|
PASSING NEEDLE CERCLAGE MD STRAIGHT SINGLE USE AR-7821
|
Facility
|
OP
|
$2,213.00
|
|
| Hospital Charge Code |
6166116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$644.43 |
| Max. Negotiated Rate |
$2,117.40 |
| Rate for Payer: Aetna Commercial |
$2,071.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,979.31
|
| Rate for Payer: Aetna Managed Medicare |
$644.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,495.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,150.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,104.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,219.81
|
| Rate for Payer: Cash Price |
$663.90
|
| Rate for Payer: Cigna Commercial |
$2,117.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,287.97
|
| Rate for Payer: Health EOS Commercial |
$2,048.35
|
| Rate for Payer: HFN Commercial |
$2,117.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,726.14
|
| Rate for Payer: Multiplan Commercial |
$1,841.22
|
| Rate for Payer: NAPHCARE Commercial |
$1,380.91
|
| Rate for Payer: Preferred Network Access Commercial |
$2,117.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,127.74
|
| Rate for Payer: Quartz Commercial |
$1,495.99
|
| Rate for Payer: Quartz Medicare Advantage |
$1,380.91
|
| Rate for Payer: The Alliance Commercial |
$1,150.76
|
| Rate for Payer: WEA Trust Commercial |
$1,265.84
|
| Rate for Payer: WPS Commercial |
$1,704.67
|
|
|
PASSING NEEDLE CERCLAGE MD STRAIGHT SINGLE USE AR-7821
|
Facility
|
IP
|
$2,213.00
|
|
| Hospital Charge Code |
6166116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,127.74 |
| Max. Negotiated Rate |
$2,117.40 |
| Rate for Payer: Aetna Commercial |
$2,071.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,979.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,219.81
|
| Rate for Payer: Cash Price |
$663.90
|
| Rate for Payer: Cigna Commercial |
$2,117.40
|
| Rate for Payer: Health EOS Commercial |
$2,048.35
|
| Rate for Payer: HFN Commercial |
$2,117.40
|
| Rate for Payer: Multiplan Commercial |
$1,841.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,117.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,127.74
|
| Rate for Payer: Quartz Commercial |
$1,380.91
|
| Rate for Payer: WEA Trust Commercial |
$1,265.84
|
| Rate for Payer: WPS Commercial |
$1,704.67
|
|
|
PASSING WIRE SUTURE AR-1255-18
|
Facility
|
OP
|
$1,581.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2964709
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$460.39 |
| Max. Negotiated Rate |
$1,512.70 |
| Rate for Payer: Aetna Commercial |
$1,479.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,414.05
|
| Rate for Payer: Aetna Managed Medicare |
$460.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,068.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$822.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$789.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$871.45
|
| Rate for Payer: Cash Price |
$474.30
|
| Rate for Payer: Cigna Commercial |
$1,512.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$920.14
|
| Rate for Payer: Health EOS Commercial |
$1,463.37
|
| Rate for Payer: HFN Commercial |
$1,512.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,233.18
|
| Rate for Payer: Multiplan Commercial |
$1,315.39
|
| Rate for Payer: NAPHCARE Commercial |
$986.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,512.70
|
| Rate for Payer: Quartz Beloit One Network |
$805.68
|
| Rate for Payer: Quartz Commercial |
$1,068.76
|
| Rate for Payer: Quartz Medicare Advantage |
$986.54
|
| Rate for Payer: The Alliance Commercial |
$822.12
|
| Rate for Payer: WEA Trust Commercial |
$904.33
|
| Rate for Payer: WPS Commercial |
$1,217.84
|
|
|
PASSING WIRE SUTURE AR-1255-18
|
Facility
|
IP
|
$1,581.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2964709
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$805.68 |
| Max. Negotiated Rate |
$1,512.70 |
| Rate for Payer: Aetna Commercial |
$1,479.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,414.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$871.45
|
| Rate for Payer: Cash Price |
$474.30
|
| Rate for Payer: Cigna Commercial |
$1,512.70
|
| Rate for Payer: Health EOS Commercial |
$1,463.37
|
| Rate for Payer: HFN Commercial |
$1,512.70
|
| Rate for Payer: Multiplan Commercial |
$1,315.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,512.70
|
| Rate for Payer: Quartz Beloit One Network |
