|
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 |
$6,841.38 |
| 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: 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: Health EOS Commercial |
$12,426.18
|
| Rate for Payer: HFN Commercial |
$12,845.04
|
| Rate for Payer: Multiplan Commercial |
$11,169.60
|
| 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 |
$8,377.20
|
| Rate for Payer: WEA Trust Commercial |
$7,679.10
|
| Rate for Payer: WPS Commercial |
$10,341.28
|
|
|
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 |
$7,736.89 |
| Max. Negotiated Rate |
$25,421.22 |
| Rate for Payer: Aetna Commercial |
$24,868.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23,763.31
|
| Rate for Payer: Aetna Managed Medicare |
$7,736.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,960.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,815.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,263.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,644.83
|
| Rate for Payer: Cash Price |
$7,970.70
|
| Rate for Payer: Cigna Commercial |
$25,421.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,463.16
|
| Rate for Payer: Health EOS Commercial |
$24,592.27
|
| Rate for Payer: HFN Commercial |
$25,421.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,723.82
|
| Rate for Payer: Multiplan Commercial |
$22,105.41
|
| Rate for Payer: NAPHCARE Commercial |
$16,579.06
|
| Rate for Payer: Preferred Network Access Commercial |
$25,421.22
|
| Rate for Payer: Quartz Beloit One Network |
$13,539.56
|
| Rate for Payer: Quartz Commercial |
$17,960.64
|
| Rate for Payer: Quartz Medicare Advantage |
$16,579.06
|
| Rate for Payer: The Alliance Commercial |
$13,815.88
|
| Rate for Payer: WEA Trust Commercial |
$15,197.47
|
| Rate for Payer: WPS Commercial |
$20,466.10
|
|
|
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 |
$13,539.56 |
| Max. Negotiated Rate |
$25,421.22 |
| Rate for Payer: Aetna Commercial |
$24,868.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23,763.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,644.83
|
| Rate for Payer: Cash Price |
$7,970.70
|
| Rate for Payer: Cigna Commercial |
$25,421.22
|
| Rate for Payer: Health EOS Commercial |
$24,592.27
|
| Rate for Payer: HFN Commercial |
$25,421.22
|
| Rate for Payer: Multiplan Commercial |
$22,105.41
|
| Rate for Payer: Preferred Network Access Commercial |
$25,421.22
|
| Rate for Payer: Quartz Beloit One Network |
$13,539.56
|
| Rate for Payer: Quartz Commercial |
$16,579.06
|
| Rate for Payer: WEA Trust Commercial |
$15,197.47
|
| Rate for Payer: WPS Commercial |
$20,466.10
|
|
|
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 |
$3,992.35 |
| Max. Negotiated Rate |
$13,117.73 |
| Rate for Payer: Aetna Commercial |
$12,832.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,262.22
|
| Rate for Payer: Aetna Managed Medicare |
$3,992.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,267.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,129.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,844.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,556.95
|
| Rate for Payer: Cash Price |
$4,113.00
|
| Rate for Payer: Cigna Commercial |
$13,117.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,979.22
|
| Rate for Payer: Health EOS Commercial |
$12,689.98
|
| Rate for Payer: HFN Commercial |
$13,117.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,693.80
|
| Rate for Payer: Multiplan Commercial |
$11,406.72
|
| Rate for Payer: NAPHCARE Commercial |
$8,555.04
|
| Rate for Payer: Preferred Network Access Commercial |
$13,117.73
|
| Rate for Payer: Quartz Beloit One Network |
$6,986.62
|
| Rate for Payer: Quartz Commercial |
$9,267.96
|
| Rate for Payer: Quartz Medicare Advantage |
$8,555.04
|
| Rate for Payer: The Alliance Commercial |
$7,129.20
|
| Rate for Payer: WEA Trust Commercial |
$7,842.12
|
| Rate for Payer: WPS Commercial |
$10,560.81
|
|
|
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 |
$6,986.62 |
| Max. Negotiated Rate |
$13,117.73 |
| Rate for Payer: Aetna Commercial |
$12,832.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,262.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,556.95
|
| Rate for Payer: Cash Price |
