|
MESH 3D MAX RT LARGE 0115321
|
Facility
|
IP
|
$3,139.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4594848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,599.63 |
| Max. Negotiated Rate |
$3,003.40 |
| Rate for Payer: Aetna Commercial |
$2,938.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,807.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,730.22
|
| Rate for Payer: Cash Price |
$941.70
|
| Rate for Payer: Cigna Commercial |
$3,003.40
|
| Rate for Payer: Health EOS Commercial |
$2,905.46
|
| Rate for Payer: HFN Commercial |
$3,003.40
|
| Rate for Payer: Multiplan Commercial |
$2,611.65
|
| Rate for Payer: Preferred Network Access Commercial |
$3,003.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,599.63
|
| Rate for Payer: Quartz Commercial |
$1,958.74
|
| Rate for Payer: WEA Trust Commercial |
$1,795.51
|
| Rate for Payer: WPS Commercial |
$2,417.97
|
|
|
MESH 3D MAX RT MED 0115320
|
Facility
|
IP
|
$2,869.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4594891
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,462.04 |
| Max. Negotiated Rate |
$2,745.06 |
| Rate for Payer: Aetna Commercial |
$2,685.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,566.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,581.39
|
| Rate for Payer: Cash Price |
$860.70
|
| Rate for Payer: Cigna Commercial |
$2,745.06
|
| Rate for Payer: Health EOS Commercial |
$2,655.55
|
| Rate for Payer: HFN Commercial |
$2,745.06
|
| Rate for Payer: Multiplan Commercial |
$2,387.01
|
| Rate for Payer: Preferred Network Access Commercial |
$2,745.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,462.04
|
| Rate for Payer: Quartz Commercial |
$1,790.26
|
| Rate for Payer: WEA Trust Commercial |
$1,641.07
|
| Rate for Payer: WPS Commercial |
$2,209.99
|
|
|
MESH 3D MAX RT MED 0115320
|
Facility
|
OP
|
$2,869.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4594891
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$835.45 |
| Max. Negotiated Rate |
$2,745.06 |
| Rate for Payer: Aetna Commercial |
$2,685.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,566.03
|
| Rate for Payer: Aetna Managed Medicare |
$835.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,939.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,491.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,432.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,581.39
|
| Rate for Payer: Cash Price |
$860.70
|
| Rate for Payer: Cigna Commercial |
$2,745.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,669.76
|
| Rate for Payer: Health EOS Commercial |
$2,655.55
|
| Rate for Payer: HFN Commercial |
$2,745.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,237.82
|
| Rate for Payer: Multiplan Commercial |
$2,387.01
|
| Rate for Payer: NAPHCARE Commercial |
$1,790.26
|
| Rate for Payer: Preferred Network Access Commercial |
$2,745.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,462.04
|
| Rate for Payer: Quartz Commercial |
$1,939.44
|
| Rate for Payer: Quartz Medicare Advantage |
$1,790.26
|
| Rate for Payer: The Alliance Commercial |
$1,491.88
|
| Rate for Payer: WEA Trust Commercial |
$1,641.07
|
| Rate for Payer: WPS Commercial |
$2,209.99
|
|
|
MESH 3 X 6 ULTRAPRO UMR3
|
Facility
|
OP
|
$1,519.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965543
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$442.33 |
| Max. Negotiated Rate |
$1,453.38 |
| Rate for Payer: Aetna Commercial |
$1,421.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,358.59
|
| Rate for Payer: Aetna Managed Medicare |
$442.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,026.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$789.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$758.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$837.27
|
| Rate for Payer: Cash Price |
$455.70
|
| Rate for Payer: Cigna Commercial |
$1,453.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$884.06
|
| Rate for Payer: Health EOS Commercial |
$1,405.99
|
