|
MESH VENTRALEX ST HERNIA PATCH 4.3 CM/1.7 IN SMALL 5950007
|
Facility
|
OP
|
$5,700.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4594846
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,659.84 |
| Max. Negotiated Rate |
$5,453.76 |
| Rate for Payer: Aetna Commercial |
$5,335.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,098.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,659.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,853.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,964.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,845.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,141.84
|
| Rate for Payer: Cash Price |
$1,710.00
|
| Rate for Payer: Cigna Commercial |
$5,453.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,317.40
|
| Rate for Payer: Health EOS Commercial |
$5,275.92
|
| Rate for Payer: HFN Commercial |
$5,453.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,446.00
|
| Rate for Payer: Multiplan Commercial |
$4,742.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,556.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,453.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,904.72
|
| Rate for Payer: Quartz Commercial |
$3,853.20
|
| Rate for Payer: Quartz Medicare Advantage |
$3,556.80
|
| Rate for Payer: The Alliance Commercial |
$2,964.00
|
| Rate for Payer: WEA Trust Commercial |
$3,260.40
|
| Rate for Payer: WPS Commercial |
$4,390.71
|
|
|
MESH VENTRALEX ST HERNIA PATCH 4.3 CM/1.7 IN SMALL 5950007
|
Facility
|
IP
|
$5,700.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4594846
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,904.72 |
| Max. Negotiated Rate |
$5,453.76 |
| Rate for Payer: Aetna Commercial |
$5,335.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,098.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,141.84
|
| Rate for Payer: Cash Price |
$1,710.00
|
| Rate for Payer: Cigna Commercial |
$5,453.76
|
| Rate for Payer: Health EOS Commercial |
$5,275.92
|
| Rate for Payer: HFN Commercial |
$5,453.76
|
| Rate for Payer: Multiplan Commercial |
$4,742.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,453.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,904.72
|
| Rate for Payer: Quartz Commercial |
$3,556.80
|
| Rate for Payer: WEA Trust Commercial |
$3,260.40
|
| Rate for Payer: WPS Commercial |
$4,390.71
|
|
|
MESH VENTRALEX ST HERNIA PATCH 6.4 CM/2.5 IN MED 5950008
|
Facility
|
OP
|
$5,130.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4595104
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,493.86 |
| Max. Negotiated Rate |
$4,908.38 |
| Rate for Payer: Aetna Commercial |
$4,801.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,588.27
|
| Rate for Payer: Aetna Managed Medicare |
$1,493.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,467.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,667.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,560.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,827.66
|
| Rate for Payer: Cash Price |
$1,539.00
|
| Rate for Payer: Cigna Commercial |
$4,908.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,985.66
|
| Rate for Payer: Health EOS Commercial |
$4,748.33
|
| Rate for Payer: HFN Commercial |
$4,908.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,001.40
|
| Rate for Payer: Multiplan Commercial |
$4,268.16
|
| Rate for Payer: NAPHCARE Commercial |
$3,201.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4,908.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,614.25
|
| Rate for Payer: Quartz Commercial |
$3,467.88
|
| Rate for Payer: Quartz Medicare Advantage |
$3,201.12
|
| Rate for Payer: The Alliance Commercial |
$2,667.60
|
| Rate for Payer: WEA Trust Commercial |
$2,934.36
|
| Rate for Payer: WPS Commercial |
$3,951.64
|
|
|
MESH VENTRALEX ST HERNIA PATCH 6.4 CM/2.5 IN MED 5950008
|
Facility
|
IP
|
$5,130.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4595104
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,614.25 |
| Max. Negotiated Rate |
$4,908.38 |
| Rate for Payer: Aetna Commercial |