$4,113.00
|
| Rate for Payer: Cigna Commercial |
$13,117.73
|
| Rate for Payer: Health EOS Commercial |
$12,689.98
|
| Rate for Payer: HFN Commercial |
$13,117.73
|
| Rate for Payer: Multiplan Commercial |
$11,406.72
|
| Rate for Payer: Preferred Network Access Commercial |
$13,117.73
|
| Rate for Payer: Quartz Beloit One Network |
$6,986.62
|
| Rate for Payer: Quartz Commercial |
$8,555.04
|
| Rate for Payer: WEA Trust Commercial |
$7,842.12
|
| Rate for Payer: WPS Commercial |
$10,560.81
|
|
|
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 |
$12,437.30 |
| Max. Negotiated Rate |
$23,351.66 |
| Rate for Payer: Aetna Commercial |
$22,844.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,828.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,452.59
|
| Rate for Payer: Cash Price |
$7,321.80
|
| Rate for Payer: Cigna Commercial |
$23,351.66
|
| Rate for Payer: Health EOS Commercial |
$22,590.19
|
| Rate for Payer: HFN Commercial |
$23,351.66
|
| Rate for Payer: Multiplan Commercial |
$20,305.79
|
| Rate for Payer: Preferred Network Access Commercial |
$23,351.66
|
| Rate for Payer: Quartz Beloit One Network |
$12,437.30
|
| Rate for Payer: Quartz Commercial |
$15,229.34
|
| Rate for Payer: WEA Trust Commercial |
$13,960.23
|
| Rate for Payer: WPS Commercial |
$18,799.94
|
|
|
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 |
$7,107.03 |
| Max. Negotiated Rate |
$23,351.66 |
| Rate for Payer: Aetna Commercial |
$22,844.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,828.73
|
| Rate for Payer: Aetna Managed Medicare |
$7,107.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,498.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,691.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,183.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,452.59
|
| Rate for Payer: Cash Price |
$7,321.80
|
| Rate for Payer: Cigna Commercial |
$23,351.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,204.29
|
| Rate for Payer: Health EOS Commercial |
$22,590.19
|
| Rate for Payer: HFN Commercial |
$23,351.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,036.68
|
| Rate for Payer: Multiplan Commercial |
$20,305.79
|
| Rate for Payer: NAPHCARE Commercial |
$15,229.34
|
| Rate for Payer: Preferred Network Access Commercial |
$23,351.66
|
| Rate for Payer: Quartz Beloit One Network |
$12,437.30
|
| Rate for Payer: Quartz Commercial |
$16,498.46
|
| Rate for Payer: Quartz Medicare Advantage |
$15,229.34
|
| Rate for Payer: The Alliance Commercial |
$12,691.12
|
| Rate for Payer: WEA Trust Commercial |
$13,960.23
|
| Rate for Payer: WPS Commercial |
$18,799.94
|
|
|
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 |
$15,105.42 |
| Max. Negotiated Rate |
$49,632.09 |
| Rate for Payer: Aetna Commercial |
$48,553.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46,395.21
|
| Rate for Payer: Aetna Managed Medicare |
$15,105.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35,066.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,973.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,895.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28,592.40
|
| Rate for Payer: Cash Price |
$15,561.90
|
| Rate for Payer: Cigna Commercial |
$49,632.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30,190.09
|
| Rate for Payer: Health EOS Commercial |
$48,013.65
|
| Rate for Payer: HFN Commercial |
$49,632.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40,460.94
|
| Rate for Payer: Multiplan Commercial |
$43,158.34
|
| Rate for Payer: NAPHCARE Commercial |
$32,368.75
|
| Rate for Payer: Preferred Network Access Commercial |
$49,632.09
|
| Rate for Payer: Quartz Beloit One Network |
$26,434.48
|
| Rate for Payer: Quartz Commercial |
$35,066.15
|
| Rate for Payer: Quartz Medicare Advantage |
$32,368.75
|
| Rate for Payer: The Alliance Commercial |
$26,973.96
|
| Rate for Payer: WEA Trust Commercial |
$29,671.36
|
| Rate for Payer: WPS Commercial |
$39,957.77
|
|
|
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 |
$26,434.48 |
| Max. Negotiated Rate |
$49,632.09 |
| Rate for Payer: Aetna Commercial |
$48,553.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46,395.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28,592.40
|
