|
MESH PARIETENE DS 15CM X 10CM PPDS1510
|
Facility
|
OP
|
$3,239.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5384725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$943.20 |
| Max. Negotiated Rate |
$3,099.08 |
| Rate for Payer: Aetna Commercial |
$3,031.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,896.96
|
| Rate for Payer: Aetna Managed Medicare |
$943.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,189.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,684.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,616.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,785.34
|
| Rate for Payer: Cash Price |
$971.70
|
| Rate for Payer: Cigna Commercial |
$3,099.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,885.10
|
| Rate for Payer: Health EOS Commercial |
$2,998.02
|
| Rate for Payer: HFN Commercial |
$3,099.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,526.42
|
| Rate for Payer: Multiplan Commercial |
$2,694.85
|
| Rate for Payer: NAPHCARE Commercial |
$2,021.14
|
| Rate for Payer: Preferred Network Access Commercial |
$3,099.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,650.59
|
| Rate for Payer: Quartz Commercial |
$2,189.56
|
| Rate for Payer: Quartz Medicare Advantage |
$2,021.14
|
| Rate for Payer: The Alliance Commercial |
$1,684.28
|
| Rate for Payer: WEA Trust Commercial |
$1,852.71
|
| Rate for Payer: WPS Commercial |
$2,495.00
|
|
|
MESH PARIETENE DS 15CM X 10CM PPDS1510
|
Facility
|
IP
|
$3,239.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5384725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,650.59 |
| Max. Negotiated Rate |
$3,099.08 |
| Rate for Payer: Aetna Commercial |
$3,031.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,896.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,785.34
|
| Rate for Payer: Cash Price |
$971.70
|
| Rate for Payer: Cigna Commercial |
$3,099.08
|
| Rate for Payer: Health EOS Commercial |
$2,998.02
|
| Rate for Payer: HFN Commercial |
$3,099.08
|
| Rate for Payer: Multiplan Commercial |
$2,694.85
|
| Rate for Payer: Preferred Network Access Commercial |
$3,099.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,650.59
|
| Rate for Payer: Quartz Commercial |
$2,021.14
|
| Rate for Payer: WEA Trust Commercial |
$1,852.71
|
| Rate for Payer: WPS Commercial |
$2,495.00
|
|
|
MESH PARIETEX VENTRAL PATCH ROUND PCO4VP
|
Facility
|
OP
|
$3,681.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5306781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,071.91 |
| Max. Negotiated Rate |
$3,521.98 |
| Rate for Payer: Aetna Commercial |
$3,445.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,292.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,071.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,488.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,914.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,837.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,028.97
|
| Rate for Payer: Cash Price |
$1,104.30
|
| Rate for Payer: Cigna Commercial |
$3,521.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,142.34
|
| Rate for Payer: Health EOS Commercial |
$3,407.13
|
| Rate for Payer: HFN Commercial |
$3,521.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,871.18
|
| Rate for Payer: Multiplan Commercial |
$3,062.59
|
| Rate for Payer: NAPHCARE Commercial |
$2,296.94
|
| Rate for Payer: Preferred Network Access Commercial |
$3,521.98
|
| Rate for Payer: Quartz Beloit One Network |
$1,875.84
|
| Rate for Payer: Quartz Commercial |
$2,488.36
|
| Rate for Payer: Quartz Medicare Advantage |
$2,296.94
|
| Rate for Payer: The Alliance Commercial |
$1,914.12
|
| Rate for Payer: WEA Trust Commercial |
$2,105.53
|
| Rate for Payer: WPS Commercial |
$2,835.47
|
|
|
MESH PARIETEX VENTRAL PATCH ROUND PCO4VP
|
Facility
|
IP
|
$3,681.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5306781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,875.84 |
| Max. Negotiated Rate |
$3,521.98 |
| Rate for Payer: Aetna Commercial |