$4,801.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,588.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,827.66
|
| Rate for Payer: Cash Price |
$1,539.00
|
| Rate for Payer: Cigna Commercial |
$4,908.38
|
| Rate for Payer: Health EOS Commercial |
$4,748.33
|
| Rate for Payer: HFN Commercial |
$4,908.38
|
| Rate for Payer: Multiplan Commercial |
$4,268.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4,908.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,614.25
|
| Rate for Payer: Quartz Commercial |
$3,201.12
|
| Rate for Payer: WEA Trust Commercial |
$2,934.36
|
| Rate for Payer: WPS Commercial |
$3,951.64
|
|
|
MESH VENTRALEX ST LARGE 5950009
|
Facility
|
OP
|
$6,764.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4595191
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,969.68 |
| Max. Negotiated Rate |
$6,471.80 |
| Rate for Payer: Aetna Commercial |
$6,331.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,049.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,969.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,572.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,517.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,376.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,728.32
|
| Rate for Payer: Cash Price |
$2,029.20
|
| Rate for Payer: Cigna Commercial |
$6,471.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,936.65
|
| Rate for Payer: Health EOS Commercial |
$6,260.76
|
| Rate for Payer: HFN Commercial |
$6,471.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,275.92
|
| Rate for Payer: Multiplan Commercial |
$5,627.65
|
| Rate for Payer: NAPHCARE Commercial |
$4,220.74
|
| Rate for Payer: Preferred Network Access Commercial |
$6,471.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,446.93
|
| Rate for Payer: Quartz Commercial |
$4,572.46
|
| Rate for Payer: Quartz Medicare Advantage |
$4,220.74
|
| Rate for Payer: The Alliance Commercial |
$3,517.28
|
| Rate for Payer: WEA Trust Commercial |
$3,869.01
|
| Rate for Payer: WPS Commercial |
$5,210.31
|
|
|
MESH VENTRALEX ST LARGE 5950009
|
Facility
|
IP
|
$6,764.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4595191
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,446.93 |
| Max. Negotiated Rate |
$6,471.80 |
| Rate for Payer: Aetna Commercial |
$6,331.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,049.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,728.32
|
| Rate for Payer: Cash Price |
$2,029.20
|
| Rate for Payer: Cigna Commercial |
$6,471.80
|
| Rate for Payer: Health EOS Commercial |
$6,260.76
|
| Rate for Payer: HFN Commercial |
$6,471.80
|
| Rate for Payer: Multiplan Commercial |
$5,627.65
|
| Rate for Payer: Preferred Network Access Commercial |
$6,471.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,446.93
|
| Rate for Payer: Quartz Commercial |
$4,220.74
|
| Rate for Payer: WEA Trust Commercial |
$3,869.01
|
| Rate for Payer: WPS Commercial |
$5,210.31
|
|
|
MESH VENTRALIGHT ECHO (25X30CM) 5955113
|
Facility
|
IP
|
$16,435.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998676
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,375.28 |
| Max. Negotiated Rate |
$15,725.01 |
| Rate for Payer: Aetna Commercial |
$15,383.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,699.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,058.97
|
| Rate for Payer: Cash Price |
$4,930.50
|
| Rate for Payer: Cigna Commercial |
$15,725.01
|
| Rate for Payer: Health EOS Commercial |
$15,212.24
|
| Rate for Payer: HFN Commercial |
$15,725.01
|
| Rate for Payer: Multiplan Commercial |
$13,673.92
|
| Rate for Payer: Preferred Network Access Commercial |
$15,725.01
|
| Rate for Payer: Quartz Beloit One Network |
$8,375.28
|
| Rate for Payer: Quartz Commercial |
$10,255.44
|
| Rate for Payer: WEA Trust Commercial |
$9,400.82
|
| Rate for Payer: WPS Commercial |
$12,659.88
|
|
|
MESH VENTRALIGHT ECHO (25X30CM) 5955113
|
Facility
|
OP
|
$16,435.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998676
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,785.87 |
| Max. Negotiated Rate |
$15,725.01 |
| Rate for Payer: Aetna Commercial |
