|
Evercross 12mm x 20mm 80cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: HFN Commercial |
$1,622.60
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 12mm x 20mm 80cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 12mm x 20mm 80cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 12mm x 40mm 80cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: HFN Commercial |
$1,622.60
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 12mm x 40mm 80cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 12mm x 40mm 80cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 12mm x 60mm 80cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 12mm x 60mm 80cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: HFN Commercial |
$1,622.60
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 12mm x 60mm 80cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 100mm 135cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547098
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: HFN Commercial |
$1,622.60
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 100mm 135cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547098
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 100mm 135cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547098
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 120mm 135cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547100
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 120mm 135cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547100
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: HFN Commercial |
$1,622.60
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 120mm 135cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547100
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 150mm 135cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547102
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 150mm 135cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547102
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: HFN Commercial |
$1,622.60
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 150mm 135cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547102
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 20mm 135cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547090
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 20mm 135cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547090
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 20mm 135cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547090
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: HFN Commercial |
$1,622.60
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 40mm 135cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 40mm 135cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: HFN Commercial |
$1,622.60
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 40mm 135cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Evercross 3mm x 60mm 135cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547094
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
