|
STAPLER RELOAD VAS 45MM 030454
|
Facility
|
IP
|
$968.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2962875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$493.29 |
| Max. Negotiated Rate |
$926.18 |
| Rate for Payer: Aetna Commercial |
$906.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.56
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cigna Commercial |
$926.18
|
| Rate for Payer: Health EOS Commercial |
$895.98
|
| Rate for Payer: HFN Commercial |
$926.18
|
| Rate for Payer: Multiplan Commercial |
$805.38
|
| Rate for Payer: Preferred Network Access Commercial |
$926.18
|
| Rate for Payer: Quartz Beloit One Network |
$493.29
|
| Rate for Payer: Quartz Commercial |
$604.03
|
| Rate for Payer: WEA Trust Commercial |
$553.70
|
| Rate for Payer: WPS Commercial |
$745.65
|
|
|
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 |
$506.98 |
| Max. Negotiated Rate |
$1,665.79 |
| Rate for Payer: Aetna Commercial |
$1,629.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,557.15
|
| Rate for Payer: Aetna Managed Medicare |
$506.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,176.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$905.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$869.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$959.64
|
| Rate for Payer: Cash Price |
$522.30
|
| Rate for Payer: Cigna Commercial |
$1,665.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,013.26
|
| Rate for Payer: Health EOS Commercial |
$1,611.47
|
| Rate for Payer: HFN Commercial |
$1,665.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,357.98
|
| Rate for Payer: Multiplan Commercial |
$1,448.51
|
| Rate for Payer: NAPHCARE Commercial |
$1,086.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,665.79
|
| Rate for Payer: Quartz Beloit One Network |
$887.21
|
| Rate for Payer: Quartz Commercial |
$1,176.92
|
| Rate for Payer: Quartz Medicare Advantage |
$1,086.38
|
| Rate for Payer: The Alliance Commercial |
$905.32
|
| Rate for Payer: WEA Trust Commercial |
$995.85
|
| Rate for Payer: WPS Commercial |
$1,341.09
|
|
|
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 |
$887.21 |
| Max. Negotiated Rate |
$1,665.79 |
| Rate for Payer: Aetna Commercial |
$1,629.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,557.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$959.64
|
| Rate for Payer: Cash Price |
$522.30
|
| Rate for Payer: Cigna Commercial |
$1,665.79
|
| Rate for Payer: Health EOS Commercial |
$1,611.47
|
| Rate for Payer: HFN Commercial |
$1,665.79
|
| Rate for Payer: Multiplan Commercial |
$1,448.51
|
| Rate for Payer: Preferred Network Access Commercial |
$1,665.79
|
| Rate for Payer: Quartz Beloit One Network |
$887.21
|
| Rate for Payer: Quartz Commercial |
$1,086.38
|
| Rate for Payer: WEA Trust Commercial |
$995.85
|
| Rate for Payer: WPS Commercial |
$1,341.09
|
|
|
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 |
$2,438.44 |
| Max. Negotiated Rate |
$4,578.29 |
| Rate for Payer: Aetna Commercial |
$4,478.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,279.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,637.49
|
| Rate for Payer: Cash Price |
$1,435.50
|
| Rate for Payer: Cigna Commercial |
$4,578.29
|
| Rate for Payer: Health EOS Commercial |
$4,429.00
|
| Rate for Payer: HFN Commercial |
$4,578.29
|
| Rate for Payer: Multiplan Commercial |
$3,981.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4,578.29
|
| Rate for Payer: Quartz Beloit One Network |
$2,438.44
|
| Rate for Payer: Quartz Commercial |
$2,985.84
|
| Rate for Payer: WEA Trust Commercial |
$2,737.02
|
| Rate for Payer: WPS Commercial |
$3,685.89
|
|
|
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 |
$1,393.39 |
| Max. Negotiated Rate |
$4,578.29 |
| Rate for Payer: Aetna Commercial |
$4,478.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,279.70
|
| Rate for Payer: Aetna Managed Medicare |
$1,393.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,234.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,488.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,388.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,637.49
|
| Rate for Payer: Cash Price |
$1,435.50
|
| Rate for Payer: Cigna Commercial |
$4,578.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,784.87
|
| Rate for Payer: Health EOS Commercial |
$4,429.00
|
| Rate for Payer: HFN Commercial |
$4,578.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,732.30
|
| Rate for Payer: Multiplan Commercial |
$3,981.12
|
| Rate for Payer: NAPHCARE Commercial |
$2,985.84
|
| Rate for Payer: Preferred Network Access Commercial |
$4,578.29
|
| Rate for Payer: Quartz Beloit One Network |
$2,438.44
|
| Rate for Payer: Quartz Commercial |
$3,234.66
|
| Rate for Payer: Quartz Medicare Advantage |