$15,383.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,699.46
|
| Rate for Payer: Aetna Managed Medicare |
$4,785.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,110.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,546.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,204.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,058.97
|
| Rate for Payer: Cash Price |
$4,930.50
|
| Rate for Payer: Cigna Commercial |
$15,725.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,565.17
|
| Rate for Payer: Health EOS Commercial |
$15,212.24
|
| Rate for Payer: HFN Commercial |
$15,725.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,819.30
|
| Rate for Payer: Multiplan Commercial |
$13,673.92
|
| Rate for Payer: NAPHCARE Commercial |
$10,255.44
|
| Rate for Payer: Preferred Network Access Commercial |
$15,725.01
|
| Rate for Payer: Quartz Beloit One Network |
$8,375.28
|
| Rate for Payer: Quartz Commercial |
$11,110.06
|
| Rate for Payer: Quartz Medicare Advantage |
$10,255.44
|
| Rate for Payer: The Alliance Commercial |
$8,546.20
|
| Rate for Payer: WEA Trust Commercial |
$9,400.82
|
| Rate for Payer: WPS Commercial |
$12,659.88
|
|
|
MESH VENTRALIGHT ECHO 4 X 6 (10X15CM) 5955460
|
Facility
|
IP
|
$6,413.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4595207
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,268.06 |
| Max. Negotiated Rate |
$6,135.96 |
| Rate for Payer: Aetna Commercial |
$6,002.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,735.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,534.85
|
| Rate for Payer: Cash Price |
$1,923.90
|
| Rate for Payer: Cigna Commercial |
$6,135.96
|
| Rate for Payer: Health EOS Commercial |
$5,935.87
|
| Rate for Payer: HFN Commercial |
$6,135.96
|
| Rate for Payer: Multiplan Commercial |
$5,335.62
|
| Rate for Payer: Preferred Network Access Commercial |
$6,135.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,268.06
|
| Rate for Payer: Quartz Commercial |
$4,001.71
|
| Rate for Payer: WEA Trust Commercial |
$3,668.24
|
| Rate for Payer: WPS Commercial |
$4,939.93
|
|
|
MESH VENTRALIGHT ECHO 4 X 6 (10X15CM) 5955460
|
Facility
|
OP
|
$6,413.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4595207
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,867.47 |
| Max. Negotiated Rate |
$6,135.96 |
| Rate for Payer: Aetna Commercial |
$6,002.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,735.79
|
| Rate for Payer: Aetna Managed Medicare |
$1,867.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,335.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,334.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,201.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,534.85
|
| Rate for Payer: Cash Price |
$1,923.90
|
| Rate for Payer: Cigna Commercial |
$6,135.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,732.37
|
| Rate for Payer: Health EOS Commercial |
$5,935.87
|
| Rate for Payer: HFN Commercial |
$6,135.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,002.14
|
| Rate for Payer: Multiplan Commercial |
$5,335.62
|
| Rate for Payer: NAPHCARE Commercial |
$4,001.71
|
| Rate for Payer: Preferred Network Access Commercial |
$6,135.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,268.06
|
| Rate for Payer: Quartz Commercial |
$4,335.19
|
| Rate for Payer: Quartz Medicare Advantage |
$4,001.71
|
| Rate for Payer: The Alliance Commercial |
$3,334.76
|
| Rate for Payer: WEA Trust Commercial |
$3,668.24
|
| Rate for Payer: WPS Commercial |
$4,939.93
|
|
|
MESH VENTRALIGHT ECHO 6 X 8 (15X20CM) 5955680
|
Facility
|
IP
|
$8,551.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4640731
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,357.59 |
| Max. Negotiated Rate |
$8,181.60 |
| Rate for Payer: Aetna Commercial |
$8,003.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,648.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,713.31
|
| Rate for Payer: Cash Price |
$2,565.30
|
| Rate for Payer: Cigna Commercial |
$8,181.60
|
| Rate for Payer: Health EOS Commercial |
$7,914.81
|
| Rate for Payer: HFN Commercial |
$8,181.60
|
| Rate for Payer: Multiplan Commercial |