$3,445.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,292.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,028.97
|
| Rate for Payer: Cash Price |
$1,104.30
|
| Rate for Payer: Cigna Commercial |
$3,521.98
|
| Rate for Payer: Health EOS Commercial |
$3,407.13
|
| Rate for Payer: HFN Commercial |
$3,521.98
|
| Rate for Payer: Multiplan Commercial |
$3,062.59
|
| Rate for Payer: Preferred Network Access Commercial |
$3,521.98
|
| Rate for Payer: Quartz Beloit One Network |
$1,875.84
|
| Rate for Payer: Quartz Commercial |
$2,296.94
|
| Rate for Payer: WEA Trust Commercial |
$2,105.53
|
| Rate for Payer: WPS Commercial |
$2,835.47
|
|
|
MESH PERFIX PLUG & PATCH MEDIUM 1.3 IN X 1.55 IN 0112760
|
Facility
|
IP
|
$1,537.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965822
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$783.26 |
| Max. Negotiated Rate |
$1,470.60 |
| Rate for Payer: Aetna Commercial |
$1,438.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,374.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$847.19
|
| Rate for Payer: Cash Price |
$461.10
|
| Rate for Payer: Cigna Commercial |
$1,470.60
|
| Rate for Payer: Health EOS Commercial |
$1,422.65
|
| Rate for Payer: HFN Commercial |
$1,470.60
|
| Rate for Payer: Multiplan Commercial |
$1,278.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,470.60
|
| Rate for Payer: Quartz Beloit One Network |
$783.26
|
| Rate for Payer: Quartz Commercial |
$959.09
|
| Rate for Payer: WEA Trust Commercial |
$879.16
|
| Rate for Payer: WPS Commercial |
$1,183.95
|
|
|
MESH PERFIX PLUG & PATCH MEDIUM 1.3 IN X 1.55 IN 0112760
|
Facility
|
OP
|
$1,537.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965822
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$447.57 |
| Max. Negotiated Rate |
$1,470.60 |
| Rate for Payer: Aetna Commercial |
$1,438.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,374.69
|
| Rate for Payer: Aetna Managed Medicare |
$447.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,039.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$799.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$767.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$847.19
|
| Rate for Payer: Cash Price |
$461.10
|
| Rate for Payer: Cigna Commercial |
$1,470.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$894.53
|
| Rate for Payer: Health EOS Commercial |
$1,422.65
|
| Rate for Payer: HFN Commercial |
$1,470.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,198.86
|
| Rate for Payer: Multiplan Commercial |
$1,278.78
|
| Rate for Payer: NAPHCARE Commercial |
$959.09
|
| Rate for Payer: Preferred Network Access Commercial |
$1,470.60
|
| Rate for Payer: Quartz Beloit One Network |
$783.26
|
| Rate for Payer: Quartz Commercial |
$1,039.01
|
| Rate for Payer: Quartz Medicare Advantage |
$959.09
|
| Rate for Payer: The Alliance Commercial |
$799.24
|
| Rate for Payer: WEA Trust Commercial |
$879.16
|
| Rate for Payer: WPS Commercial |
$1,183.95
|
|
|
MESH PERFIX PLUG & PATCH SMALL 1 IN X 1.35 IN 0112750
|
Facility
|
IP
|
$1,481.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965823
|
|
Hospital Revenue Code
|
278
|
| 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
|
|
|
MESH PERFIX PLUG & PATCH SMALL 1 IN X 1.35 IN 0112750
|
Facility
|
OP
|
$1,481.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965823
|
|
Hospital Revenue Code
|
278
|
| 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
|
|
|
MESH PERFIX PLUG & PATCH X-LG 1.6 IN X 2 IN 0112780
|
Facility
|
IP
|
$2,986.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,521.67 |
| Max. Negotiated Rate |
$2,857.00 |
| Rate for Payer: Aetna Commercial |
$2,794.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,670.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,645.88
|
| Rate for Payer: Cash Price |
$895.80
|
| Rate for Payer: Cigna Commercial |
$2,857.00
|
| Rate for Payer: Health EOS Commercial |
$2,763.84
|
| Rate for Payer: HFN Commercial |
$2,857.00
|
| Rate for Payer: Multiplan Commercial |
$2,484.35
|
| Rate for Payer: Preferred Network Access Commercial |