$2,985.84
|
| Rate for Payer: The Alliance Commercial |
$2,488.20
|
| Rate for Payer: WEA Trust Commercial |
$2,737.02
|
| Rate for Payer: WPS Commercial |
$3,685.89
|
|
|
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 |
$2,566.35 |
| Max. Negotiated Rate |
$4,818.44 |
| Rate for Payer: Aetna Commercial |
$4,713.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,504.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,775.84
|
| Rate for Payer: Cash Price |
$1,510.80
|
| Rate for Payer: Cigna Commercial |
$4,818.44
|
| Rate for Payer: Health EOS Commercial |
$4,661.32
|
| Rate for Payer: HFN Commercial |
$4,818.44
|
| Rate for Payer: Multiplan Commercial |
$4,189.95
|
| Rate for Payer: Preferred Network Access Commercial |
$4,818.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,566.35
|
| Rate for Payer: Quartz Commercial |
$3,142.46
|
| Rate for Payer: WEA Trust Commercial |
$2,880.59
|
| Rate for Payer: WPS Commercial |
$3,879.23
|
|
|
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 |
$1,466.48 |
| Max. Negotiated Rate |
$4,818.44 |
| Rate for Payer: Aetna Commercial |
$4,713.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,504.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,466.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,404.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,618.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,513.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,775.84
|
| Rate for Payer: Cash Price |
$1,510.80
|
| Rate for Payer: Cigna Commercial |
$4,818.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,930.95
|
| Rate for Payer: Health EOS Commercial |
$4,661.32
|
| Rate for Payer: HFN Commercial |
$4,818.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,928.08
|
| Rate for Payer: Multiplan Commercial |
$4,189.95
|
| Rate for Payer: NAPHCARE Commercial |
$3,142.46
|
| Rate for Payer: Preferred Network Access Commercial |
$4,818.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,566.35
|
| Rate for Payer: Quartz Commercial |
$3,404.34
|
| Rate for Payer: Quartz Medicare Advantage |
$3,142.46
|
| Rate for Payer: The Alliance Commercial |
$2,618.72
|
| Rate for Payer: WEA Trust Commercial |
$2,880.59
|
| Rate for Payer: WPS Commercial |
$3,879.23
|
|
|
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 |
$1,553.84 |
| Max. Negotiated Rate |
$5,105.48 |
| Rate for Payer: Aetna Commercial |
$4,994.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,772.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,553.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,607.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,774.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,663.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,941.20
|
| Rate for Payer: Cash Price |
$1,600.80
|
| Rate for Payer: Cigna Commercial |
$5,105.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,105.55
|
| Rate for Payer: Health EOS Commercial |
$4,939.00
|
| Rate for Payer: HFN Commercial |
$5,105.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,162.08
|
| Rate for Payer: Multiplan Commercial |
$4,439.55
|
| Rate for Payer: NAPHCARE Commercial |
$3,329.66
|
| Rate for Payer: Preferred Network Access Commercial |
$5,105.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,719.23
|
| Rate for Payer: Quartz Commercial |
$3,607.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,329.66
|
| Rate for Payer: The Alliance Commercial |
$2,774.72
|
| Rate for Payer: WEA Trust Commercial |
$3,052.19
|
| Rate for Payer: WPS Commercial |
$4,110.32
|
|
|
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 |
$2,719.23 |
| Max. Negotiated Rate |
$5,105.48 |
| Rate for Payer: Aetna Commercial |
$4,994.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,772.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,941.20
|
| Rate for Payer: Cash Price |
$1,600.80
|
| Rate for Payer: Cigna Commercial |
$5,105.48
|
| Rate for Payer: Health EOS Commercial |
$4,939.00
|
| Rate for Payer: HFN Commercial |
$5,105.48
|
| Rate for Payer: Multiplan Commercial |
$4,439.55
|
| Rate for Payer: Preferred Network Access Commercial |
$5,105.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,719.23
|
| Rate for Payer: Quartz Commercial |
$3,329.66
|
| Rate for Payer: WEA Trust Commercial |
$3,052.19
|
| Rate for Payer: WPS Commercial |
$4,110.32
|
|
|
STAPLER SKIN 35W 8886803712 / 900-7010
|
Facility
|
OP
|
$164.00
|
|
| Hospital Charge Code |
2963244
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.76 |
| Max. Negotiated Rate |
$156.92 |
| Rate for Payer: Aetna Commercial |
$153.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.68
|
| Rate for Payer: Aetna Managed Medicare |