| Rate for Payer: HFN Commercial |
$1,453.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,184.82
|
| Rate for Payer: Multiplan Commercial |
$1,263.81
|
| Rate for Payer: NAPHCARE Commercial |
$947.86
|
| Rate for Payer: Preferred Network Access Commercial |
$1,453.38
|
| Rate for Payer: Quartz Beloit One Network |
$774.08
|
| Rate for Payer: Quartz Commercial |
$1,026.84
|
| Rate for Payer: Quartz Medicare Advantage |
$947.86
|
| Rate for Payer: The Alliance Commercial |
$789.88
|
| Rate for Payer: WEA Trust Commercial |
$868.87
|
| Rate for Payer: WPS Commercial |
$1,170.09
|
|
|
MESH 3 X 6 ULTRAPRO UMR3
|
Facility
|
IP
|
$1,519.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965543
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$774.08 |
| Max. Negotiated Rate |
$1,453.38 |
| Rate for Payer: Aetna Commercial |
$1,421.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,358.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$837.27
|
| Rate for Payer: Cash Price |
$455.70
|
| Rate for Payer: Cigna Commercial |
$1,453.38
|
| Rate for Payer: Health EOS Commercial |
$1,405.99
|
| Rate for Payer: HFN Commercial |
$1,453.38
|
| Rate for Payer: Multiplan Commercial |
$1,263.81
|
| Rate for Payer: Preferred Network Access Commercial |
$1,453.38
|
| Rate for Payer: Quartz Beloit One Network |
$774.08
|
| Rate for Payer: Quartz Commercial |
$947.86
|
| Rate for Payer: WEA Trust Commercial |
$868.87
|
| Rate for Payer: WPS Commercial |
$1,170.09
|
|
|
MESH 4 X 6 OVAL PROCEED PCDN1
|
Facility
|
OP
|
$3,960.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965544
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,153.15 |
| Max. Negotiated Rate |
$3,788.93 |
| Rate for Payer: Aetna Commercial |
$3,706.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,541.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,153.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,676.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,059.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,976.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,182.75
|
| Rate for Payer: Cash Price |
$1,188.00
|
| Rate for Payer: Cigna Commercial |
$3,788.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,304.72
|
| Rate for Payer: Health EOS Commercial |
$3,665.38
|
| Rate for Payer: HFN Commercial |
$3,788.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,088.80
|
| Rate for Payer: Multiplan Commercial |
$3,294.72
|
| Rate for Payer: NAPHCARE Commercial |
$2,471.04
|
| Rate for Payer: Preferred Network Access Commercial |
$3,788.93
|
| Rate for Payer: Quartz Beloit One Network |
$2,018.02
|
| Rate for Payer: Quartz Commercial |
$2,676.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,471.04
|
| Rate for Payer: The Alliance Commercial |
$2,059.20
|
| Rate for Payer: WEA Trust Commercial |
$2,265.12
|
| Rate for Payer: WPS Commercial |
$3,050.39
|
|
|
MESH 4 X 6 OVAL PROCEED PCDN1
|
Facility
|
IP
|
$3,960.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965544
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,018.02 |
| Max. Negotiated Rate |
$3,788.93 |
| Rate for Payer: Aetna Commercial |
$3,706.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,541.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,182.75
|
| Rate for Payer: Cash Price |
$1,188.00
|
| Rate for Payer: Cigna Commercial |
$3,788.93
|
| Rate for Payer: Health EOS Commercial |
$3,665.38
|
| Rate for Payer: HFN Commercial |
$3,788.93
|
| Rate for Payer: Multiplan Commercial |
$3,294.72
|
| Rate for Payer: Preferred Network Access Commercial |
$3,788.93
|
| Rate for Payer: Quartz Beloit One Network |
$2,018.02
|
| Rate for Payer: Quartz Commercial |
$2,471.04
|
| Rate for Payer: WEA Trust Commercial |
$2,265.12
|
| Rate for Payer: WPS Commercial |
$3,050.39
|
|
|
MESH 4 X 6 PHYSIOMESH PHY1015V
|
Facility
|
OP
|
$4,630.00
|
|
| Hospital Charge Code |
2969371
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,348.26 |
| Max. Negotiated Rate |
$4,429.98 |
