|
STAPLER RELOAD ECHELON ENDOCUTTER 45MM (VASCULAR) GST45W/ECR45W
|
Facility
|
OP
|
$1,688.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3633515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$472.64 |
| Max. Negotiated Rate |
$6,752.00 |
| Rate for Payer: Aetna Commercial |
$1,519.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,451.68
|
| Rate for Payer: Aetna Managed Medicare |
$472.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,097.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$844.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$810.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$894.64
|
| Rate for Payer: Cash Price |
$506.40
|
| Rate for Payer: Cigna Commercial |
$1,552.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$944.60
|
| Rate for Payer: Health EOS Commercial |
$1,502.32
|
| Rate for Payer: HFN Commercial |
$1,552.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,266.00
|
| Rate for Payer: Multiplan Commercial |
$1,350.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,012.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,552.96
|
| Rate for Payer: Quartz Beloit One Network |
$827.12
|
| Rate for Payer: Quartz Commercial |
$1,097.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,012.80
|
| Rate for Payer: The Alliance Commercial |
$6,752.00
|
| Rate for Payer: WEA Trust Commercial |
$928.40
|
| Rate for Payer: WPS Commercial |
$1,250.30
|
|
|
STAPLER RELOAD ECHELON FLEX POWERED VASCULAR 35MM VASECR35
|
Facility
|
OP
|
$1,953.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4595663
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$546.84 |
| Max. Negotiated Rate |
$7,812.00 |
| Rate for Payer: Aetna Commercial |
$1,757.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,679.58
|
| Rate for Payer: Aetna Managed Medicare |
$546.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,269.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$976.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$937.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,035.09
|
| Rate for Payer: Cash Price |
$585.90
|
| Rate for Payer: Cigna Commercial |
$1,796.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,092.90
|
| Rate for Payer: Health EOS Commercial |
$1,738.17
|
| Rate for Payer: HFN Commercial |
$1,796.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,464.75
|
| Rate for Payer: Multiplan Commercial |
$1,562.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,171.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,796.76
|
| Rate for Payer: Quartz Beloit One Network |
$956.97
|
| Rate for Payer: Quartz Commercial |
$1,269.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,171.80
|
| Rate for Payer: The Alliance Commercial |
$7,812.00
|
| Rate for Payer: WEA Trust Commercial |
$1,074.15
|
| Rate for Payer: WPS Commercial |
$1,446.59
|
|
|
STAPLER RELOAD ECHELON FLEX POWERED VASCULAR 35MM VASECR35
|
Facility
|
IP
|
$1,953.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4595663
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$956.97 |
| Max. Negotiated Rate |
$1,796.76 |
| Rate for Payer: Aetna Commercial |
$1,757.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,679.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,035.09
|
| Rate for Payer: Cash Price |
$585.90
|
| Rate for Payer: Cigna Commercial |
$1,796.76
|
| Rate for Payer: Health EOS Commercial |
$1,738.17
|
| Rate for Payer: HFN Commercial |
$1,796.76
|
| Rate for Payer: Multiplan Commercial |
$1,562.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,171.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,796.76
|
| Rate for Payer: Quartz Beloit One Network |
$956.97
|
| Rate for Payer: Quartz Commercial |
$1,171.80
|
| Rate for Payer: WEA Trust Commercial |
$1,074.15
|
| Rate for Payer: WPS Commercial |
$1,446.59
|
|
|
STAPLER RELOAD ECHELON POWERED 60MM (BLUE) GST60B
|
Facility
|
IP
|
$2,060.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4494248
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,009.40 |
| Max. Negotiated Rate |
$1,895.20 |
| Rate for Payer: Aetna Commercial |
$1,854.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,771.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,091.80
|
| Rate for Payer: Cash Price |
$618.00
|
| Rate for Payer: Cigna Commercial |
$1,895.20
|
| Rate for Payer: Health EOS Commercial |
$1,833.40
|
| Rate for Payer: HFN Commercial |
$1,895.20
|
| Rate for Payer: Multiplan Commercial |
$1,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,236.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,895.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,009.40
|