$7,114.43
|
| Rate for Payer: Preferred Network Access Commercial |
$8,181.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,357.59
|
| Rate for Payer: Quartz Commercial |
$5,335.82
|
| Rate for Payer: WEA Trust Commercial |
$4,891.17
|
| Rate for Payer: WPS Commercial |
$6,586.84
|
|
|
MESH VENTRALIGHT ECHO 6 X 8 (15X20CM) 5955680
|
Facility
|
OP
|
$8,551.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4640731
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,490.05 |
| Max. Negotiated Rate |
$8,181.60 |
| Rate for Payer: Aetna Commercial |
$8,003.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,648.01
|
| Rate for Payer: Aetna Managed Medicare |
$2,490.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,780.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,446.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,268.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,713.31
|
| Rate for Payer: Cash Price |
$2,565.30
|
| Rate for Payer: Cigna Commercial |
$8,181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,976.68
|
| Rate for Payer: Health EOS Commercial |
$7,914.81
|
| Rate for Payer: HFN Commercial |
$8,181.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,669.78
|
| Rate for Payer: Multiplan Commercial |
$7,114.43
|
| Rate for Payer: NAPHCARE Commercial |
$5,335.82
|
| Rate for Payer: Preferred Network Access Commercial |
$8,181.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,357.59
|
| Rate for Payer: Quartz Commercial |
$5,780.48
|
| Rate for Payer: Quartz Medicare Advantage |
$5,335.82
|
| Rate for Payer: The Alliance Commercial |
$4,446.52
|
| Rate for Payer: WEA Trust Commercial |
$4,891.17
|
| Rate for Payer: WPS Commercial |
$6,586.84
|
|
|
MESH VENTRALIGHT ECHO 8 x 10 IN (20X25CM) 5955810
|
Facility
|
IP
|
$13,680.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,971.33 |
| Max. Negotiated Rate |
$13,089.02 |
| Rate for Payer: Aetna Commercial |
$12,804.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,235.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,540.42
|
| Rate for Payer: Cash Price |
$4,104.00
|
| Rate for Payer: Cigna Commercial |
$13,089.02
|
| Rate for Payer: Health EOS Commercial |
$12,662.21
|
| Rate for Payer: HFN Commercial |
$13,089.02
|
| Rate for Payer: Multiplan Commercial |
$11,381.76
|
| Rate for Payer: Preferred Network Access Commercial |
$13,089.02
|
| Rate for Payer: Quartz Beloit One Network |
$6,971.33
|
| Rate for Payer: Quartz Commercial |
$8,536.32
|
| Rate for Payer: WEA Trust Commercial |
$7,824.96
|
| Rate for Payer: WPS Commercial |
$10,537.70
|
|
|
MESH VENTRALIGHT ECHO 8 x 10 IN (20X25CM) 5955810
|
Facility
|
OP
|
$13,680.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,983.62 |
| Max. Negotiated Rate |
$13,089.02 |
| Rate for Payer: Aetna Commercial |
$12,804.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,235.39
|
| Rate for Payer: Aetna Managed Medicare |
$3,983.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,247.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,113.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,829.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,540.42
|
| Rate for Payer: Cash Price |
$4,104.00
|
| Rate for Payer: Cigna Commercial |
$13,089.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,961.76
|
| Rate for Payer: Health EOS Commercial |
$12,662.21
|
| Rate for Payer: HFN Commercial |
$13,089.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,670.40
|
| Rate for Payer: Multiplan Commercial |
$11,381.76
|
| Rate for Payer: NAPHCARE Commercial |
$8,536.32
|
| Rate for Payer: Preferred Network Access Commercial |
$13,089.02
|
| Rate for Payer: Quartz Beloit One Network |
$6,971.33
|
| Rate for Payer: Quartz Commercial |
$9,247.68
|
| Rate for Payer: Quartz Medicare Advantage |
$8,536.32
|
| Rate for Payer: The Alliance Commercial |
$7,113.60
|
| Rate for Payer: WEA Trust Commercial |
$7,824.96
|
| Rate for Payer: WPS Commercial |
$10,537.70
|
|
|
MESH VENTRALIGHT ST 20 X 25CM 5954810
|
Facility
|
OP
|
$8,081.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,353.19 |
| Max. Negotiated Rate |