$805.68
|
| Rate for Payer: Quartz Commercial |
$986.54
|
| Rate for Payer: WEA Trust Commercial |
$904.33
|
| Rate for Payer: WPS Commercial |
$1,217.84
|
|
|
PASSPORT BUTTON CANNULA AR--6592-12-40
|
Facility
|
IP
|
$1,321.00
|
|
| Hospital Charge Code |
5611602
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$673.18 |
| Max. Negotiated Rate |
$1,263.93 |
| Rate for Payer: Aetna Commercial |
$1,236.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.14
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,263.93
|
| Rate for Payer: Health EOS Commercial |
$1,222.72
|
| Rate for Payer: HFN Commercial |
$1,263.93
|
| Rate for Payer: Multiplan Commercial |
$1,099.07
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.93
|
| Rate for Payer: Quartz Beloit One Network |
$673.18
|
| Rate for Payer: Quartz Commercial |
$824.30
|
| Rate for Payer: WEA Trust Commercial |
$755.61
|
| Rate for Payer: WPS Commercial |
$1,017.57
|
|
|
PASSPORT BUTTON CANNULA AR--6592-12-40
|
Facility
|
OP
|
$1,321.00
|
|
| Hospital Charge Code |
5611602
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$384.68 |
| Max. Negotiated Rate |
$1,263.93 |
| Rate for Payer: Aetna Commercial |
$1,236.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.50
|
| Rate for Payer: Aetna Managed Medicare |
$384.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$893.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$686.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$659.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.14
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,263.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$768.82
|
| Rate for Payer: Health EOS Commercial |
$1,222.72
|
| Rate for Payer: HFN Commercial |
$1,263.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,030.38
|
| Rate for Payer: Multiplan Commercial |
$1,099.07
|
| Rate for Payer: NAPHCARE Commercial |
$824.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.93
|
| Rate for Payer: Quartz Beloit One Network |
$673.18
|
| Rate for Payer: Quartz Commercial |
$893.00
|
| Rate for Payer: Quartz Medicare Advantage |
$824.30
|
| Rate for Payer: The Alliance Commercial |
$686.92
|
| Rate for Payer: WEA Trust Commercial |
$755.61
|
| Rate for Payer: WPS Commercial |
$1,017.57
|
|
|
PASSPORT DIVIDER AR-6592-12D
|
Facility
|
IP
|
$1,321.00
|
|
| Hospital Charge Code |
5611603
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$673.18 |
| Max. Negotiated Rate |
$1,263.93 |
| Rate for Payer: Aetna Commercial |
$1,236.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.14
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,263.93
|
| Rate for Payer: Health EOS Commercial |
$1,222.72
|
| Rate for Payer: HFN Commercial |
$1,263.93
|
| Rate for Payer: Multiplan Commercial |
$1,099.07
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.93
|
| Rate for Payer: Quartz Beloit One Network |
$673.18
|
| Rate for Payer: Quartz Commercial |
$824.30
|
| Rate for Payer: WEA Trust Commercial |
$755.61
|
| Rate for Payer: WPS Commercial |
$1,017.57
|
|
|
PASSPORT DIVIDER AR-6592-12D
|
Facility
|
OP
|
$1,321.00
|
|
| Hospital Charge Code |
5611603
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$384.68 |
| Max. Negotiated Rate |
$1,263.93 |
| Rate for Payer: Aetna Commercial |
$1,236.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.50
|
| Rate for Payer: Aetna Managed Medicare |
$384.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$893.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$686.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$659.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.14
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,263.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$768.82
|
| Rate for Payer: Health EOS Commercial |
$1,222.72
|
| Rate for Payer: HFN Commercial |
$1,263.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,030.38
|
| Rate for Payer: Multiplan Commercial |
$1,099.07
|
| Rate for Payer: NAPHCARE Commercial |
$824.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.93
|
| Rate for Payer: Quartz Beloit One Network |
$673.18
|
| Rate for Payer: Quartz Commercial |
$893.00
|
| Rate for Payer: Quartz Medicare Advantage |
$824.30
|
| Rate for Payer: The Alliance Commercial |
$686.92
|
| Rate for Payer: WEA Trust Commercial |
$755.61
|
| Rate for Payer: WPS Commercial |
$1,017.57
|
|
|
PASTE STOMA ADAPT 2oz 79300