| Rate for Payer: Quartz Commercial |
$1,236.00
|
| Rate for Payer: WEA Trust Commercial |
$1,133.00
|
| Rate for Payer: WPS Commercial |
$1,525.84
|
|
|
STAPLER RELOAD ECHELON POWERED 60MM (BLUE) GST60B
|
Facility
|
OP
|
$2,060.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4494248
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$576.80 |
| Max. Negotiated Rate |
$8,240.00 |
| Rate for Payer: Aetna Commercial |
$1,854.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,771.60
|
| Rate for Payer: Aetna Managed Medicare |
$576.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,339.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,030.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$988.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,091.80
|
| Rate for Payer: Cash Price |
$618.00
|
| Rate for Payer: Cigna Commercial |
$1,895.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,152.78
|
| Rate for Payer: Health EOS Commercial |
$1,833.40
|
| Rate for Payer: HFN Commercial |
$1,895.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,545.00
|
| Rate for Payer: Multiplan Commercial |
$1,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,236.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,895.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,009.40
|
| Rate for Payer: Quartz Commercial |
$1,339.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,236.00
|
| Rate for Payer: The Alliance Commercial |
$8,240.00
|
| Rate for Payer: WEA Trust Commercial |
$1,133.00
|
| Rate for Payer: WPS Commercial |
$1,525.84
|
|
|
STAPLER RELOAD ENDOCUTTER 45MM (GREEN) GST45G
|
Facility
|
IP
|
$1,688.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3697500
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$827.12 |
| Max. Negotiated Rate |
$1,552.96 |
| Rate for Payer: Aetna Commercial |
$1,519.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,451.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$894.64
|
| Rate for Payer: Cash Price |
$506.40
|
| Rate for Payer: Cigna Commercial |
$1,552.96
|
| Rate for Payer: Health EOS Commercial |
$1,502.32
|
| Rate for Payer: HFN Commercial |
$1,552.96
|
| Rate for Payer: Multiplan Commercial |
$1,350.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,012.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,552.96
|
| Rate for Payer: Quartz Beloit One Network |
$827.12
|
| Rate for Payer: Quartz Commercial |
$1,012.80
|
| Rate for Payer: WEA Trust Commercial |
$928.40
|
| Rate for Payer: WPS Commercial |
$1,250.30
|
|
|
STAPLER RELOAD ENDOCUTTER 45MM (GREEN) GST45G
|
Facility
|
OP
|
$1,688.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3697500
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$472.64 |
| Max. Negotiated Rate |
$6,752.00 |
| Rate for Payer: Aetna Commercial |
$1,519.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,451.68
|
| Rate for Payer: Aetna Managed Medicare |
$472.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,097.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$844.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$810.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$894.64
|
| Rate for Payer: Cash Price |
$506.40
|
| Rate for Payer: Cigna Commercial |
$1,552.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$944.60
|
| Rate for Payer: Health EOS Commercial |
$1,502.32
|
| Rate for Payer: HFN Commercial |
$1,552.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,266.00
|
| Rate for Payer: Multiplan Commercial |
$1,350.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,012.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,552.96
|
| Rate for Payer: Quartz Beloit One Network |
$827.12
|
| Rate for Payer: Quartz Commercial |
$1,097.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,012.80
|
| Rate for Payer: The Alliance Commercial |
$6,752.00
|
| Rate for Payer: WEA Trust Commercial |
$928.40
|
| Rate for Payer: WPS Commercial |
$1,250.30
|
|
|
STAPLER RELOAD FLEX ETS/45MM GRAY 6R45M***SEE 2001716
|
Facility
|
IP
|
$1,624.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4491012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$795.76 |
| Max. Negotiated Rate |
$1,494.08 |
| Rate for Payer: Aetna Commercial |
$1,461.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,396.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$860.72
|
| Rate for Payer: Cash Price |
$487.20
|
| Rate for Payer: Cigna Commercial |
$1,494.08
|
| Rate for Payer: Health EOS Commercial |
$1,445.36
|
| Rate for Payer: HFN Commercial |
$1,494.08
|
| Rate for Payer: Multiplan Commercial |
$1,299.20
|
| Rate for Payer: NAPHCARE Commercial |
$974.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,494.08
