|
STAPLER RELOAD VAS 45MM 030454
|
Facility
|
OP
|
$968.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2962875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$271.04 |
| Max. Negotiated Rate |
$3,872.00 |
| Rate for Payer: Aetna Commercial |
$871.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$832.48
|
| Rate for Payer: Aetna Managed Medicare |
$271.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$629.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$484.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$464.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$513.04
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cigna Commercial |
$890.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$541.69
|
| Rate for Payer: Health EOS Commercial |
$861.52
|
| Rate for Payer: HFN Commercial |
$890.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$726.00
|
| Rate for Payer: Multiplan Commercial |
$774.40
|
| Rate for Payer: NAPHCARE Commercial |
$580.80
|
| Rate for Payer: Preferred Network Access Commercial |
$890.56
|
| Rate for Payer: Quartz Beloit One Network |
$474.32
|
| Rate for Payer: Quartz Commercial |
$629.20
|
| Rate for Payer: Quartz Medicare Advantage |
$580.80
|
| Rate for Payer: The Alliance Commercial |
$3,872.00
|
| Rate for Payer: WEA Trust Commercial |
$532.40
|
| Rate for Payer: WPS Commercial |
$717.00
|
|
|
STAPLER RELOAD VASC 30-2.5
|
Facility
|
IP
|
$1,741.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2962882
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$853.09 |
| Max. Negotiated Rate |
$1,601.72 |
| Rate for Payer: Aetna Commercial |
$1,566.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,497.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$922.73
|
| Rate for Payer: Cash Price |
$522.30
|
| Rate for Payer: Cigna Commercial |
$1,601.72
|
| Rate for Payer: Health EOS Commercial |
$1,549.49
|
| Rate for Payer: HFN Commercial |
$1,601.72
|
| Rate for Payer: Multiplan Commercial |
$1,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,044.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,601.72
|
| Rate for Payer: Quartz Beloit One Network |
$853.09
|
| Rate for Payer: Quartz Commercial |
$1,044.60
|
| Rate for Payer: WEA Trust Commercial |
$957.55
|
| Rate for Payer: WPS Commercial |
$1,289.56
|
|
|
STAPLER RELOAD VASC 30-2.5
|
Facility
|
OP
|
$1,741.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2962882
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$487.48 |
| Max. Negotiated Rate |
$6,964.00 |
| Rate for Payer: Aetna Commercial |
$1,566.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,497.26
|
| Rate for Payer: Aetna Managed Medicare |
$487.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,131.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$870.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$835.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$922.73
|
| Rate for Payer: Cash Price |
$522.30
|
| Rate for Payer: Cigna Commercial |
$1,601.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$974.26
|
| Rate for Payer: Health EOS Commercial |
$1,549.49
|
| Rate for Payer: HFN Commercial |
$1,601.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,305.75
|
| Rate for Payer: Multiplan Commercial |
$1,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,044.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,601.72
|
| Rate for Payer: Quartz Beloit One Network |
$853.09
|
| Rate for Payer: Quartz Commercial |
$1,131.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,044.60
|
| Rate for Payer: The Alliance Commercial |
$6,964.00
|
| Rate for Payer: WEA Trust Commercial |
$957.55
|
| Rate for Payer: WPS Commercial |
$1,289.56
|
|
|
STAPLER RELOAD VASCULAR 30MM SHORT SD CT GRAY SIGSDS30CTV
|
Facility
|
OP
|
$4,785.00
|
|
| Hospital Charge Code |
5729696
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,339.80 |
| Max. Negotiated Rate |
$19,140.00 |
| Rate for Payer: Aetna Commercial |
$4,306.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,115.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,339.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,110.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,392.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,296.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,536.05
|
| Rate for Payer: Cash Price |
$1,435.50
|
| Rate for Payer: Cigna Commercial |
$4,402.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,677.69
|
| Rate for Payer: Health EOS Commercial |
$4,258.65
|
| Rate for Payer: HFN Commercial |
$4,402.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,588.75
|
| Rate for Payer: Multiplan Commercial |
$3,828.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,871.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,402.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,344.65
|
| Rate for Payer: Quartz Commercial |
$3,110.25
|
| Rate for Payer: Quartz Medicare Advantage |
$2,871.00
|
| Rate for Payer: The Alliance Commercial |
$19,140.00
|
| Rate for Payer: WEA Trust Commercial |