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS A4406
|
| Hospital Charge Code |
2964041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$92.75 |
| Max. Negotiated Rate |
$174.14 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$113.57
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$140.19
|
|
|
PASTE STOMA ADAPT 2oz 79300
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS A4406
|
| Hospital Charge Code |
2964041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.95 |
| Max. Negotiated Rate |
$174.14 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Aetna Managed Medicare |
$53.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$123.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$94.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$90.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.92
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.96
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: NAPHCARE Commercial |
$113.57
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$123.03
|
| Rate for Payer: Quartz Medicare Advantage |
$113.57
|
| Rate for Payer: The Alliance Commercial |
$33.95
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$140.19
|
|
|
PATCH CARDIOVASCULAR 0.3IN X 3IN (0.8CM X 75CM) M002000195090
|
Facility
|
OP
|
$1,721.00
|
|
| Hospital Charge Code |
2964758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$501.16 |
| Max. Negotiated Rate |
$1,646.65 |
| Rate for Payer: Aetna Commercial |
$1,610.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,539.26
|
| Rate for Payer: Aetna Managed Medicare |
$501.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,163.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$894.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$859.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$948.62
|
| Rate for Payer: Cash Price |
$516.30
|
| Rate for Payer: Cigna Commercial |
$1,646.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,001.62
|
| Rate for Payer: Health EOS Commercial |
$1,592.96
|
| Rate for Payer: HFN Commercial |
$1,646.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,342.38
|
| Rate for Payer: Multiplan Commercial |
$1,431.87
|
| Rate for Payer: NAPHCARE Commercial |
$1,073.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,646.65
|
| Rate for Payer: Quartz Beloit One Network |
$877.02
|
| Rate for Payer: Quartz Commercial |
$1,163.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,073.90
|
| Rate for Payer: The Alliance Commercial |
$894.92
|
| Rate for Payer: WEA Trust Commercial |
$984.41
|
| Rate for Payer: WPS Commercial |
$1,325.69
|
|
|
PATCH CARDIOVASCULAR 0.3IN X 3IN (0.8CM X 75CM) M002000195090
|
Facility
|
IP
|
$1,721.00
|
|
| Hospital Charge Code |
2964758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$877.02 |
| Max. Negotiated Rate |
$1,646.65 |
| Rate for Payer: Aetna Commercial |
$1,610.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,539.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$948.62
|
| Rate for Payer: Cash Price |
$516.30
|
| Rate for Payer: Cigna Commercial |
$1,646.65
|
| Rate for Payer: Health EOS Commercial |
$1,592.96
|
| Rate for Payer: HFN Commercial |
$1,646.65
|
| Rate for Payer: Multiplan Commercial |
$1,431.87
|
| Rate for Payer: Preferred Network Access Commercial |
$1,646.65
|
| Rate for Payer: Quartz Beloit One Network |
$877.02
|
| Rate for Payer: Quartz Commercial |
$1,073.90
|
| Rate for Payer: WEA Trust Commercial |
$984.41
|
| Rate for Payer: WPS Commercial |
$1,325.69
|
|
|
PATCH FELT TEFLON 2X2 007977
|
Facility
|
IP
|
$514.00
|
|
| Hospital Charge Code |
2973437
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.93 |
| Max. Negotiated Rate |
$491.80 |
| Rate for Payer: Aetna Commercial |
$481.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$459.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.32
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$491.80
|
| Rate for Payer: Health EOS Commercial |
$475.76
|
| Rate for Payer: HFN Commercial |
$491.80
|
| Rate for Payer: Multiplan Commercial |
$427.65
|
| Rate for Payer: Preferred Network Access Commercial |
$491.80
|
| Rate for Payer: Quartz Beloit One Network |
$261.93
|
| Rate for Payer: Quartz Commercial |
$320.74
|
| Rate for Payer: WEA Trust Commercial |
$294.01
|
| Rate for Payer: WPS Commercial |
$395.93
|
|
|
PATCH FELT TEFLON 2X2 007977
|
Facility
|
OP
|
$514.00
|
|
| Hospital Charge Code |