| Rate for Payer: Aetna Commercial |
$4,333.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,141.07
|
| Rate for Payer: Aetna Managed Medicare |
$1,348.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,129.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,407.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,311.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,552.06
|
| Rate for Payer: Cash Price |
$1,389.00
|
| Rate for Payer: Cigna Commercial |
$4,429.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,694.66
|
| Rate for Payer: Health EOS Commercial |
$4,285.53
|
| Rate for Payer: HFN Commercial |
$4,429.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,611.40
|
| Rate for Payer: Multiplan Commercial |
$3,852.16
|
| Rate for Payer: NAPHCARE Commercial |
$2,889.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4,429.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,359.45
|
| Rate for Payer: Quartz Commercial |
$3,129.88
|
| Rate for Payer: Quartz Medicare Advantage |
$2,889.12
|
| Rate for Payer: The Alliance Commercial |
$2,407.60
|
| Rate for Payer: WEA Trust Commercial |
$2,648.36
|
| Rate for Payer: WPS Commercial |
$3,566.49
|
|
|
MESH 4 X 6 PHYSIOMESH PHY1015V
|
Facility
|
IP
|
$4,630.00
|
|
| Hospital Charge Code |
2969371
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.45 |
| Max. Negotiated Rate |
$4,429.98 |
| Rate for Payer: Aetna Commercial |
$4,333.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,141.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,552.06
|
| Rate for Payer: Cash Price |
$1,389.00
|
| Rate for Payer: Cigna Commercial |
$4,429.98
|
| Rate for Payer: Health EOS Commercial |
$4,285.53
|
| Rate for Payer: HFN Commercial |
$4,429.98
|
| Rate for Payer: Multiplan Commercial |
$3,852.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4,429.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,359.45
|
| Rate for Payer: Quartz Commercial |
$2,889.12
|
| Rate for Payer: WEA Trust Commercial |
$2,648.36
|
| Rate for Payer: WPS Commercial |
$3,566.49
|
|
|
MESH 6 X 6 ULTRAPRO UMM3
|
Facility
|
OP
|
$1,929.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965545
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.72 |
| Max. Negotiated Rate |
$1,845.67 |
| Rate for Payer: Aetna Commercial |
$1,805.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,725.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,003.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,063.26
|
| Rate for Payer: Cash Price |
$578.70
|
| Rate for Payer: Cigna Commercial |
$1,845.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.68
|
| Rate for Payer: Health EOS Commercial |
$1,785.48
|
| Rate for Payer: HFN Commercial |
$1,845.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,504.62
|
| Rate for Payer: Multiplan Commercial |
$1,604.93
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,845.67
|
| Rate for Payer: Quartz Beloit One Network |
$983.02
|
| Rate for Payer: Quartz Commercial |
$1,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.70
|
| Rate for Payer: The Alliance Commercial |
$1,003.08
|
| Rate for Payer: WEA Trust Commercial |
$1,103.39
|
| Rate for Payer: WPS Commercial |
$1,485.91
|
|
|
MESH 6 X 6 ULTRAPRO UMM3
|
Facility
|
IP
|
$1,929.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965545
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$983.02 |
| Max. Negotiated Rate |
$1,845.67 |
| Rate for Payer: Aetna Commercial |
$1,805.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,725.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,063.26
|
| Rate for Payer: Cash Price |
$578.70
|
| Rate for Payer: Cigna Commercial |
$1,845.67
|
| Rate for Payer: Health EOS Commercial |
$1,785.48
|
| Rate for Payer: HFN Commercial |
$1,845.67
|
| Rate for Payer: Multiplan Commercial |
$1,604.93
|
| Rate for Payer: Preferred Network Access Commercial |
$1,845.67
|
| Rate for Payer: Quartz Beloit One Network |
$983.02
|
| Rate for Payer: Quartz Commercial |
$1,203.70
|