$2,857.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,521.67
|
| Rate for Payer: Quartz Commercial |
$1,863.26
|
| Rate for Payer: WEA Trust Commercial |
$1,707.99
|
| Rate for Payer: WPS Commercial |
$2,300.12
|
|
|
MESH PERFIX PLUG & PATCH X-LG 1.6 IN X 2 IN 0112780
|
Facility
|
OP
|
$2,986.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$869.52 |
| Max. Negotiated Rate |
$2,857.00 |
| Rate for Payer: Aetna Commercial |
$2,794.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,670.68
|
| Rate for Payer: Aetna Managed Medicare |
$869.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,018.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,552.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,490.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,645.88
|
| Rate for Payer: Cash Price |
$895.80
|
| Rate for Payer: Cigna Commercial |
$2,857.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,737.85
|
| Rate for Payer: Health EOS Commercial |
$2,763.84
|
| Rate for Payer: HFN Commercial |
$2,857.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,329.08
|
| Rate for Payer: Multiplan Commercial |
$2,484.35
|
| Rate for Payer: NAPHCARE Commercial |
$1,863.26
|
| Rate for Payer: Preferred Network Access Commercial |
$2,857.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,521.67
|
| Rate for Payer: Quartz Commercial |
$2,018.54
|
| Rate for Payer: Quartz Medicare Advantage |
$1,863.26
|
| Rate for Payer: The Alliance Commercial |
$1,552.72
|
| Rate for Payer: WEA Trust Commercial |
$1,707.99
|
| Rate for Payer: WPS Commercial |
$2,300.12
|
|
|
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 |
$19.22 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Aetna Managed Medicare |
$19.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.41
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.48
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: NAPHCARE Commercial |
$41.18
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$44.62
|
| Rate for Payer: Quartz Medicare Advantage |
$41.18
|
| Rate for Payer: The Alliance Commercial |
$34.32
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$50.84
|
|
|
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 |
$33.63 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$41.18
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$50.84
|
|
|
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 |
$6,691.19 |
| Max. Negotiated Rate |
$21,985.35 |
| Rate for Payer: Aetna Commercial |
$21,507.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,551.52
|
| Rate for Payer: Aetna Managed Medicare |
$6,691.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,533.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,948.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,470.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,665.47
|
| Rate for Payer: Cash Price |
$6,893.40
|
| Rate for Payer: Cigna Commercial |
$21,985.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,373.20
|
| Rate for Payer: Health EOS Commercial |
$21,268.44
|
| Rate for Payer: HFN Commercial |
$21,985.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,922.84
|
| Rate for Payer: Multiplan Commercial |
$19,117.70
|
| Rate for Payer: NAPHCARE Commercial |
$14,338.27
|
| Rate for Payer: Preferred Network Access Commercial |
$21,985.35
|
| Rate for Payer: Quartz Beloit One Network |
$11,709.59
|
| Rate for Payer: Quartz Commercial |
$15,533.13
|
| Rate for Payer: Quartz Medicare Advantage |
$14,338.27
|
| Rate for Payer: The Alliance Commercial |
$11,948.56
|
| Rate for Payer: WEA Trust Commercial |
$13,143.42
|
| Rate for Payer: WPS Commercial |
$17,699.95
|
|
|
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 |
$11,709.59 |
| Max. Negotiated Rate |
$21,985.35 |
| Rate for Payer: Aetna Commercial |
$21,507.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,551.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,665.47
|
| Rate for Payer: Cash Price |
$6,893.40
|
| Rate for Payer: Cigna Commercial |
$21,985.35
|
| Rate for Payer: Health EOS Commercial |
$21,268.44
|