2973437
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.68 |
| Max. Negotiated Rate |
$491.80 |
| Rate for Payer: Aetna Commercial |
$481.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$459.72
|
| Rate for Payer: Aetna Managed Medicare |
$149.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$347.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$267.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$256.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.32
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$491.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$299.15
|
| Rate for Payer: Health EOS Commercial |
$475.76
|
| Rate for Payer: HFN Commercial |
$491.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$400.92
|
| Rate for Payer: Multiplan Commercial |
$427.65
|
| Rate for Payer: NAPHCARE Commercial |
$320.74
|
| Rate for Payer: Preferred Network Access Commercial |
$491.80
|
| Rate for Payer: Quartz Beloit One Network |
$261.93
|
| Rate for Payer: Quartz Commercial |
$347.46
|
| Rate for Payer: Quartz Medicare Advantage |
$320.74
|
| Rate for Payer: The Alliance Commercial |
$267.28
|
| Rate for Payer: WEA Trust Commercial |
$294.01
|
| Rate for Payer: WPS Commercial |
$395.93
|
|
|
PATCH IONTO #199589-001***OBSOLETE FROM DJO
|
Facility
|
IP
|
$197.00
|
|
| Hospital Charge Code |
2969754
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.39 |
| Max. Negotiated Rate |
$188.49 |
| Rate for Payer: Aetna Commercial |
$184.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.59
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$188.49
|
| Rate for Payer: Health EOS Commercial |
$182.34
|
| Rate for Payer: HFN Commercial |
$188.49
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: Preferred Network Access Commercial |
$188.49
|
| Rate for Payer: Quartz Beloit One Network |
$100.39
|
| Rate for Payer: Quartz Commercial |
$122.93
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: WPS Commercial |
$151.75
|
|
|
PATCH IONTO #199589-001***OBSOLETE FROM DJO
|
Facility
|
OP
|
$197.00
|
|
| Hospital Charge Code |
2969754
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.37 |
| Max. Negotiated Rate |
$188.49 |
| Rate for Payer: Aetna Commercial |
$184.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Aetna Managed Medicare |
$57.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$133.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$102.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$98.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.59
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$188.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.65
|
| Rate for Payer: Health EOS Commercial |
$182.34
|
| Rate for Payer: HFN Commercial |
$188.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$153.66
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: NAPHCARE Commercial |
$122.93
|
| Rate for Payer: Preferred Network Access Commercial |
$188.49
|
| Rate for Payer: Quartz Beloit One Network |
$100.39
|
| Rate for Payer: Quartz Commercial |
$133.17
|
| Rate for Payer: Quartz Medicare Advantage |
$122.93
|
| Rate for Payer: The Alliance Commercial |
$102.44
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: WPS Commercial |
$151.75
|
|
|
PATCH VASCU-GUARD PERIPHERAL VASCULAR BOVINE VG-0108N/VG-0108
|
Facility
|
OP
|
$2,488.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3707495
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.51 |
| Max. Negotiated Rate |
$2,380.52 |
| Rate for Payer: Aetna Commercial |
$2,328.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,225.27
|
| Rate for Payer: Aetna Managed Medicare |
$724.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,681.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,293.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,242.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,371.39
|
| Rate for Payer: Cash Price |
$746.40
|
| Rate for Payer: Cigna Commercial |
$2,380.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,448.02
|
| Rate for Payer: Health EOS Commercial |
$2,302.89
|
| Rate for Payer: HFN Commercial |
$2,380.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,940.64
|
| Rate for Payer: Multiplan Commercial |
$2,070.02
|
| Rate for Payer: NAPHCARE Commercial |
$1,552.51
|
| Rate for Payer: Preferred Network Access Commercial |
$2,380.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,267.88