$2,631.75
|
| Rate for Payer: WPS Commercial |
$3,544.25
|
|
|
STAPLER RELOAD VASCULAR 30MM SHORT SD CT GRAY SIGSDS30CTV
|
Facility
|
IP
|
$4,785.00
|
|
| Hospital Charge Code |
5729696
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,344.65 |
| Max. Negotiated Rate |
$4,402.20 |
| Rate for Payer: Aetna Commercial |
$4,306.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,115.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,536.05
|
| Rate for Payer: Cash Price |
$1,435.50
|
| Rate for Payer: Cigna Commercial |
$4,402.20
|
| Rate for Payer: Health EOS Commercial |
$4,258.65
|
| Rate for Payer: HFN Commercial |
$4,402.20
|
| Rate for Payer: Multiplan Commercial |
$3,828.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,871.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,402.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,344.65
|
| Rate for Payer: Quartz Commercial |
$2,871.00
|
| Rate for Payer: WEA Trust Commercial |
$2,631.75
|
| Rate for Payer: WPS Commercial |
$3,544.25
|
|
|
STAPLER RELOAD VASCULAR 30MM THIN SHORT SD CT WHITE SIGSDS30CTVT
|
Facility
|
OP
|
$5,036.00
|
|
| Hospital Charge Code |
5729697
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,410.08 |
| Max. Negotiated Rate |
$20,144.00 |
| Rate for Payer: Aetna Commercial |
$4,532.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,330.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,410.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,273.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,518.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,417.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,669.08
|
| Rate for Payer: Cash Price |
$1,510.80
|
| Rate for Payer: Cigna Commercial |
$4,633.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,818.15
|
| Rate for Payer: Health EOS Commercial |
$4,482.04
|
| Rate for Payer: HFN Commercial |
$4,633.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,777.00
|
| Rate for Payer: Multiplan Commercial |
$4,028.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,021.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,633.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,467.64
|
| Rate for Payer: Quartz Commercial |
$3,273.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,021.60
|
| Rate for Payer: The Alliance Commercial |
$20,144.00
|
| Rate for Payer: WEA Trust Commercial |
$2,769.80
|
| Rate for Payer: WPS Commercial |
$3,730.17
|
|
|
STAPLER RELOAD VASCULAR 30MM THIN SHORT SD CT WHITE SIGSDS30CTVT
|
Facility
|
IP
|
$5,036.00
|
|
| Hospital Charge Code |
5729697
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,467.64 |
| Max. Negotiated Rate |
$4,633.12 |
| Rate for Payer: Aetna Commercial |
$4,532.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,330.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,669.08
|
| Rate for Payer: Cash Price |
$1,510.80
|
| Rate for Payer: Cigna Commercial |
$4,633.12
|
| Rate for Payer: Health EOS Commercial |
$4,482.04
|
| Rate for Payer: HFN Commercial |
$4,633.12
|
| Rate for Payer: Multiplan Commercial |
$4,028.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,021.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,633.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,467.64
|
| Rate for Payer: Quartz Commercial |
$3,021.60
|
| Rate for Payer: WEA Trust Commercial |
$2,769.80
|
| Rate for Payer: WPS Commercial |
$3,730.17
|
|
|
STAPLER RELOAD VASCULAR 45MM THIN LONG SD CT WHITE SIGSDL45CTVT
|
Facility
|
OP
|
$5,336.00
|
|
| Hospital Charge Code |
5729698
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,494.08 |
| Max. Negotiated Rate |
$21,344.00 |
| Rate for Payer: Aetna Commercial |
$4,802.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,588.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,494.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,468.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,668.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,561.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,828.08
|
| Rate for Payer: Cash Price |
$1,600.80
|
| Rate for Payer: Cigna Commercial |
$4,909.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,986.03
|
| Rate for Payer: Health EOS Commercial |
$4,749.04
|
| Rate for Payer: HFN Commercial |
$4,909.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,002.00
|
| Rate for Payer: Multiplan Commercial |
$4,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,201.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,909.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,614.64
|
| Rate for Payer: Quartz Commercial |
$3,468.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,201.60
|
| Rate for Payer: The Alliance Commercial |
$21,344.00
|
| Rate for Payer: WEA Trust Commercial |
$2,934.80
|
| Rate for Payer: WPS Commercial |
$3,952.38
|
|
|
STAPLER RELOAD VASCULAR 45MM THIN LONG SD CT WHITE SIGSDL45CTVT
|
Facility
|
IP
|
$5,336.00
|
|
| Hospital Charge Code |
5729698
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,614.64 |
| Max. Negotiated Rate |