|
| Rate for Payer: Quartz Beloit One Network |
$795.76
|
| Rate for Payer: Quartz Commercial |
$974.40
|
| Rate for Payer: WEA Trust Commercial |
$893.20
|
| Rate for Payer: WPS Commercial |
$1,202.90
|
|
|
STAPLER RELOAD FLEX ETS/45MM GRAY 6R45M***SEE 2001716
|
Facility
|
OP
|
$1,624.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4491012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$454.72 |
| Max. Negotiated Rate |
$6,496.00 |
| Rate for Payer: Aetna Commercial |
$1,461.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,396.64
|
| Rate for Payer: Aetna Managed Medicare |
$454.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,055.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$812.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$779.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$860.72
|
| Rate for Payer: Cash Price |
$487.20
|
| Rate for Payer: Cigna Commercial |
$1,494.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$908.79
|
| Rate for Payer: Health EOS Commercial |
$1,445.36
|
| Rate for Payer: HFN Commercial |
$1,494.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,218.00
|
| Rate for Payer: Multiplan Commercial |
$1,299.20
|
| Rate for Payer: NAPHCARE Commercial |
$974.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,494.08
|
| Rate for Payer: Quartz Beloit One Network |
$795.76
|
| Rate for Payer: Quartz Commercial |
$1,055.60
|
| Rate for Payer: Quartz Medicare Advantage |
$974.40
|
| Rate for Payer: The Alliance Commercial |
$6,496.00
|
| Rate for Payer: WEA Trust Commercial |
$893.20
|
| Rate for Payer: WPS Commercial |
$1,202.90
|
|
|
STAPLER RELOAD GREEN 030456
|
Facility
|
OP
|
$1,648.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2962863
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$461.44 |
| Max. Negotiated Rate |
$6,592.00 |
| Rate for Payer: Aetna Commercial |
$1,483.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,417.28
|
| Rate for Payer: Aetna Managed Medicare |
$461.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,071.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$824.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$791.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$873.44
|
| Rate for Payer: Cash Price |
$494.40
|
| Rate for Payer: Cigna Commercial |
$1,516.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$922.22
|
| Rate for Payer: Health EOS Commercial |
$1,466.72
|
| Rate for Payer: HFN Commercial |
$1,516.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,236.00
|
| Rate for Payer: Multiplan Commercial |
$1,318.40
|
| Rate for Payer: NAPHCARE Commercial |
$988.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,516.16
|
| Rate for Payer: Quartz Beloit One Network |
$807.52
|
| Rate for Payer: Quartz Commercial |
$1,071.20
|
| Rate for Payer: Quartz Medicare Advantage |
$988.80
|
| Rate for Payer: The Alliance Commercial |
$6,592.00
|
| Rate for Payer: WEA Trust Commercial |
$906.40
|
| Rate for Payer: WPS Commercial |
$1,220.67
|
|
|
STAPLER RELOAD GREEN 030456
|
Facility
|
IP
|
$1,648.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2962863
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$807.52 |
| Max. Negotiated Rate |
$1,516.16 |
| Rate for Payer: Aetna Commercial |
$1,483.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,417.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$873.44
|
| Rate for Payer: Cash Price |
$494.40
|
| Rate for Payer: Cigna Commercial |
$1,516.16
|
| Rate for Payer: Health EOS Commercial |
$1,466.72
|
| Rate for Payer: HFN Commercial |
$1,516.16
|
| Rate for Payer: Multiplan Commercial |
$1,318.40
|
| Rate for Payer: NAPHCARE Commercial |
$988.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,516.16
|
| Rate for Payer: Quartz Beloit One Network |
$807.52
|
| Rate for Payer: Quartz Commercial |
$988.80
|
| Rate for Payer: WEA Trust Commercial |
$906.40
|
| Rate for Payer: WPS Commercial |
$1,220.67
|
|
|
STAPLER RELOAD HERNIA 4.8MM
|
Facility
|
OP
|
$1,504.00
|
|
| Hospital Charge Code |
2962990
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$421.12 |
| Max. Negotiated Rate |
$6,016.00 |
| Rate for Payer: Aetna Commercial |
$1,353.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,293.44
|
| Rate for Payer: Aetna Managed Medicare |
$421.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$977.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$752.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$721.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$797.12
|
| Rate for Payer: Cash Price |
$451.20
|
| Rate for Payer: Cigna Commercial |
$1,383.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$841.64