| Rate for Payer: Cash Price |
$15,561.90
|
| Rate for Payer: Cigna Commercial |
$49,632.09
|
| Rate for Payer: Health EOS Commercial |
$48,013.65
|
| Rate for Payer: HFN Commercial |
$49,632.09
|
| Rate for Payer: Multiplan Commercial |
$43,158.34
|
| Rate for Payer: Preferred Network Access Commercial |
$49,632.09
|
| Rate for Payer: Quartz Beloit One Network |
$26,434.48
|
| Rate for Payer: Quartz Commercial |
$32,368.75
|
| Rate for Payer: WEA Trust Commercial |
$29,671.36
|
| Rate for Payer: WPS Commercial |
$39,957.77
|
|
|
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 |
$12,507.04 |
| Max. Negotiated Rate |
$41,094.56 |
| Rate for Payer: Aetna Commercial |
$40,201.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38,414.48
|
| Rate for Payer: Aetna Managed Medicare |
$12,507.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,034.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,334.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,440.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23,674.04
|
| Rate for Payer: Cash Price |
$12,885.00
|
| Rate for Payer: Cigna Commercial |
$41,094.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24,996.90
|
| Rate for Payer: Health EOS Commercial |
$39,754.52
|
| Rate for Payer: HFN Commercial |
$41,094.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33,501.00
|
| Rate for Payer: Multiplan Commercial |
$35,734.40
|
| Rate for Payer: NAPHCARE Commercial |
$26,800.80
|
| Rate for Payer: Preferred Network Access Commercial |
$41,094.56
|
| Rate for Payer: Quartz Beloit One Network |
$21,887.32
|
| Rate for Payer: Quartz Commercial |
$29,034.20
|
| Rate for Payer: Quartz Medicare Advantage |
$26,800.80
|
| Rate for Payer: The Alliance Commercial |
$22,334.00
|
| Rate for Payer: WEA Trust Commercial |
$24,567.40
|
| Rate for Payer: WPS Commercial |
$33,084.39
|
|
|
MESH PHASIX ST 8 X 10 WITH ECHO 2.0 (20CM X 25CM) 1212025
|
Facility
|
IP
|
$42,950.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
5563380
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,887.32 |
| Max. Negotiated Rate |
$41,094.56 |
| Rate for Payer: Aetna Commercial |
$40,201.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38,414.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23,674.04
|
| Rate for Payer: Cash Price |
$12,885.00
|
| Rate for Payer: Cigna Commercial |
$41,094.56
|
| Rate for Payer: Health EOS Commercial |
$39,754.52
|
| Rate for Payer: HFN Commercial |
$41,094.56
|
| Rate for Payer: Multiplan Commercial |
$35,734.40
|
| Rate for Payer: Preferred Network Access Commercial |
$41,094.56
|
| Rate for Payer: Quartz Beloit One Network |
$21,887.32
|
| Rate for Payer: Quartz Commercial |
$26,800.80
|
| Rate for Payer: WEA Trust Commercial |
$24,567.40
|
| Rate for Payer: WPS Commercial |
$33,084.39
|
|
|
MESH PROCEED VENTRAL MED CIRCLE PVPM
|
Facility
|
OP
|
$4,454.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965549
|
|
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 PROCEED VENTRAL MED CIRCLE PVPM
|
Facility
|
IP
|
$4,454.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965549
|
|
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 PROCEED VENTRAL SM CIRCLE PVPS
|
Facility
|
IP
|
$3,724.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965551
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,897.75 |
| Max. Negotiated Rate |
$3,563.12 |
| Rate for Payer: Aetna Commercial |
$3,485.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,330.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,052.67
|
| Rate for Payer: Cash Price |
$1,117.20
|
| Rate for Payer: Cigna Commercial |
$3,563.12
|
| Rate for Payer: Health EOS Commercial |
$3,446.93
|
| Rate for Payer: HFN Commercial |
$3,563.12
|
| Rate for Payer: Multiplan Commercial |
$3,098.37
|
| Rate for Payer: Preferred Network Access Commercial |
$3,563.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,897.75
|
| Rate for Payer: Quartz Commercial |
$2,323.78
|
| Rate for Payer: WEA Trust Commercial |
$2,130.13
|
| Rate for Payer: WPS Commercial |
$2,868.60
|
|
|
MESH PROCEED VENTRAL SM CIRCLE PVPS
|
Facility
|
OP
|
$3,724.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965551
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,084.43 |