| Rate for Payer: WEA Trust Commercial |
$1,103.39
|
| Rate for Payer: WPS Commercial |
$1,485.91
|
|
|
MESH 6 X 8 OVAL PROCEED PCDG1
|
Facility
|
OP
|
$7,171.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965546
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,088.20 |
| Max. Negotiated Rate |
$6,861.21 |
| Rate for Payer: Aetna Commercial |
$6,712.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,413.74
|
| Rate for Payer: Aetna Managed Medicare |
$2,088.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,847.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,728.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,579.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,952.66
|
| Rate for Payer: Cash Price |
$2,151.30
|
| Rate for Payer: Cigna Commercial |
$6,861.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,173.52
|
| Rate for Payer: Health EOS Commercial |
$6,637.48
|
| Rate for Payer: HFN Commercial |
$6,861.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,593.38
|
| Rate for Payer: Multiplan Commercial |
$5,966.27
|
| Rate for Payer: NAPHCARE Commercial |
$4,474.70
|
| Rate for Payer: Preferred Network Access Commercial |
$6,861.21
|
| Rate for Payer: Quartz Beloit One Network |
$3,654.34
|
| Rate for Payer: Quartz Commercial |
$4,847.60
|
| Rate for Payer: Quartz Medicare Advantage |
$4,474.70
|
| Rate for Payer: The Alliance Commercial |
$3,728.92
|
| Rate for Payer: WEA Trust Commercial |
$4,101.81
|
| Rate for Payer: WPS Commercial |
$5,523.82
|
|
|
MESH 6 X 8 OVAL PROCEED PCDG1
|
Facility
|
IP
|
$7,171.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965546
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,654.34 |
| Max. Negotiated Rate |
$6,861.21 |
| Rate for Payer: Aetna Commercial |
$6,712.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,413.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,952.66
|
| Rate for Payer: Cash Price |
$2,151.30
|
| Rate for Payer: Cigna Commercial |
$6,861.21
|
| Rate for Payer: Health EOS Commercial |
$6,637.48
|
| Rate for Payer: HFN Commercial |
$6,861.21
|
| Rate for Payer: Multiplan Commercial |
$5,966.27
|
| Rate for Payer: Preferred Network Access Commercial |
$6,861.21
|
| Rate for Payer: Quartz Beloit One Network |
$3,654.34
|
| Rate for Payer: Quartz Commercial |
$4,474.70
|
| Rate for Payer: WEA Trust Commercial |
$4,101.81
|
| Rate for Payer: WPS Commercial |
$5,523.82
|
|
|
MESH 6 X 8 PHYSIOMESH PHY1520V
|
Facility
|
OP
|
$6,307.00
|
|
| Hospital Charge Code |
2969372
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,836.60 |
| Max. Negotiated Rate |
$6,034.54 |
| Rate for Payer: Aetna Commercial |
$5,903.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,640.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,836.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,263.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,279.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,148.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,476.42
|
| Rate for Payer: Cash Price |
$1,892.10
|
| Rate for Payer: Cigna Commercial |
$6,034.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,670.67
|
| Rate for Payer: Health EOS Commercial |
$5,837.76
|
| Rate for Payer: HFN Commercial |
$6,034.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,919.46
|
| Rate for Payer: Multiplan Commercial |
$5,247.42
|
| Rate for Payer: NAPHCARE Commercial |
$3,935.57
|
| Rate for Payer: Preferred Network Access Commercial |
$6,034.54
|
| Rate for Payer: Quartz Beloit One Network |
$3,214.05
|
| Rate for Payer: Quartz Commercial |
$4,263.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,935.57
|
| Rate for Payer: The Alliance Commercial |
$3,279.64
|
| Rate for Payer: WEA Trust Commercial |
$3,607.60
|
| Rate for Payer: WPS Commercial |
$4,858.28
|
|
|
MESH 6 X 8 PHYSIOMESH PHY1520V
|
Facility
|
IP
|
$6,307.00
|
|
| Hospital Charge Code |
2969372
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,214.05 |
| Max. Negotiated Rate |
$6,034.54 |