|
| Rate for Payer: Health EOS Commercial |
$1,338.56
|
| Rate for Payer: HFN Commercial |
$1,383.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,128.00
|
| Rate for Payer: Multiplan Commercial |
$1,203.20
|
| Rate for Payer: NAPHCARE Commercial |
$902.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,383.68
|
| Rate for Payer: Quartz Beloit One Network |
$736.96
|
| Rate for Payer: Quartz Commercial |
$977.60
|
| Rate for Payer: Quartz Medicare Advantage |
$902.40
|
| Rate for Payer: The Alliance Commercial |
$6,016.00
|
| Rate for Payer: WEA Trust Commercial |
$827.20
|
| Rate for Payer: WPS Commercial |
$1,114.01
|
|
|
STAPLER RELOAD HERNIA 4.8MM
|
Facility
|
IP
|
$1,504.00
|
|
| Hospital Charge Code |
2962990
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$736.96 |
| Max. Negotiated Rate |
$1,383.68 |
| Rate for Payer: Aetna Commercial |
$1,353.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,293.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$797.12
|
| Rate for Payer: Cash Price |
$451.20
|
| Rate for Payer: Cigna Commercial |
$1,383.68
|
| Rate for Payer: Health EOS Commercial |
$1,338.56
|
| Rate for Payer: HFN Commercial |
$1,383.68
|
| Rate for Payer: Multiplan Commercial |
$1,203.20
|
| Rate for Payer: NAPHCARE Commercial |
$902.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,383.68
|
| Rate for Payer: Quartz Beloit One Network |
$736.96
|
| Rate for Payer: Quartz Commercial |
$902.40
|
| Rate for Payer: WEA Trust Commercial |
$827.20
|
| Rate for Payer: WPS Commercial |
$1,114.01
|
|
|
STAPLER RELOAD LINEAR 90MM TRH90/TRT10
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3633521
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$263.20 |
| Max. Negotiated Rate |
$3,760.00 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.40
|
| Rate for Payer: Aetna Managed Medicare |
$263.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.02
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.00
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$611.00
|
| Rate for Payer: Quartz Medicare Advantage |
$564.00
|
| Rate for Payer: The Alliance Commercial |
$3,760.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
STAPLER RELOAD LINEAR 90MM TRH90/TRT10
|
Facility
|
IP
|
$940.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3633521
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$460.60 |
| Max. Negotiated Rate |
$864.80 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$564.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
STAPLER RELOAD LINEAR (BLUE) 30MM XR30B
|
Facility
|
IP
|
$759.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3633510
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$371.91 |
| Max. Negotiated Rate |
$698.28 |
| Rate for Payer: Aetna Commercial |
$683.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$652.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$402.27
|
| Rate for Payer: Cash Price |
$227.70
|
| Rate for Payer: Cigna Commercial |
$698.28
|
| Rate for Payer: Health EOS Commercial |
$675.51
|
| Rate for Payer: HFN Commercial |
$698.28
|
| Rate for Payer: Multiplan Commercial |
$607.20
|
| Rate for Payer: NAPHCARE Commercial |
$455.40
|
| Rate for Payer: Preferred Network Access Commercial |
$698.28
|
| Rate for Payer: Quartz Beloit One Network |
$371.91
|
| Rate for Payer: Quartz Commercial |
$455.40
|
| Rate for Payer: WEA Trust Commercial |
$417.45
|
| Rate for Payer: WPS Commercial |
$562.19
|
|
|
STAPLER RELOAD LINEAR (BLUE) 30MM XR30B
|
Facility
|
OP
|
$759.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3633510
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$212.52 |
| Max. Negotiated Rate |
$3,036.00 |
| Rate for Payer: Aetna Commercial |
$683.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$652.74
|
| Rate for Payer: Aetna Managed Medicare |
$212.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$493.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$379.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$364.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$402.27
|
| Rate for Payer: Cash Price |
$227.70
|
| Rate for Payer: Cigna Commercial |
$698.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$424.74
|
| Rate for Payer: Health EOS Commercial |
$675.51
|
| Rate for Payer: HFN Commercial |
$698.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$569.25
|
| Rate for Payer: Multiplan Commercial |
$607.20
|
| Rate for Payer: NAPHCARE Commercial |
$455.40
|
| Rate for Payer: Preferred Network Access Commercial |
$698.28
|
| Rate for Payer: Quartz Beloit One Network |
$371.91
|
| Rate for Payer: Quartz Commercial |
$493.35
|