$4,909.12 |
| Rate for Payer: Aetna Commercial |
$4,802.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,588.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,828.08
|
| Rate for Payer: Cash Price |
$1,600.80
|
| Rate for Payer: Cigna Commercial |
$4,909.12
|
| Rate for Payer: Health EOS Commercial |
$4,749.04
|
| Rate for Payer: HFN Commercial |
$4,909.12
|
| Rate for Payer: Multiplan Commercial |
$4,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,201.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,909.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,614.64
|
| Rate for Payer: Quartz Commercial |
$3,201.60
|
| Rate for Payer: WEA Trust Commercial |
$2,934.80
|
| Rate for Payer: WPS Commercial |
$3,952.38
|
|
|
STAPLER SKIN 35W 8886803712 / 900-7010
|
Facility
|
OP
|
$164.00
|
|
| Hospital Charge Code |
2963244
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.92 |
| Max. Negotiated Rate |
$656.00 |
| Rate for Payer: Aetna Commercial |
$147.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.04
|
| Rate for Payer: Aetna Managed Medicare |
$45.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.92
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$150.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.77
|
| Rate for Payer: Health EOS Commercial |
$145.96
|
| Rate for Payer: HFN Commercial |
$150.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.00
|
| Rate for Payer: Multiplan Commercial |
$131.20
|
| Rate for Payer: NAPHCARE Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.88
|
| Rate for Payer: Quartz Beloit One Network |
$80.36
|
| Rate for Payer: Quartz Commercial |
$106.60
|
| Rate for Payer: Quartz Medicare Advantage |
$98.40
|
| Rate for Payer: The Alliance Commercial |
$656.00
|
| Rate for Payer: WEA Trust Commercial |
$90.20
|
| Rate for Payer: WPS Commercial |
$121.47
|
|
|
STAPLER SKIN 35W 8886803712 / 900-7010
|
Facility
|
IP
|
$164.00
|
|
| Hospital Charge Code |
2963244
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$80.36 |
| Max. Negotiated Rate |
$150.88 |
| Rate for Payer: Aetna Commercial |
$147.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.92
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$150.88
|
| Rate for Payer: Health EOS Commercial |
$145.96
|
| Rate for Payer: HFN Commercial |
$150.88
|
| Rate for Payer: Multiplan Commercial |
$131.20
|
| Rate for Payer: NAPHCARE Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.88
|
| Rate for Payer: Quartz Beloit One Network |
$80.36
|
| Rate for Payer: Quartz Commercial |
$98.40
|
| Rate for Payer: WEA Trust Commercial |
$90.20
|
| Rate for Payer: WPS Commercial |
$121.47
|
|
|
STAPLER SKIN SMALL 5 STAPLE DS-5
|
Facility
|
IP
|
$105.00
|
|
| Hospital Charge Code |
4493753
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.45 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
STAPLER SKIN SMALL 5 STAPLE DS-5
|
Facility
|
OP
|
$105.00
|
|
| Hospital Charge Code |
4493753
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Aetna Managed Medicare |
$29.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.76
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.75
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$68.25
|
| Rate for Payer: Quartz Medicare Advantage |
$63.00
|
| Rate for Payer: The Alliance Commercial |
$420.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
STAPLE SYSTEM 10MM X 10MM 500-10-001
|
Facility
|
OP
|
$7,006.00
|
|
| Hospital Charge Code |
5248832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.68 |
| Max. Negotiated Rate |
$28,024.00 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,961.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,553.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,920.56
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,254.50
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,553.90
|
| Rate for Payer: Quartz Medicare Advantage |
$4,203.60
|
| Rate for Payer: The Alliance Commercial |
$28,024.00
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
STAPLE SYSTEM 10MM X 10MM 500-10-001
|
Facility
|
IP
|
$7,006.00
|
|
| Hospital Charge Code |
5248832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,432.94 |
| Max. Negotiated Rate |
$6,445.52 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,203.60
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
STAPLE SYSTEM 10MM X 10MM SNIPER 500-10-101
|
Facility
|
OP
|
$7,419.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5414669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,077.32 |
| Max. Negotiated Rate |
$29,676.00 |
| Rate for Payer: Aetna Commercial |
$6,677.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,380.34
|
| Rate for Payer: Aetna Managed Medicare |
$2,077.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,822.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,709.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,561.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,932.07
|
| Rate for Payer: Cash Price |
$2,225.70
|
| Rate for Payer: Cigna Commercial |