|
| Rate for Payer: Quartz Commercial |
$1,681.89
|
| Rate for Payer: Quartz Medicare Advantage |
$1,552.51
|
| Rate for Payer: The Alliance Commercial |
$1,293.76
|
| Rate for Payer: WEA Trust Commercial |
$1,423.14
|
| Rate for Payer: WPS Commercial |
$1,916.51
|
|
|
PATCH VASCU-GUARD PERIPHERAL VASCULAR BOVINE VG-0108N/VG-0108
|
Facility
|
IP
|
$2,488.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3707495
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,267.88 |
| Max. Negotiated Rate |
$2,380.52 |
| Rate for Payer: Aetna Commercial |
$2,328.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,225.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,371.39
|
| Rate for Payer: Cash Price |
$746.40
|
| Rate for Payer: Cigna Commercial |
$2,380.52
|
| Rate for Payer: Health EOS Commercial |
$2,302.89
|
| Rate for Payer: HFN Commercial |
$2,380.52
|
| Rate for Payer: Multiplan Commercial |
$2,070.02
|
| Rate for Payer: Preferred Network Access Commercial |
$2,380.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,267.88
|
| Rate for Payer: Quartz Commercial |
$1,552.51
|
| Rate for Payer: WEA Trust Commercial |
$1,423.14
|
| Rate for Payer: WPS Commercial |
$1,916.51
|
|
|
PATCH XENOSURE BOVINE 0.8CMX8CM 0.8P8
|
Facility
|
IP
|
$2,536.00
|
|
| Hospital Charge Code |
4519241
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,292.35 |
| Max. Negotiated Rate |
$2,426.44 |
| Rate for Payer: Aetna Commercial |
$2,373.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,268.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,397.84
|
| Rate for Payer: Cash Price |
$760.80
|
| Rate for Payer: Cigna Commercial |
$2,426.44
|
| Rate for Payer: Health EOS Commercial |
$2,347.32
|
| Rate for Payer: HFN Commercial |
$2,426.44
|
| Rate for Payer: Multiplan Commercial |
$2,109.95
|
| Rate for Payer: Preferred Network Access Commercial |
$2,426.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,292.35
|
| Rate for Payer: Quartz Commercial |
$1,582.46
|
| Rate for Payer: WEA Trust Commercial |
$1,450.59
|
| Rate for Payer: WPS Commercial |
$1,953.48
|
|
|
PATCH XENOSURE BOVINE 0.8CMX8CM 0.8P8
|
Facility
|
OP
|
$2,536.00
|
|
| Hospital Charge Code |
4519241
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$738.48 |
| Max. Negotiated Rate |
$2,426.44 |
| Rate for Payer: Aetna Commercial |
$2,373.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,268.20
|
| Rate for Payer: Aetna Managed Medicare |
$738.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,714.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,318.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,265.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,397.84
|
| Rate for Payer: Cash Price |
$760.80
|
| Rate for Payer: Cigna Commercial |
$2,426.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,475.95
|
| Rate for Payer: Health EOS Commercial |
$2,347.32
|
| Rate for Payer: HFN Commercial |
$2,426.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,978.08
|
| Rate for Payer: Multiplan Commercial |
$2,109.95
|
| Rate for Payer: NAPHCARE Commercial |
$1,582.46
|
| Rate for Payer: Preferred Network Access Commercial |
$2,426.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,292.35
|
| Rate for Payer: Quartz Commercial |
$1,714.34
|
| Rate for Payer: Quartz Medicare Advantage |
$1,582.46
|
| Rate for Payer: The Alliance Commercial |
$1,318.72
|
| Rate for Payer: WEA Trust Commercial |
$1,450.59
|
| Rate for Payer: WPS Commercial |
$1,953.48
|
|
|
PATELLA 26MM PROLONG 00-5972-066-26
|
Facility
|
OP
|
$7,229.00
|
|
| Hospital Charge Code |
2967764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,105.08 |
| Max. Negotiated Rate |
$6,916.71 |
| Rate for Payer: Aetna Commercial |
$6,766.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,465.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,105.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,886.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,759.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,608.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,984.62
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,916.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,207.28
|
| Rate for Payer: Health EOS Commercial |
$6,691.16
|
| Rate for Payer: HFN Commercial |
$6,916.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,638.62
|
| Rate for Payer: Multiplan Commercial |