| Rate for Payer: Quartz Medicare Advantage |
$455.40
|
| Rate for Payer: The Alliance Commercial |
$3,036.00
|
| Rate for Payer: WEA Trust Commercial |
$417.45
|
| Rate for Payer: WPS Commercial |
$562.19
|
|
|
STAPLER RELOAD LINEAR (BLUE) 60MM XR60B
|
Facility
|
OP
|
$787.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3633512
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$220.36 |
| Max. Negotiated Rate |
$3,148.00 |
| Rate for Payer: Aetna Commercial |
$708.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$676.82
|
| Rate for Payer: Aetna Managed Medicare |
$220.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$511.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$393.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$377.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$417.11
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cigna Commercial |
$724.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$440.41
|
| Rate for Payer: Health EOS Commercial |
$700.43
|
| Rate for Payer: HFN Commercial |
$724.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$590.25
|
| Rate for Payer: Multiplan Commercial |
$629.60
|
| Rate for Payer: NAPHCARE Commercial |
$472.20
|
| Rate for Payer: Preferred Network Access Commercial |
$724.04
|
| Rate for Payer: Quartz Beloit One Network |
$385.63
|
| Rate for Payer: Quartz Commercial |
$511.55
|
| Rate for Payer: Quartz Medicare Advantage |
$472.20
|
| Rate for Payer: The Alliance Commercial |
$3,148.00
|
| Rate for Payer: WEA Trust Commercial |
$432.85
|
| Rate for Payer: WPS Commercial |
$582.93
|
|
|
STAPLER RELOAD LINEAR (BLUE) 60MM XR60B
|
Facility
|
IP
|
$787.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3633512
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$385.63 |
| Max. Negotiated Rate |
$724.04 |
| Rate for Payer: Aetna Commercial |
$708.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$676.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$417.11
|
| Rate for Payer: Cash Price |
$236.10
|
| Rate for Payer: Cigna Commercial |
$724.04
|
| Rate for Payer: Health EOS Commercial |
$700.43
|
| Rate for Payer: HFN Commercial |
$724.04
|
| Rate for Payer: Multiplan Commercial |
$629.60
|
| Rate for Payer: NAPHCARE Commercial |
$472.20
|
| Rate for Payer: Preferred Network Access Commercial |
$724.04
|
| Rate for Payer: Quartz Beloit One Network |
$385.63
|
| Rate for Payer: Quartz Commercial |
$472.20
|
| Rate for Payer: WEA Trust Commercial |
$432.85
|
| Rate for Payer: WPS Commercial |
$582.93
|
|
|
STAPLER RELOAD LINEAR (BLUE) 90MM 4.8MM TA9048L
|
Facility
|
OP
|
$2,547.00
|
|
| Hospital Charge Code |
5599673
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$713.16 |
| Max. Negotiated Rate |
$10,188.00 |
| Rate for Payer: Aetna Commercial |
$2,292.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,190.42
|
| Rate for Payer: Aetna Managed Medicare |
$713.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,655.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,273.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,222.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,349.91
|
| Rate for Payer: Cash Price |
$764.10
|
| Rate for Payer: Cigna Commercial |
$2,343.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,425.30
|
| Rate for Payer: Health EOS Commercial |
$2,266.83
|
| Rate for Payer: HFN Commercial |
$2,343.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,910.25
|
| Rate for Payer: Multiplan Commercial |
$2,037.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,528.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,343.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,248.03
|
| Rate for Payer: Quartz Commercial |
$1,655.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,528.20
|
| Rate for Payer: The Alliance Commercial |
$10,188.00
|
| Rate for Payer: WEA Trust Commercial |
$1,400.85
|
| Rate for Payer: WPS Commercial |
$1,886.56
|
|
|
STAPLER RELOAD LINEAR (BLUE) 90MM 4.8MM TA9048L
|
Facility
|
IP
|
$2,547.00
|
|
| Hospital Charge Code |
5599673
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,248.03 |
| Max. Negotiated Rate |
$2,343.24 |
| Rate for Payer: Aetna Commercial |
$2,292.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,190.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,349.91
|
| Rate for Payer: Cash Price |
$764.10
|
| Rate for Payer: Cigna Commercial |
$2,343.24
|
| Rate for Payer: Health EOS Commercial |
$2,266.83
|
| Rate for Payer: HFN Commercial |
$2,343.24
|
| Rate for Payer: Multiplan Commercial |
$2,037.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,528.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,343.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,248.03