| Rate for Payer: HFN Commercial |
$21,985.35
|
| Rate for Payer: Multiplan Commercial |
$19,117.70
|
| Rate for Payer: Preferred Network Access Commercial |
$21,985.35
|
| Rate for Payer: Quartz Beloit One Network |
$11,709.59
|
| Rate for Payer: Quartz Commercial |
$14,338.27
|
| Rate for Payer: WEA Trust Commercial |
$13,143.42
|
| Rate for Payer: WPS Commercial |
$17,699.95
|
|
|
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 |
$10,339.06 |
| Max. Negotiated Rate |
$33,971.18 |
| Rate for Payer: Aetna Commercial |
$33,232.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31,755.67
|
| Rate for Payer: Aetna Managed Medicare |
$10,339.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,001.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,462.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,724.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,570.36
|
| Rate for Payer: Cash Price |
$10,651.50
|
| Rate for Payer: Cigna Commercial |
$33,971.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,663.91
|
| Rate for Payer: Health EOS Commercial |
$32,863.43
|
| Rate for Payer: HFN Commercial |
$33,971.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,693.90
|
| Rate for Payer: Multiplan Commercial |
$29,540.16
|
| Rate for Payer: NAPHCARE Commercial |
$22,155.12
|
| Rate for Payer: Preferred Network Access Commercial |
$33,971.18
|
| Rate for Payer: Quartz Beloit One Network |
$18,093.35
|
| Rate for Payer: Quartz Commercial |
$24,001.38
|
| Rate for Payer: Quartz Medicare Advantage |
$22,155.12
|
| Rate for Payer: The Alliance Commercial |
$18,462.60
|
| Rate for Payer: WEA Trust Commercial |
$20,308.86
|
| Rate for Payer: WPS Commercial |
$27,349.50
|
|
|
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 |
$18,093.35 |
| Max. Negotiated Rate |
$33,971.18 |
| Rate for Payer: Aetna Commercial |
$33,232.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31,755.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,570.36
|
| Rate for Payer: Cash Price |
$10,651.50
|
| Rate for Payer: Cigna Commercial |
$33,971.18
|
| Rate for Payer: Health EOS Commercial |
$32,863.43
|
| Rate for Payer: HFN Commercial |
$33,971.18
|
| Rate for Payer: Multiplan Commercial |
$29,540.16
|
| Rate for Payer: Preferred Network Access Commercial |
$33,971.18
|
| Rate for Payer: Quartz Beloit One Network |
$18,093.35
|
| Rate for Payer: Quartz Commercial |
$22,155.12
|
| Rate for Payer: WEA Trust Commercial |
$20,308.86
|
| Rate for Payer: WPS Commercial |
$27,349.50
|
|
|
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 |
$1,564.62 |
| Max. Negotiated Rate |
$5,140.89 |
| Rate for Payer: Aetna Commercial |
$5,029.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,805.61
|
| Rate for Payer: Aetna Managed Medicare |
$1,564.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,632.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,793.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,682.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,961.60
|
| Rate for Payer: Cash Price |
$1,611.90
|
| Rate for Payer: Cigna Commercial |
$5,140.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,127.09
|
| Rate for Payer: Health EOS Commercial |
$4,973.25
|
| Rate for Payer: HFN Commercial |
$5,140.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,190.94
|
| Rate for Payer: Multiplan Commercial |
$4,470.34
|
| Rate for Payer: NAPHCARE Commercial |
$3,352.75
|
| Rate for Payer: Preferred Network Access Commercial |
$5,140.89
|
| Rate for Payer: Quartz Beloit One Network |
$2,738.08
|
| Rate for Payer: Quartz Commercial |
$3,632.15
|
| Rate for Payer: Quartz Medicare Advantage |
$3,352.75
|
| Rate for Payer: The Alliance Commercial |
$2,793.96
|
| Rate for Payer: WEA Trust Commercial |
$3,073.36
|
| Rate for Payer: WPS Commercial |
$4,138.82
|
|
|
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 |
$2,738.08 |
| Max. Negotiated Rate |
$5,140.89 |
| Rate for Payer: Aetna Commercial |
$5,029.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,805.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,961.60