$6,825.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,151.67
|
| Rate for Payer: Health EOS Commercial |
$6,602.91
|
| Rate for Payer: HFN Commercial |
$6,825.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,564.25
|
| Rate for Payer: Multiplan Commercial |
$5,935.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,451.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,825.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,635.31
|
| Rate for Payer: Quartz Commercial |
$4,822.35
|
| Rate for Payer: Quartz Medicare Advantage |
$4,451.40
|
| Rate for Payer: The Alliance Commercial |
$29,676.00
|
| Rate for Payer: WEA Trust Commercial |
$4,080.45
|
| Rate for Payer: WPS Commercial |
$5,495.25
|
|
|
STAPLE SYSTEM 10MM X 10MM SNIPER 500-10-101
|
Facility
|
IP
|
$7,419.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5414669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,635.31 |
| Max. Negotiated Rate |
$6,825.48 |
| Rate for Payer: Aetna Commercial |
$6,677.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,380.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,932.07
|
| Rate for Payer: Cash Price |
$2,225.70
|
| Rate for Payer: Cigna Commercial |
$6,825.48
|
| Rate for Payer: Health EOS Commercial |
$6,602.91
|
| Rate for Payer: HFN Commercial |
$6,825.48
|
| Rate for Payer: Multiplan Commercial |
$5,935.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,451.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,825.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,635.31
|
| Rate for Payer: Quartz Commercial |
$4,451.40
|
| Rate for Payer: WEA Trust Commercial |
$4,080.45
|
| Rate for Payer: WPS Commercial |
$5,495.25
|
|
|
STAPLE SYSTEM 15MM X 15MM 500-15-001
|
Facility
|
OP
|
$5,824.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.72 |
| Max. Negotiated Rate |
$23,296.00 |
| Rate for Payer: Aetna Commercial |
$5,241.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,008.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,630.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,785.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,912.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,795.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,086.72
|
| Rate for Payer: Cash Price |
$1,747.20
|
| Rate for Payer: Cigna Commercial |
$5,358.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,259.11
|
| Rate for Payer: Health EOS Commercial |
$5,183.36
|
| Rate for Payer: HFN Commercial |
$5,358.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,368.00
|
| Rate for Payer: Multiplan Commercial |
$4,659.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,494.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,358.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,853.76
|
| Rate for Payer: Quartz Commercial |
$3,785.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,494.40
|
| Rate for Payer: The Alliance Commercial |
$23,296.00
|
| Rate for Payer: WEA Trust Commercial |
$3,203.20
|
| Rate for Payer: WPS Commercial |
$4,313.84
|
|
|
STAPLE SYSTEM 15MM X 15MM 500-15-001
|
Facility
|
IP
|
$5,824.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,853.76 |
| Max. Negotiated Rate |
$5,358.08 |
| Rate for Payer: Aetna Commercial |
$5,241.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,008.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,086.72
|
| Rate for Payer: Cash Price |
$1,747.20
|
| Rate for Payer: Cigna Commercial |
$5,358.08
|
| Rate for Payer: Health EOS Commercial |
$5,183.36
|
| Rate for Payer: HFN Commercial |
$5,358.08
|
| Rate for Payer: Multiplan Commercial |
$4,659.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,494.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,358.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,853.76
|
| Rate for Payer: Quartz Commercial |
$3,494.40
|
| Rate for Payer: WEA Trust Commercial |
$3,203.20
|
| Rate for Payer: WPS Commercial |
$4,313.84
|
|
|
State Supplied - Bexsero Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$88.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Bexsero Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$286.95 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$226.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.20
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: HFN Commercial |
$20.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$286.95
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: United Healthcare Medicaid |
$226.32
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Bexsero Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - DTap Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$88.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - DTap Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$43.16 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.20
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: HFN Commercial |
$20.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.16
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - DTap Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