| Rate for Payer: Aetna Commercial |
$5,903.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,640.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,476.42
|
| Rate for Payer: Cash Price |
$1,892.10
|
| Rate for Payer: Cigna Commercial |
$6,034.54
|
| Rate for Payer: Health EOS Commercial |
$5,837.76
|
| Rate for Payer: HFN Commercial |
$6,034.54
|
| Rate for Payer: Multiplan Commercial |
$5,247.42
|
| Rate for Payer: Preferred Network Access Commercial |
$6,034.54
|
| Rate for Payer: Quartz Beloit One Network |
$3,214.05
|
| Rate for Payer: Quartz Commercial |
$3,935.57
|
| Rate for Payer: WEA Trust Commercial |
$3,607.60
|
| Rate for Payer: WPS Commercial |
$4,858.28
|
|
|
MESH 8 X 10 OVAL PROCEED PCDH1
|
Facility
|
OP
|
$7,732.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965547
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,251.56 |
| Max. Negotiated Rate |
$7,397.98 |
| Rate for Payer: Aetna Commercial |
$7,237.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,915.50
|
| Rate for Payer: Aetna Managed Medicare |
$2,251.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,226.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,020.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,859.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,261.88
|
| Rate for Payer: Cash Price |
$2,319.60
|
| Rate for Payer: Cigna Commercial |
$7,397.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,500.02
|
| Rate for Payer: Health EOS Commercial |
$7,156.74
|
| Rate for Payer: HFN Commercial |
$7,397.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,030.96
|
| Rate for Payer: Multiplan Commercial |
$6,433.02
|
| Rate for Payer: NAPHCARE Commercial |
$4,824.77
|
| Rate for Payer: Preferred Network Access Commercial |
$7,397.98
|
| Rate for Payer: Quartz Beloit One Network |
$3,940.23
|
| Rate for Payer: Quartz Commercial |
$5,226.83
|
| Rate for Payer: Quartz Medicare Advantage |
$4,824.77
|
| Rate for Payer: The Alliance Commercial |
$4,020.64
|
| Rate for Payer: WEA Trust Commercial |
$4,422.70
|
| Rate for Payer: WPS Commercial |
$5,955.96
|
|
|
MESH 8 X 10 OVAL PROCEED PCDH1
|
Facility
|
IP
|
$7,732.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965547
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,940.23 |
| Max. Negotiated Rate |
$7,397.98 |
| Rate for Payer: Aetna Commercial |
$7,237.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,915.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,261.88
|
| Rate for Payer: Cash Price |
$2,319.60
|
| Rate for Payer: Cigna Commercial |
$7,397.98
|
| Rate for Payer: Health EOS Commercial |
$7,156.74
|
| Rate for Payer: HFN Commercial |
$7,397.98
|
| Rate for Payer: Multiplan Commercial |
$6,433.02
|
| Rate for Payer: Preferred Network Access Commercial |
$7,397.98
|
| Rate for Payer: Quartz Beloit One Network |
$3,940.23
|
| Rate for Payer: Quartz Commercial |
$4,824.77
|
| Rate for Payer: WEA Trust Commercial |
$4,422.70
|
| Rate for Payer: WPS Commercial |
$5,955.96
|
|
|
MESH BARD SOFT 3 X 6CM 0117009
|
Facility
|
OP
|
$946.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998606
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$275.48 |
| Max. Negotiated Rate |
$905.13 |
| Rate for Payer: Aetna Commercial |
$885.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$846.10
|
| Rate for Payer: Aetna Managed Medicare |
$275.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$639.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$491.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$472.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$521.44
|
| Rate for Payer: Cash Price |
$283.80
|
| Rate for Payer: Cigna Commercial |
$905.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$550.57
|
| Rate for Payer: Health EOS Commercial |
$875.62
|
| Rate for Payer: HFN Commercial |
$905.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$737.88
|
| Rate for Payer: Multiplan Commercial |
$787.07
|
| Rate for Payer: NAPHCARE Commercial |
$590.30
|