| Max. Negotiated Rate |
$3,563.12 |
| Rate for Payer: Aetna Commercial |
$3,485.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,330.75
|
| Rate for Payer: Aetna Managed Medicare |
$1,084.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,517.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,936.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,859.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,052.67
|
| Rate for Payer: Cash Price |
$1,117.20
|
| Rate for Payer: Cigna Commercial |
$3,563.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,167.37
|
| Rate for Payer: Health EOS Commercial |
$3,446.93
|
| Rate for Payer: HFN Commercial |
$3,563.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,904.72
|
| Rate for Payer: Multiplan Commercial |
$3,098.37
|
| Rate for Payer: NAPHCARE Commercial |
$2,323.78
|
| Rate for Payer: Preferred Network Access Commercial |
$3,563.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,897.75
|
| Rate for Payer: Quartz Commercial |
$2,517.42
|
| Rate for Payer: Quartz Medicare Advantage |
$2,323.78
|
| Rate for Payer: The Alliance Commercial |
$1,936.48
|
| Rate for Payer: WEA Trust Commercial |
$2,130.13
|
| Rate for Payer: WPS Commercial |
$2,868.60
|
|
|
MESH PROGRIP 15 X 10CM LPG1510
|
Facility
|
OP
|
$3,424.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4493783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$997.07 |
| Max. Negotiated Rate |
$3,276.08 |
| Rate for Payer: Aetna Commercial |
$3,204.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,062.43
|
| Rate for Payer: Aetna Managed Medicare |
$997.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,314.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,780.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,709.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,887.31
|
| Rate for Payer: Cash Price |
$1,027.20
|
| Rate for Payer: Cigna Commercial |
$3,276.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,992.77
|
| Rate for Payer: Health EOS Commercial |
$3,169.25
|
| Rate for Payer: HFN Commercial |
$3,276.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,670.72
|
| Rate for Payer: Multiplan Commercial |
$2,848.77
|
| Rate for Payer: NAPHCARE Commercial |
$2,136.58
|
| Rate for Payer: Preferred Network Access Commercial |
$3,276.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,744.87
|
| Rate for Payer: Quartz Commercial |
$2,314.62
|
| Rate for Payer: Quartz Medicare Advantage |
$2,136.58
|
| Rate for Payer: The Alliance Commercial |
$1,780.48
|
| Rate for Payer: WEA Trust Commercial |
$1,958.53
|
| Rate for Payer: WPS Commercial |
$2,637.51
|
|
|
MESH PROGRIP 15 X 10CM LPG1510
|
Facility
|
IP
|
$3,424.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4493783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,744.87 |
| Max. Negotiated Rate |
$3,276.08 |
| Rate for Payer: Aetna Commercial |
$3,204.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,062.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,887.31
|
| Rate for Payer: Cash Price |
$1,027.20
|
| Rate for Payer: Cigna Commercial |
$3,276.08
|
| Rate for Payer: Health EOS Commercial |
$3,169.25
|
| Rate for Payer: HFN Commercial |
$3,276.08
|
| Rate for Payer: Multiplan Commercial |
$2,848.77
|
| Rate for Payer: Preferred Network Access Commercial |
$3,276.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,744.87
|
| Rate for Payer: Quartz Commercial |
$2,136.58
|
| Rate for Payer: WEA Trust Commercial |
$1,958.53
|
| Rate for Payer: WPS Commercial |
$2,637.51
|
|
|
MESH PROGRIP 16 X 12CM LPG1612
|
Facility
|
OP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
6179165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,346.80 |
| Max. Negotiated Rate |
$4,425.20 |
| Rate for Payer: Aetna Commercial |
$4,329.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,136.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,346.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,126.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,405.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,308.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,549.30
|
| Rate for Payer: Cash Price |
$1,387.50
|
| Rate for Payer: Cigna Commercial |