|
| Rate for Payer: Cash Price |
$1,611.90
|
| Rate for Payer: Cigna Commercial |
$5,140.89
|
| Rate for Payer: Health EOS Commercial |
$4,973.25
|
| Rate for Payer: HFN Commercial |
$5,140.89
|
| Rate for Payer: Multiplan Commercial |
$4,470.34
|
| Rate for Payer: Preferred Network Access Commercial |
$5,140.89
|
| Rate for Payer: Quartz Beloit One Network |
$2,738.08
|
| Rate for Payer: Quartz Commercial |
$3,352.75
|
| Rate for Payer: WEA Trust Commercial |
$3,073.36
|
| Rate for Payer: WPS Commercial |
$4,138.82
|
|
|
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 |
$2,269.76 |
| Max. Negotiated Rate |
$4,261.59 |
| Rate for Payer: Aetna Commercial |
$4,168.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,983.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,455.04
|
| Rate for Payer: Cash Price |
$1,336.20
|
| Rate for Payer: Cigna Commercial |
$4,261.59
|
| Rate for Payer: Health EOS Commercial |
$4,122.62
|
| Rate for Payer: HFN Commercial |
$4,261.59
|
| Rate for Payer: Multiplan Commercial |
$3,705.73
|
| Rate for Payer: Preferred Network Access Commercial |
$4,261.59
|
| Rate for Payer: Quartz Beloit One Network |
$2,269.76
|
| Rate for Payer: Quartz Commercial |
$2,779.30
|
| Rate for Payer: WEA Trust Commercial |
$2,547.69
|
| Rate for Payer: WPS Commercial |
$3,430.92
|
|
|
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 |
$1,297.00 |
| Max. Negotiated Rate |
$4,261.59 |
| Rate for Payer: Aetna Commercial |
$4,168.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,983.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,297.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,010.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,316.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,223.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,455.04
|
| Rate for Payer: Cash Price |
$1,336.20
|
| Rate for Payer: Cigna Commercial |
$4,261.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,592.23
|
| Rate for Payer: Health EOS Commercial |
$4,122.62
|
| Rate for Payer: HFN Commercial |
$4,261.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,474.12
|
| Rate for Payer: Multiplan Commercial |
$3,705.73
|
| Rate for Payer: NAPHCARE Commercial |
$2,779.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,261.59
|
| Rate for Payer: Quartz Beloit One Network |
$2,269.76
|
| Rate for Payer: Quartz Commercial |
$3,010.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,779.30
|
| Rate for Payer: The Alliance Commercial |
$2,316.08
|
| Rate for Payer: WEA Trust Commercial |
$2,547.69
|
| Rate for Payer: WPS Commercial |
$3,430.92
|
|
|
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 |
$2,217.78 |
| Max. Negotiated Rate |
$4,163.99 |
| Rate for Payer: Aetna Commercial |
$4,073.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,892.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,398.82
|
| Rate for Payer: Cash Price |
$1,305.60
|
| Rate for Payer: Cigna Commercial |
$4,163.99
|
| Rate for Payer: Health EOS Commercial |
$4,028.21
|
| Rate for Payer: HFN Commercial |
$4,163.99
|
| Rate for Payer: Multiplan Commercial |
$3,620.86
|
| Rate for Payer: Preferred Network Access Commercial |
$4,163.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,217.78
|
| Rate for Payer: Quartz Commercial |
$2,715.65
|
| Rate for Payer: WEA Trust Commercial |
$2,489.34
|
| Rate for Payer: WPS Commercial |
$3,352.35
|
|
|
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 |
$1,267.30 |
| Max. Negotiated Rate |
$4,163.99 |
| Rate for Payer: Aetna Commercial |
$4,073.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,892.43
|
| Rate for Payer: Aetna Managed Medicare |
$1,267.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,941.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,263.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,172.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,398.82
|
| Rate for Payer: Cash Price |
$1,305.60
|
| Rate for Payer: Cigna Commercial |
$4,163.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,532.86