| Rate for Payer: Preferred Network Access Commercial |
$905.13
|
| Rate for Payer: Quartz Beloit One Network |
$482.08
|
| Rate for Payer: Quartz Commercial |
$639.50
|
| Rate for Payer: Quartz Medicare Advantage |
$590.30
|
| Rate for Payer: The Alliance Commercial |
$491.92
|
| Rate for Payer: WEA Trust Commercial |
$541.11
|
| Rate for Payer: WPS Commercial |
$728.70
|
|
|
MESH BARD SOFT 3 X 6CM 0117009
|
Facility
|
IP
|
$946.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998606
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$482.08 |
| Max. Negotiated Rate |
$905.13 |
| Rate for Payer: Aetna Commercial |
$885.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$846.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$521.44
|
| Rate for Payer: Cash Price |
$283.80
|
| Rate for Payer: Cigna Commercial |
$905.13
|
| Rate for Payer: Health EOS Commercial |
$875.62
|
| Rate for Payer: HFN Commercial |
$905.13
|
| Rate for Payer: Multiplan Commercial |
$787.07
|
| Rate for Payer: Preferred Network Access Commercial |
$905.13
|
| Rate for Payer: Quartz Beloit One Network |
$482.08
|
| Rate for Payer: Quartz Commercial |
$590.30
|
| Rate for Payer: WEA Trust Commercial |
$541.11
|
| Rate for Payer: WPS Commercial |
$728.70
|
|
|
MESH DUAL BIO 10 x 15 x 1
|
Facility
|
IP
|
$4,759.00
|
|
| Hospital Charge Code |
2967380
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,425.19 |
| Max. Negotiated Rate |
$4,553.41 |
| Rate for Payer: Aetna Commercial |
$4,454.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,256.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,623.16
|
| Rate for Payer: Cash Price |
$1,427.70
|
| Rate for Payer: Cigna Commercial |
$4,553.41
|
| Rate for Payer: Health EOS Commercial |
$4,404.93
|
| Rate for Payer: HFN Commercial |
$4,553.41
|
| Rate for Payer: Multiplan Commercial |
$3,959.49
|
| Rate for Payer: Preferred Network Access Commercial |
$4,553.41
|
| Rate for Payer: Quartz Beloit One Network |
$2,425.19
|
| Rate for Payer: Quartz Commercial |
$2,969.62
|
| Rate for Payer: WEA Trust Commercial |
$2,722.15
|
| Rate for Payer: WPS Commercial |
$3,665.86
|
|
|
MESH DUAL BIO 10 x 15 x 1
|
Facility
|
OP
|
$4,759.00
|
|
| Hospital Charge Code |
2967380
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,385.82 |
| Max. Negotiated Rate |
$4,553.41 |
| Rate for Payer: Aetna Commercial |
$4,454.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,256.45
|
| Rate for Payer: Aetna Managed Medicare |
$1,385.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,217.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,474.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,375.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,623.16
|
| Rate for Payer: Cash Price |
$1,427.70
|
| Rate for Payer: Cigna Commercial |
$4,553.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,769.74
|
| Rate for Payer: Health EOS Commercial |
$4,404.93
|
| Rate for Payer: HFN Commercial |
$4,553.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,712.02
|
| Rate for Payer: Multiplan Commercial |
$3,959.49
|
| Rate for Payer: NAPHCARE Commercial |
$2,969.62
|
| Rate for Payer: Preferred Network Access Commercial |
$4,553.41
|
| Rate for Payer: Quartz Beloit One Network |
$2,425.19
|
| Rate for Payer: Quartz Commercial |
$3,217.08
|
| Rate for Payer: Quartz Medicare Advantage |
$2,969.62
|
| Rate for Payer: The Alliance Commercial |
$2,474.68
|
| Rate for Payer: WEA Trust Commercial |
$2,722.15
|
| Rate for Payer: WPS Commercial |
$3,665.86
|
|
|
MESH LARGE ULTRA PRO PLUG UPPL
|
Facility
|
OP
|
$3,002.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
3072517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$874.18 |
| Max. Negotiated Rate |
$2,872.31 |
| Rate for Payer: Aetna Commercial |
$2,809.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,684.99
|
| Rate for Payer: Aetna Managed Medicare |
$874.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,029.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,561.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,498.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,654.70