$47.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$85.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.40
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$156.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.45
|
| Rate for Payer: Health EOS Commercial |
$151.80
|
| Rate for Payer: HFN Commercial |
$156.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.92
|
| Rate for Payer: Multiplan Commercial |
$136.45
|
| Rate for Payer: NAPHCARE Commercial |
$102.34
|
| Rate for Payer: Preferred Network Access Commercial |
$156.92
|
| Rate for Payer: Quartz Beloit One Network |
$83.57
|
| Rate for Payer: Quartz Commercial |
$110.86
|
| Rate for Payer: Quartz Medicare Advantage |
$102.34
|
| Rate for Payer: The Alliance Commercial |
$85.28
|
| Rate for Payer: WEA Trust Commercial |
$93.81
|
| Rate for Payer: WPS Commercial |
$126.33
|
|
|
STAPLER SKIN 35W 8886803712 / 900-7010
|
Facility
|
IP
|
$164.00
|
|
| Hospital Charge Code |
2963244
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.57 |
| Max. Negotiated Rate |
$156.92 |
| Rate for Payer: Aetna Commercial |
$153.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.40
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$156.92
|
| Rate for Payer: Health EOS Commercial |
$151.80
|
| Rate for Payer: HFN Commercial |
$156.92
|
| Rate for Payer: Multiplan Commercial |
$136.45
|
| Rate for Payer: Preferred Network Access Commercial |
$156.92
|
| Rate for Payer: Quartz Beloit One Network |
$83.57
|
| Rate for Payer: Quartz Commercial |
$102.34
|
| Rate for Payer: WEA Trust Commercial |
$93.81
|
| Rate for Payer: WPS Commercial |
$126.33
|
|
|
STAPLER SKIN SMALL 5 STAPLE DS-5
|
Facility
|
IP
|
$105.00
|
|
| Hospital Charge Code |
4493753
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.51 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$65.52
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
STAPLER SKIN SMALL 5 STAPLE DS-5
|
Facility
|
OP
|
$105.00
|
|
| Hospital Charge Code |
4493753
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Aetna Managed Medicare |
$30.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.11
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.90
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: NAPHCARE Commercial |
$65.52
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$70.98
|
| Rate for Payer: Quartz Medicare Advantage |
$65.52
|
| Rate for Payer: The Alliance Commercial |
$54.60
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
STAPLE SYSTEM 10MM X 10MM 500-10-001
|
Facility
|
OP
|
$7,006.00
|
|
| Hospital Charge Code |
5248832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.15 |
| Max. Negotiated Rate |
$6,703.34 |
| Rate for Payer: Aetna Commercial |
$6,557.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,266.17
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,736.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,643.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,497.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.71
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,703.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,077.49
|
| Rate for Payer: Health EOS Commercial |
$6,484.75
|
| Rate for Payer: HFN Commercial |
$6,703.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,464.68
|
| Rate for Payer: Multiplan Commercial |
$5,828.99
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.74
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.26
|
| Rate for Payer: Quartz Commercial |
$4,736.06
|
| Rate for Payer: Quartz Medicare Advantage |
$4,371.74
|
| Rate for Payer: The Alliance Commercial |
$3,643.12
|
| Rate for Payer: WEA Trust Commercial |
$4,007.43
|
| Rate for Payer: WPS Commercial |
$5,396.72
|
|
|
STAPLE SYSTEM 10MM X 10MM 500-10-001
|
Facility
|
IP
|
$7,006.00
|
|
| Hospital Charge Code |
5248832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,570.26 |
| Max. Negotiated Rate |
$6,703.34 |
| Rate for Payer: Aetna Commercial |
$6,557.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,266.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.71
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,703.34
|
| Rate for Payer: Health EOS Commercial |
$6,484.75
|
| Rate for Payer: HFN Commercial |
$6,703.34
|
| Rate for Payer: Multiplan Commercial |
$5,828.99
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.26
|
| Rate for Payer: Quartz Commercial |
$4,371.74
|
| Rate for Payer: WEA Trust Commercial |
$4,007.43
|
| Rate for Payer: WPS Commercial |
$5,396.72
|
|
|
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 |
$2,160.41 |
| Max. Negotiated Rate |
$7,098.50 |
| Rate for Payer: Aetna Commercial |
$6,944.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,635.55
|
| Rate for Payer: Aetna Managed Medicare |