$7,731.90 |
| Rate for Payer: Aetna Commercial |
$7,563.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,227.65
|
| Rate for Payer: Aetna Managed Medicare |
$2,353.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,462.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,202.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,034.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,454.25
|
| Rate for Payer: Cash Price |
$2,424.30
|
| Rate for Payer: Cigna Commercial |
$7,731.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,703.14
|
| Rate for Payer: Health EOS Commercial |
$7,479.77
|
| Rate for Payer: HFN Commercial |
$7,731.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,303.18
|
| Rate for Payer: Multiplan Commercial |
$6,723.39
|
| Rate for Payer: NAPHCARE Commercial |
$5,042.54
|
| Rate for Payer: Preferred Network Access Commercial |
$7,731.90
|
| Rate for Payer: Quartz Beloit One Network |
$4,118.08
|
| Rate for Payer: Quartz Commercial |
$5,462.76
|
| Rate for Payer: Quartz Medicare Advantage |
$5,042.54
|
| Rate for Payer: The Alliance Commercial |
$4,202.12
|
| Rate for Payer: WEA Trust Commercial |
$4,622.33
|
| Rate for Payer: WPS Commercial |
$6,224.79
|
|
|
MESH VENTRALIGHT ST 20 X 25CM 5954810
|
Facility
|
IP
|
$8,081.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,118.08 |
| Max. Negotiated Rate |
$7,731.90 |
| Rate for Payer: Aetna Commercial |
$7,563.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,227.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,454.25
|
| Rate for Payer: Cash Price |
$2,424.30
|
| Rate for Payer: Cigna Commercial |
$7,731.90
|
| Rate for Payer: Health EOS Commercial |
$7,479.77
|
| Rate for Payer: HFN Commercial |
$7,731.90
|
| Rate for Payer: Multiplan Commercial |
$6,723.39
|
| Rate for Payer: Preferred Network Access Commercial |
$7,731.90
|
| Rate for Payer: Quartz Beloit One Network |
$4,118.08
|
| Rate for Payer: Quartz Commercial |
$5,042.54
|
| Rate for Payer: WEA Trust Commercial |
$4,622.33
|
| Rate for Payer: WPS Commercial |
$6,224.79
|
|
|
MESH VENTRALIGHT ST 25 X 30CM 5954113
|
Facility
|
OP
|
$10,276.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,992.37 |
| Max. Negotiated Rate |
$9,832.08 |
| Rate for Payer: Aetna Commercial |
$9,618.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,190.85
|
| Rate for Payer: Aetna Managed Medicare |
$2,992.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,946.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,343.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,129.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,664.13
|
| Rate for Payer: Cash Price |
$3,082.80
|
| Rate for Payer: Cigna Commercial |
$9,832.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,980.63
|
| Rate for Payer: Health EOS Commercial |
$9,511.47
|
| Rate for Payer: HFN Commercial |
$9,832.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,015.28
|
| Rate for Payer: Multiplan Commercial |
$8,549.63
|
| Rate for Payer: NAPHCARE Commercial |
$6,412.22
|
| Rate for Payer: Preferred Network Access Commercial |
$9,832.08
|
| Rate for Payer: Quartz Beloit One Network |
$5,236.65
|
| Rate for Payer: Quartz Commercial |
$6,946.58
|
| Rate for Payer: Quartz Medicare Advantage |
$6,412.22
|
| Rate for Payer: The Alliance Commercial |
$5,343.52
|
| Rate for Payer: WEA Trust Commercial |
$5,877.87
|
| Rate for Payer: WPS Commercial |
$7,915.60
|
|
|
MESH VENTRALIGHT ST 25 X 30CM 5954113
|
Facility
|
IP
|
$10,276.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,236.65 |
| Max. Negotiated Rate |
$9,832.08 |
| Rate for Payer: Aetna Commercial |
$9,618.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,190.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,664.13
|
| Rate for Payer: Cash Price |
$3,082.80
|
| Rate for Payer: Cigna Commercial |
$9,832.08
|
| Rate for Payer: Health EOS Commercial |
$9,511.47
|
| Rate for Payer: HFN Commercial |
$9,832.08
|
| Rate for Payer: Multiplan Commercial |
$8,549.63
|
| Rate for Payer: Preferred Network Access Commercial |
$9,832.08
|
| Rate for Payer: Quartz Beloit One Network |
$5,236.65