|
| Rate for Payer: Health EOS Commercial |
$4,028.21
|
| Rate for Payer: HFN Commercial |
$4,163.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,394.56
|
| Rate for Payer: Multiplan Commercial |
$3,620.86
|
| Rate for Payer: NAPHCARE Commercial |
$2,715.65
|
| Rate for Payer: Preferred Network Access Commercial |
$4,163.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,217.78
|
| Rate for Payer: Quartz Commercial |
$2,941.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,715.65
|
| Rate for Payer: The Alliance Commercial |
$2,263.04
|
| Rate for Payer: WEA Trust Commercial |
$2,489.34
|
| Rate for Payer: WPS Commercial |
$3,352.35
|
|
|
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 |
$2,368.62 |
| Max. Negotiated Rate |
$4,447.21 |
| Rate for Payer: Aetna Commercial |
$4,350.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,157.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,561.98
|
| Rate for Payer: Cash Price |
$1,394.40
|
| Rate for Payer: Cigna Commercial |
$4,447.21
|
| Rate for Payer: Health EOS Commercial |
$4,302.19
|
| Rate for Payer: HFN Commercial |
$4,447.21
|
| Rate for Payer: Multiplan Commercial |
$3,867.14
|
| Rate for Payer: Preferred Network Access Commercial |
$4,447.21
|
| Rate for Payer: Quartz Beloit One Network |
$2,368.62
|
| Rate for Payer: Quartz Commercial |
$2,900.35
|
| Rate for Payer: WEA Trust Commercial |
$2,658.66
|
| Rate for Payer: WPS Commercial |
$3,580.35
|
|
|
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 |
$1,353.50 |
| Max. Negotiated Rate |
$4,447.21 |
| Rate for Payer: Aetna Commercial |
$4,350.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,157.17
|
| Rate for Payer: Aetna Managed Medicare |
$1,353.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,142.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,416.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,320.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,561.98
|
| Rate for Payer: Cash Price |
$1,394.40
|
| Rate for Payer: Cigna Commercial |
$4,447.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,705.14
|
| Rate for Payer: Health EOS Commercial |
$4,302.19
|
| Rate for Payer: HFN Commercial |
$4,447.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,625.44
|
| Rate for Payer: Multiplan Commercial |
$3,867.14
|
| Rate for Payer: NAPHCARE Commercial |
$2,900.35
|
| Rate for Payer: Preferred Network Access Commercial |
$4,447.21
|
| Rate for Payer: Quartz Beloit One Network |
$2,368.62
|
| Rate for Payer: Quartz Commercial |
$3,142.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,900.35
|
| Rate for Payer: The Alliance Commercial |
$2,416.96
|
| Rate for Payer: WEA Trust Commercial |
$2,658.66
|
| Rate for Payer: WPS Commercial |
$3,580.35
|
|
|
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 |
$3,909.36 |
| Max. Negotiated Rate |
$12,845.04 |
| Rate for Payer: Aetna Commercial |
$12,565.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,007.32
|
| Rate for Payer: Aetna Managed Medicare |
$3,909.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,075.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,981.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,701.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,399.86
|
| Rate for Payer: Cash Price |
$4,027.50
|
| Rate for Payer: Cigna Commercial |
$12,845.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,813.35
|
| Rate for Payer: Health EOS Commercial |
$12,426.18
|
| Rate for Payer: HFN Commercial |
$12,845.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,471.50
|
| Rate for Payer: Multiplan Commercial |
$11,169.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,377.20
|
| Rate for Payer: Preferred Network Access Commercial |
$12,845.04
|
| Rate for Payer: Quartz Beloit One Network |
$6,841.38
|
| Rate for Payer: Quartz Commercial |
$9,075.30
|
| Rate for Payer: Quartz Medicare Advantage |
$8,377.20
|
| Rate for Payer: The Alliance Commercial |
$6,981.00
|
| Rate for Payer: WEA Trust Commercial |
$7,679.10
|
| Rate for Payer: WPS Commercial |
$10,341.28
|
|