$4,425.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,691.75
|
| Rate for Payer: Health EOS Commercial |
$4,280.90
|
| Rate for Payer: HFN Commercial |
$4,425.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,607.50
|
| Rate for Payer: Multiplan Commercial |
$3,848.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,886.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,425.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,356.90
|
| Rate for Payer: Quartz Commercial |
$3,126.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,886.00
|
| Rate for Payer: The Alliance Commercial |
$2,405.00
|
| Rate for Payer: WEA Trust Commercial |
$2,645.50
|
| Rate for Payer: WPS Commercial |
$3,562.64
|
|
|
MESH PROGRIP 16 X 12CM LPG1612
|
Facility
|
IP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
6179165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,356.90 |
| Max. Negotiated Rate |
$4,425.20 |
| Rate for Payer: Aetna Commercial |
$4,329.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,136.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,549.30
|
| Rate for Payer: Cash Price |
$1,387.50
|
| Rate for Payer: Cigna Commercial |
$4,425.20
|
| Rate for Payer: Health EOS Commercial |
$4,280.90
|
| Rate for Payer: HFN Commercial |
$4,425.20
|
| Rate for Payer: Multiplan Commercial |
$3,848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,425.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,356.90
|
| Rate for Payer: Quartz Commercial |
$2,886.00
|
| Rate for Payer: WEA Trust Commercial |
$2,645.50
|
| Rate for Payer: WPS Commercial |
$3,562.64
|
|
|
MESH PROGRIP POLYESTER MESH 20CM X 15CM TEM2015G
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
6179094
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$728.00 |
| Max. Negotiated Rate |
$2,392.00 |
| Rate for Payer: Aetna Commercial |
$2,340.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,236.00
|
| Rate for Payer: Aetna Managed Medicare |
$728.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,690.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,300.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,248.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,378.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$2,392.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,455.00
|
| Rate for Payer: Health EOS Commercial |
$2,314.00
|
| Rate for Payer: HFN Commercial |
$2,392.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,950.00
|
| Rate for Payer: Multiplan Commercial |
$2,080.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,560.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,392.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,274.00
|
| Rate for Payer: Quartz Commercial |
$1,690.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,560.00
|
| Rate for Payer: The Alliance Commercial |
$1,300.00
|
| Rate for Payer: WEA Trust Commercial |
$1,430.00
|
| Rate for Payer: WPS Commercial |
$1,925.75
|
|
|
MESH PROGRIP POLYESTER MESH 20CM X 15CM TEM2015G
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
6179094
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,274.00 |
| Max. Negotiated Rate |
$2,392.00 |
| Rate for Payer: Aetna Commercial |
$2,340.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,236.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,378.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$2,392.00
|
| Rate for Payer: Health EOS Commercial |
$2,314.00
|
| Rate for Payer: HFN Commercial |
$2,392.00
|
| Rate for Payer: Multiplan Commercial |
$2,080.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,392.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,274.00
|
| Rate for Payer: Quartz Commercial |
$1,560.00
|
| Rate for Payer: WEA Trust Commercial |
$1,430.00
|
| Rate for Payer: WPS Commercial |
$1,925.75
|
|
|
MESH SMALL ULTRA PRO PLUG UPPS
|
Facility
|
OP
|
$2,155.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965552
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.54 |
| Max. Negotiated Rate |
$2,061.90 |
| Rate for Payer: Aetna Commercial |
$2,017.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,927.43
|
| Rate for Payer: Aetna Managed Medicare |