|
| Rate for Payer: Quartz Commercial |
$6,412.22
|
| Rate for Payer: WEA Trust Commercial |
$5,877.87
|
| Rate for Payer: WPS Commercial |
$7,915.60
|
|
|
MESH VENTRALIGHT ST 4 X 6" (10 X 15CM) 5954460"
|
Facility
|
OP
|
$4,940.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998609
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,438.53 |
| Max. Negotiated Rate |
$4,726.59 |
| Rate for Payer: Aetna Commercial |
$4,623.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,418.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,438.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,339.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,568.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,466.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,722.93
|
| Rate for Payer: Cash Price |
$1,482.00
|
| Rate for Payer: Cigna Commercial |
$4,726.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,875.08
|
| Rate for Payer: Health EOS Commercial |
$4,572.46
|
| Rate for Payer: HFN Commercial |
$4,726.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,853.20
|
| Rate for Payer: Multiplan Commercial |
$4,110.08
|
| Rate for Payer: NAPHCARE Commercial |
$3,082.56
|
| Rate for Payer: Preferred Network Access Commercial |
$4,726.59
|
| Rate for Payer: Quartz Beloit One Network |
$2,517.42
|
| Rate for Payer: Quartz Commercial |
$3,339.44
|
| Rate for Payer: Quartz Medicare Advantage |
$3,082.56
|
| Rate for Payer: The Alliance Commercial |
$2,568.80
|
| Rate for Payer: WEA Trust Commercial |
$2,825.68
|
| Rate for Payer: WPS Commercial |
$3,805.28
|
|
|
MESH VENTRALIGHT ST 4 X 6" (10 X 15CM) 5954460"
|
Facility
|
IP
|
$4,940.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998609
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,517.42 |
| Max. Negotiated Rate |
$4,726.59 |
| Rate for Payer: Aetna Commercial |
$4,623.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,418.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,722.93
|
| Rate for Payer: Cash Price |
$1,482.00
|
| Rate for Payer: Cigna Commercial |
$4,726.59
|
| Rate for Payer: Health EOS Commercial |
$4,572.46
|
| Rate for Payer: HFN Commercial |
$4,726.59
|
| Rate for Payer: Multiplan Commercial |
$4,110.08
|
| Rate for Payer: Preferred Network Access Commercial |
$4,726.59
|
| Rate for Payer: Quartz Beloit One Network |
$2,517.42
|
| Rate for Payer: Quartz Commercial |
$3,082.56
|
| Rate for Payer: WEA Trust Commercial |
$2,825.68
|
| Rate for Payer: WPS Commercial |
$3,805.28
|
|
|
MESH VENTRALIGHT ST 6 x 8" (15 X 20CM) 5954680"
|
Facility
|
OP
|
$8,502.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4858686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,475.78 |
| Max. Negotiated Rate |
$8,134.71 |
| Rate for Payer: Aetna Commercial |
$7,957.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,604.19
|
| Rate for Payer: Aetna Managed Medicare |
$2,475.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,747.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,421.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,244.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,686.30
|
| Rate for Payer: Cash Price |
$2,550.60
|
| Rate for Payer: Cigna Commercial |
$8,134.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,948.16
|
| Rate for Payer: Health EOS Commercial |
$7,869.45
|
| Rate for Payer: HFN Commercial |
$8,134.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,631.56
|
| Rate for Payer: Multiplan Commercial |
$7,073.66
|
| Rate for Payer: NAPHCARE Commercial |
$5,305.25
|
| Rate for Payer: Preferred Network Access Commercial |
$8,134.71
|
| Rate for Payer: Quartz Beloit One Network |
$4,332.62
|
| Rate for Payer: Quartz Commercial |
$5,747.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,305.25
|
| Rate for Payer: The Alliance Commercial |
$4,421.04
|
| Rate for Payer: WEA Trust Commercial |
$4,863.14
|
| Rate for Payer: WPS Commercial |
$6,549.09
|
|
|
MESH VENTRALIGHT ST 6 x 8" (15 X 20CM) 5954680"
|
Facility
|
IP
|
$8,502.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4858686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,332.62 |