|
| Rate for Payer: Cash Price |
$900.60
|
| Rate for Payer: Cigna Commercial |
$2,872.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,747.16
|
| Rate for Payer: Health EOS Commercial |
$2,778.65
|
| Rate for Payer: HFN Commercial |
$2,872.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,341.56
|
| Rate for Payer: Multiplan Commercial |
$2,497.66
|
| Rate for Payer: NAPHCARE Commercial |
$1,873.25
|
| Rate for Payer: Preferred Network Access Commercial |
$2,872.31
|
| Rate for Payer: Quartz Beloit One Network |
$1,529.82
|
| Rate for Payer: Quartz Commercial |
$2,029.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,873.25
|
| Rate for Payer: The Alliance Commercial |
$1,561.04
|
| Rate for Payer: WEA Trust Commercial |
$1,717.14
|
| Rate for Payer: WPS Commercial |
$2,312.44
|
|
|
MESH LARGE ULTRA PRO PLUG UPPL
|
Facility
|
IP
|
$3,002.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
3072517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,529.82 |
| Max. Negotiated Rate |
$2,872.31 |
| Rate for Payer: Aetna Commercial |
$2,809.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,684.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,654.70
|
| Rate for Payer: Cash Price |
$900.60
|
| Rate for Payer: Cigna Commercial |
$2,872.31
|
| Rate for Payer: Health EOS Commercial |
$2,778.65
|
| Rate for Payer: HFN Commercial |
$2,872.31
|
| Rate for Payer: Multiplan Commercial |
$2,497.66
|
| Rate for Payer: Preferred Network Access Commercial |
$2,872.31
|
| Rate for Payer: Quartz Beloit One Network |
$1,529.82
|
| Rate for Payer: Quartz Commercial |
$1,873.25
|
| Rate for Payer: WEA Trust Commercial |
$1,717.14
|
| Rate for Payer: WPS Commercial |
$2,312.44
|
|
|
MESH MEDIUM ULTRA PRO PLUG UPPM
|
Facility
|
IP
|
$3,002.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,529.82 |
| Max. Negotiated Rate |
$2,872.31 |
| Rate for Payer: Aetna Commercial |
$2,809.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,684.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,654.70
|
| Rate for Payer: Cash Price |
$900.60
|
| Rate for Payer: Cigna Commercial |
$2,872.31
|
| Rate for Payer: Health EOS Commercial |
$2,778.65
|
| Rate for Payer: HFN Commercial |
$2,872.31
|
| Rate for Payer: Multiplan Commercial |
$2,497.66
|
| Rate for Payer: Preferred Network Access Commercial |
$2,872.31
|
| Rate for Payer: Quartz Beloit One Network |
$1,529.82
|
| Rate for Payer: Quartz Commercial |
$1,873.25
|
| Rate for Payer: WEA Trust Commercial |
$1,717.14
|
| Rate for Payer: WPS Commercial |
$2,312.44
|
|
|
MESH MEDIUM ULTRA PRO PLUG UPPM
|
Facility
|
OP
|
$3,002.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$874.18 |
| Max. Negotiated Rate |
$2,872.31 |
| Rate for Payer: Aetna Commercial |
$2,809.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,684.99
|
| Rate for Payer: Aetna Managed Medicare |
$874.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,029.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,561.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,498.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,654.70
|
| Rate for Payer: Cash Price |
$900.60
|
| Rate for Payer: Cigna Commercial |
$2,872.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,747.16
|
| Rate for Payer: Health EOS Commercial |
$2,778.65
|
| Rate for Payer: HFN Commercial |
$2,872.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,341.56
|
| Rate for Payer: Multiplan Commercial |
$2,497.66
|
| Rate for Payer: NAPHCARE Commercial |
$1,873.25
|
| Rate for Payer: Preferred Network Access Commercial |
$2,872.31
|
| Rate for Payer: Quartz Beloit One Network |
$1,529.82
|
| Rate for Payer: Quartz Commercial |
$2,029.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,873.25
|
| Rate for Payer: The Alliance Commercial |
$1,561.04
|
| Rate for Payer: WEA Trust Commercial |
$1,717.14
|
| Rate for Payer: WPS Commercial |
$2,312.44
|
|