|
| Rate for Payer: Quartz Commercial |
$1,528.20
|
| Rate for Payer: WEA Trust Commercial |
$1,400.85
|
| Rate for Payer: WPS Commercial |
$1,886.56
|
|
|
STAPLER RELOAD LINEAR CUTTER 55MM TCR55
|
Facility
|
IP
|
$895.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3591511
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$438.55 |
| Max. Negotiated Rate |
$823.40 |
| Rate for Payer: Aetna Commercial |
$805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$769.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.35
|
| Rate for Payer: Cash Price |
$268.50
|
| Rate for Payer: Cigna Commercial |
$823.40
|
| Rate for Payer: Health EOS Commercial |
$796.55
|
| Rate for Payer: HFN Commercial |
$823.40
|
| Rate for Payer: Multiplan Commercial |
$716.00
|
| Rate for Payer: NAPHCARE Commercial |
$537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$823.40
|
| Rate for Payer: Quartz Beloit One Network |
$438.55
|
| Rate for Payer: Quartz Commercial |
$537.00
|
| Rate for Payer: WEA Trust Commercial |
$492.25
|
| Rate for Payer: WPS Commercial |
$662.93
|
|
|
STAPLER RELOAD LINEAR CUTTER 55MM TCR55
|
Facility
|
OP
|
$895.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3591511
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.60 |
| Max. Negotiated Rate |
$3,580.00 |
| Rate for Payer: Aetna Commercial |
$805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$769.70
|
| Rate for Payer: Aetna Managed Medicare |
$250.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$429.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.35
|
| Rate for Payer: Cash Price |
$268.50
|
| Rate for Payer: Cigna Commercial |
$823.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$500.84
|
| Rate for Payer: Health EOS Commercial |
$796.55
|
| Rate for Payer: HFN Commercial |
$823.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$671.25
|
| Rate for Payer: Multiplan Commercial |
$716.00
|
| Rate for Payer: NAPHCARE Commercial |
$537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$823.40
|
| Rate for Payer: Quartz Beloit One Network |
$438.55
|
| Rate for Payer: Quartz Commercial |
$581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$537.00
|
| Rate for Payer: The Alliance Commercial |
$3,580.00
|
| Rate for Payer: WEA Trust Commercial |
$492.25
|
| Rate for Payer: WPS Commercial |
$662.93
|
|
|
STAPLER RELOAD LINEAR CUTTER 75MM TCR75
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3591513
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$558.60 |
| Max. Negotiated Rate |
$1,048.80 |
| Rate for Payer: Aetna Commercial |
$1,026.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$980.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$604.20
|
| Rate for Payer: Cash Price |
$342.00
|
| Rate for Payer: Cigna Commercial |
$1,048.80
|
| Rate for Payer: Health EOS Commercial |
$1,014.60
|
| Rate for Payer: HFN Commercial |
$1,048.80
|
| Rate for Payer: Multiplan Commercial |
$912.00
|
| Rate for Payer: NAPHCARE Commercial |
$684.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,048.80
|
| Rate for Payer: Quartz Beloit One Network |
$558.60
|
| Rate for Payer: Quartz Commercial |
$684.00
|
| Rate for Payer: WEA Trust Commercial |
$627.00
|
| Rate for Payer: WPS Commercial |
$844.40
|
|
|
STAPLER RELOAD LINEAR CUTTER 75MM TCR75
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3591513
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$319.20 |
| Max. Negotiated Rate |
$4,560.00 |
| Rate for Payer: Aetna Commercial |
$1,026.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$980.40
|
| Rate for Payer: Aetna Managed Medicare |
$319.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$741.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$570.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$547.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$604.20
|
| Rate for Payer: Cash Price |
$342.00
|
| Rate for Payer: Cigna Commercial |
$1,048.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$637.94
|
| Rate for Payer: Health EOS Commercial |
$1,014.60
|
| Rate for Payer: HFN Commercial |
$1,048.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$855.00
|
| Rate for Payer: Multiplan Commercial |
$912.00
|
| Rate for Payer: NAPHCARE Commercial |
$684.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,048.80
|
| Rate for Payer: Quartz Beloit One Network |
$558.60
|
| Rate for Payer: Quartz Commercial |
$741.00
|
| Rate for Payer: Quartz Medicare Advantage |
$684.00
|
| Rate for Payer: The Alliance Commercial |
$4,560.00
|
| Rate for Payer: WEA Trust Commercial |
$627.00
|
| Rate for Payer: WPS Commercial |
$844.40
|
|