| Max. Negotiated Rate |
$8,134.71 |
| Rate for Payer: Aetna Commercial |
$7,957.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,604.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,686.30
|
| Rate for Payer: Cash Price |
$2,550.60
|
| Rate for Payer: Cigna Commercial |
$8,134.71
|
| Rate for Payer: Health EOS Commercial |
$7,869.45
|
| Rate for Payer: HFN Commercial |
$8,134.71
|
| Rate for Payer: Multiplan Commercial |
$7,073.66
|
| Rate for Payer: Preferred Network Access Commercial |
$8,134.71
|
| Rate for Payer: Quartz Beloit One Network |
$4,332.62
|
| Rate for Payer: Quartz Commercial |
$5,305.25
|
| Rate for Payer: WEA Trust Commercial |
$4,863.14
|
| Rate for Payer: WPS Commercial |
$6,549.09
|
|
|
MESH VICRYL 12 X 12" VKML"
|
Facility
|
OP
|
$4,952.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4038098
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,442.02 |
| Max. Negotiated Rate |
$4,738.07 |
| Rate for Payer: Aetna Commercial |
$4,635.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,429.07
|
| Rate for Payer: Aetna Managed Medicare |
$1,442.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,347.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,575.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,472.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,729.54
|
| Rate for Payer: Cash Price |
$1,485.60
|
| Rate for Payer: Cigna Commercial |
$4,738.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,882.06
|
| Rate for Payer: Health EOS Commercial |
$4,583.57
|
| Rate for Payer: HFN Commercial |
$4,738.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,862.56
|
| Rate for Payer: Multiplan Commercial |
$4,120.06
|
| Rate for Payer: NAPHCARE Commercial |
$3,090.05
|
| Rate for Payer: Preferred Network Access Commercial |
$4,738.07
|
| Rate for Payer: Quartz Beloit One Network |
$2,523.54
|
| Rate for Payer: Quartz Commercial |
$3,347.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,090.05
|
| Rate for Payer: The Alliance Commercial |
$2,575.04
|
| Rate for Payer: WEA Trust Commercial |
$2,832.54
|
| Rate for Payer: WPS Commercial |
$3,814.53
|
|
|
MESH VICRYL 12 X 12" VKML"
|
Facility
|
IP
|
$4,952.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4038098
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.54 |
| Max. Negotiated Rate |
$4,738.07 |
| Rate for Payer: Aetna Commercial |
$4,635.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,429.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,729.54
|
| Rate for Payer: Cash Price |
$1,485.60
|
| Rate for Payer: Cigna Commercial |
$4,738.07
|
| Rate for Payer: Health EOS Commercial |
$4,583.57
|
| Rate for Payer: HFN Commercial |
$4,738.07
|
| Rate for Payer: Multiplan Commercial |
$4,120.06
|
| Rate for Payer: Preferred Network Access Commercial |
$4,738.07
|
| Rate for Payer: Quartz Beloit One Network |
$2,523.54
|
| Rate for Payer: Quartz Commercial |
$3,090.05
|
| Rate for Payer: WEA Trust Commercial |
$2,832.54
|
| Rate for Payer: WPS Commercial |
$3,814.53
|
|
|
Mesnex 200 mg Charge
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
HCPCS J9209
|
| Hospital Charge Code |
2958981
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$54.54 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.98
|
| Rate for Payer: Aetna Managed Medicare |
$16.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.42
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$54.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.42
|
| Rate for Payer: Health EOS Commercial |
$52.76
|
| Rate for Payer: HFN Commercial |
$54.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.46
|
| Rate for Payer: Multiplan Commercial |
$47.42
|
| Rate for Payer: NAPHCARE Commercial |
$35.57
|
| Rate for Payer: Preferred Network Access Commercial |
$54.54
|
| Rate for Payer: Quartz Beloit One Network |
$29.05
|
| Rate for Payer: Quartz Commercial |
$38.53
|
| Rate for Payer: Quartz Medicare Advantage |
$35.57
|
| Rate for Payer: The Alliance Commercial |
$7.07
|
| Rate for Payer: WEA Trust Commercial |
$32.60
|
| Rate for Payer: WPS Commercial |
$4.58
|
|