$6,014.53
|
| Rate for Payer: NAPHCARE Commercial |
$4,510.90
|
| Rate for Payer: Preferred Network Access Commercial |
$6,916.71
|
| Rate for Payer: Quartz Beloit One Network |
$3,683.90
|
| Rate for Payer: Quartz Commercial |
$4,886.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,510.90
|
| Rate for Payer: The Alliance Commercial |
$3,759.08
|
| Rate for Payer: WEA Trust Commercial |
$4,134.99
|
| Rate for Payer: WPS Commercial |
$5,568.50
|
|
|
PATELLA 26MM PROLONG 00-5972-066-26
|
Facility
|
IP
|
$7,229.00
|
|
| Hospital Charge Code |
2967764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,683.90 |
| Max. Negotiated Rate |
$6,916.71 |
| Rate for Payer: Aetna Commercial |
$6,766.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,465.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,984.62
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,916.71
|
| Rate for Payer: Health EOS Commercial |
$6,691.16
|
| Rate for Payer: HFN Commercial |
$6,916.71
|
| Rate for Payer: Multiplan Commercial |
$6,014.53
|
| Rate for Payer: Preferred Network Access Commercial |
$6,916.71
|
| Rate for Payer: Quartz Beloit One Network |
$3,683.90
|
| Rate for Payer: Quartz Commercial |
$4,510.90
|
| Rate for Payer: WEA Trust Commercial |
$4,134.99
|
| Rate for Payer: WPS Commercial |
$5,568.50
|
|
|
PATELLA 29MM PROLONG 00-5972-066-29
|
Facility
|
IP
|
$7,229.00
|
|
| Hospital Charge Code |
2967765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,683.90 |
| Max. Negotiated Rate |
$6,916.71 |
| Rate for Payer: Aetna Commercial |
$6,766.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,465.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,984.62
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,916.71
|
| Rate for Payer: Health EOS Commercial |
$6,691.16
|
| Rate for Payer: HFN Commercial |
$6,916.71
|
| Rate for Payer: Multiplan Commercial |
$6,014.53
|
| Rate for Payer: Preferred Network Access Commercial |
$6,916.71
|
| Rate for Payer: Quartz Beloit One Network |
$3,683.90
|
| Rate for Payer: Quartz Commercial |
$4,510.90
|
| Rate for Payer: WEA Trust Commercial |
$4,134.99
|
| Rate for Payer: WPS Commercial |
$5,568.50
|
|
|
PATELLA 29MM PROLONG 00-5972-066-29
|
Facility
|
OP
|
$7,229.00
|
|
| Hospital Charge Code |
2967765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,105.08 |
| Max. Negotiated Rate |
$6,916.71 |
| Rate for Payer: Aetna Commercial |
$6,766.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,465.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,105.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,886.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,759.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,608.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,984.62
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,916.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,207.28
|
| Rate for Payer: Health EOS Commercial |
$6,691.16
|
| Rate for Payer: HFN Commercial |
$6,916.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,638.62
|
| Rate for Payer: Multiplan Commercial |
$6,014.53
|
| Rate for Payer: NAPHCARE Commercial |
$4,510.90
|
| Rate for Payer: Preferred Network Access Commercial |
$6,916.71
|
| Rate for Payer: Quartz Beloit One Network |
$3,683.90
|
| Rate for Payer: Quartz Commercial |
$4,886.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,510.90
|
| Rate for Payer: The Alliance Commercial |
$3,759.08
|
| Rate for Payer: WEA Trust Commercial |
$4,134.99
|
| Rate for Payer: WPS Commercial |
$5,568.50
|
|
|
PATELLA 32MM PROLONG 00-5972-066-32
|
Facility
|
IP
|
$7,508.00
|
|
| Hospital Charge Code |
2967766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,826.08 |
| Max. Negotiated Rate |
$7,183.65 |
| Rate for Payer: Aetna Commercial |
$7,027.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,715.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,138.41
|
| Rate for Payer: Cash Price |
$2,252.40
|
| Rate for Payer: Cigna Commercial |
$7,183.65
|
| Rate for Payer: Health EOS Commercial |
$6,949.40
|
| Rate for Payer: HFN Commercial |
$7,183.65
|
| Rate for Payer: Multiplan Commercial |
$6,246.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7,183.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,826.08
|
| Rate for Payer: Quartz Commercial |
$4,684.99
|
| Rate for Payer: WEA Trust Commercial |
$4,294.58
|
| Rate for Payer: WPS Commercial |
$5,783.41
|
|
