202025
|
Facility
|
IP
|
$51,873.00
|
|
| Hospital Charge Code |
5179114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,417.77 |
| Max. Negotiated Rate |
$47,723.16 |
| Rate for Payer: Aetna Commercial |
$46,685.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44,610.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27,492.69
|
| Rate for Payer: Cash Price |
$15,561.90
|
| Rate for Payer: Cigna Commercial |
$47,723.16
|
| Rate for Payer: Health EOS Commercial |
$46,166.97
|
| Rate for Payer: HFN Commercial |
$47,723.16
|
| Rate for Payer: Multiplan Commercial |
$41,498.40
|
| Rate for Payer: NAPHCARE Commercial |
$31,123.80
|
| Rate for Payer: Preferred Network Access Commercial |
$47,723.16
|
| Rate for Payer: Quartz Beloit One Network |
$25,417.77
|
| Rate for Payer: Quartz Commercial |
$31,123.80
|
| Rate for Payer: WEA Trust Commercial |
$28,530.15
|
| Rate for Payer: WPS Commercial |
$38,422.33
|
|
|
MESH PHASIX ST 8 X 10 WITH ECHO 2.0 (20CM X 25CM) 1212025
|
Facility
|
OP
|
$42,950.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5563380
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,026.00 |
| Max. Negotiated Rate |
$171,800.00 |
| Rate for Payer: Aetna Commercial |
$38,655.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36,937.00
|
| Rate for Payer: Aetna Managed Medicare |
$12,026.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,917.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,475.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,616.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,763.50
|
| Rate for Payer: Cash Price |
$12,885.00
|
| Rate for Payer: Cigna Commercial |
$39,514.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24,034.82
|
| Rate for Payer: Health EOS Commercial |
$38,225.50
|
| Rate for Payer: HFN Commercial |
$39,514.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,212.50
|
| Rate for Payer: Multiplan Commercial |
$34,360.00
|
| Rate for Payer: NAPHCARE Commercial |
$25,770.00
|
| Rate for Payer: Preferred Network Access Commercial |
$39,514.00
|
| Rate for Payer: Quartz Beloit One Network |
$21,045.50
|
| Rate for Payer: Quartz Commercial |
$27,917.50
|
| Rate for Payer: Quartz Medicare Advantage |
$25,770.00
|
| Rate for Payer: The Alliance Commercial |
$171,800.00
|
| Rate for Payer: WEA Trust Commercial |
$23,622.50
|
| Rate for Payer: WPS Commercial |
$31,813.06
|
|