$2,160.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,015.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,857.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,703.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,089.35
|
| Rate for Payer: Cash Price |
$2,225.70
|
| Rate for Payer: Cigna Commercial |
$7,098.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,317.86
|
| Rate for Payer: Health EOS Commercial |
$6,867.03
|
| Rate for Payer: HFN Commercial |
$7,098.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,786.82
|
| Rate for Payer: Multiplan Commercial |
$6,172.61
|
| Rate for Payer: NAPHCARE Commercial |
$4,629.46
|
| Rate for Payer: Preferred Network Access Commercial |
$7,098.50
|
| Rate for Payer: Quartz Beloit One Network |
$3,780.72
|
| Rate for Payer: Quartz Commercial |
$5,015.24
|
| Rate for Payer: Quartz Medicare Advantage |
$4,629.46
|
| Rate for Payer: The Alliance Commercial |
$3,857.88
|
| Rate for Payer: WEA Trust Commercial |
$4,243.67
|
| Rate for Payer: WPS Commercial |
$5,714.86
|
|
|
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 |
$3,780.72 |
| Max. Negotiated Rate |
$7,098.50 |
| Rate for Payer: Aetna Commercial |
$6,944.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,635.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,089.35
|
| Rate for Payer: Cash Price |
$2,225.70
|
| Rate for Payer: Cigna Commercial |
$7,098.50
|
| Rate for Payer: Health EOS Commercial |
$6,867.03
|
| Rate for Payer: HFN Commercial |
$7,098.50
|
| Rate for Payer: Multiplan Commercial |
$6,172.61
|
| Rate for Payer: Preferred Network Access Commercial |
$7,098.50
|
| Rate for Payer: Quartz Beloit One Network |
$3,780.72
|
| Rate for Payer: Quartz Commercial |
$4,629.46
|
| Rate for Payer: WEA Trust Commercial |
$4,243.67
|
| Rate for Payer: WPS Commercial |
$5,714.86
|
|
|
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 |
$1,695.95 |
| Max. Negotiated Rate |
$5,572.40 |
| Rate for Payer: Aetna Commercial |
$5,451.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,208.99
|
| Rate for Payer: Aetna Managed Medicare |
$1,695.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,937.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,028.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,907.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,210.19
|
| Rate for Payer: Cash Price |
$1,747.20
|
| Rate for Payer: Cigna Commercial |
$5,572.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,389.57
|
| Rate for Payer: Health EOS Commercial |
$5,390.69
|
| Rate for Payer: HFN Commercial |
$5,572.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,542.72
|
| Rate for Payer: Multiplan Commercial |
$4,845.57
|
| Rate for Payer: NAPHCARE Commercial |
$3,634.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,572.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,967.91
|
| Rate for Payer: Quartz Commercial |
$3,937.02
|
| Rate for Payer: Quartz Medicare Advantage |
$3,634.18
|
| Rate for Payer: The Alliance Commercial |
$3,028.48
|
| Rate for Payer: WEA Trust Commercial |
$3,331.33
|
| Rate for Payer: WPS Commercial |
$4,486.23
|
|
|
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 |
$2,967.91 |
| Max. Negotiated Rate |
$5,572.40 |
| Rate for Payer: Aetna Commercial |
$5,451.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,208.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,210.19
|
| Rate for Payer: Cash Price |
$1,747.20
|
| Rate for Payer: Cigna Commercial |
$5,572.40
|
| Rate for Payer: Health EOS Commercial |
$5,390.69
|
| Rate for Payer: HFN Commercial |
$5,572.40
|
| Rate for Payer: Multiplan Commercial |
$4,845.57
|
| Rate for Payer: Preferred Network Access Commercial |
$5,572.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,967.91
|
| Rate for Payer: Quartz Commercial |
$3,634.18
|
| Rate for Payer: WEA Trust Commercial |
$3,331.33
|
| Rate for Payer: WPS Commercial |
$4,486.23
|
|
|
State Supplied - Bexsero Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Bexsero Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Bexsero Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$298.43 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$246.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$298.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$298.43
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: United Healthcare Medicaid |
$246.62
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - DTap Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - DTap Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - DTap Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$44.89 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.89
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: United Healthcare Medicaid |
$31.61
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