$627.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,456.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,120.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,075.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,187.84
|
| Rate for Payer: Cash Price |
$646.50
|
| Rate for Payer: Cigna Commercial |
$2,061.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,254.21
|
| Rate for Payer: Health EOS Commercial |
$1,994.67
|
| Rate for Payer: HFN Commercial |
$2,061.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,680.90
|
| Rate for Payer: Multiplan Commercial |
$1,792.96
|
| Rate for Payer: NAPHCARE Commercial |
$1,344.72
|
| Rate for Payer: Preferred Network Access Commercial |
$2,061.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,098.19
|
| Rate for Payer: Quartz Commercial |
$1,456.78
|
| Rate for Payer: Quartz Medicare Advantage |
$1,344.72
|
| Rate for Payer: The Alliance Commercial |
$1,120.60
|
| Rate for Payer: WEA Trust Commercial |
$1,232.66
|
| Rate for Payer: WPS Commercial |
$1,660.00
|
|
|
MESH SMALL ULTRA PRO PLUG UPPS
|
Facility
|
IP
|
$2,155.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965552
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,098.19 |
| Max. Negotiated Rate |
$2,061.90 |
| Rate for Payer: Aetna Commercial |
$2,017.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,927.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,187.84
|
| Rate for Payer: Cash Price |
$646.50
|
| Rate for Payer: Cigna Commercial |
$2,061.90
|
| Rate for Payer: Health EOS Commercial |
$1,994.67
|
| Rate for Payer: HFN Commercial |
$2,061.90
|
| Rate for Payer: Multiplan Commercial |
$1,792.96
|
| Rate for Payer: Preferred Network Access Commercial |
$2,061.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,098.19
|
| Rate for Payer: Quartz Commercial |
$1,344.72
|
| Rate for Payer: WEA Trust Commercial |
$1,232.66
|
| Rate for Payer: WPS Commercial |
$1,660.00
|
|
|
MESH ULTRAPRO LARGE UHSL
|
Facility
|
OP
|
$3,639.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965548
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,059.68 |
| Max. Negotiated Rate |
$3,481.80 |
| Rate for Payer: Aetna Commercial |
$3,406.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,254.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,059.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,459.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,892.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,816.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,005.82
|
| Rate for Payer: Cash Price |
$1,091.70
|
| Rate for Payer: Cigna Commercial |
$3,481.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,117.90
|
| Rate for Payer: Health EOS Commercial |
$3,368.26
|
| Rate for Payer: HFN Commercial |
$3,481.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,838.42
|
| Rate for Payer: Multiplan Commercial |
$3,027.65
|
| Rate for Payer: NAPHCARE Commercial |
$2,270.74
|
| Rate for Payer: Preferred Network Access Commercial |
$3,481.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,854.43
|
| Rate for Payer: Quartz Commercial |
$2,459.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,270.74
|
| Rate for Payer: The Alliance Commercial |
$1,892.28
|
| Rate for Payer: WEA Trust Commercial |
$2,081.51
|
| Rate for Payer: WPS Commercial |
$2,803.12
|
|
|
MESH ULTRAPRO LARGE UHSL
|
Facility
|
IP
|
$3,639.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
2965548
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,854.43 |
| Max. Negotiated Rate |
$3,481.80 |
| Rate for Payer: Aetna Commercial |
$3,406.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,254.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,005.82
|
| Rate for Payer: Cash Price |
$1,091.70
|
| Rate for Payer: Cigna Commercial |
$3,481.80
|
| Rate for Payer: Health EOS Commercial |
$3,368.26
|
| Rate for Payer: HFN Commercial |
$3,481.80
|
| Rate for Payer: Multiplan Commercial |
$3,027.65
|
| Rate for Payer: Preferred Network Access Commercial |
$3,481.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,854.43
|
| Rate for Payer: Quartz Commercial |
$2,270.74
|
| Rate for Payer: WEA Trust Commercial |
$2,081.51
|
| Rate for Payer: WPS Commercial |
$2,803.12
|
|
