|
GRAFIXPL PRIME 3 X 3CM (9 SQ CM) PS13033
|
Facility
|
IP
|
$615.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5415978
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$313.40 |
| Max. Negotiated Rate |
$588.43 |
| Rate for Payer: Aetna Commercial |
$575.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$550.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$338.99
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$588.43
|
| Rate for Payer: Health EOS Commercial |
$569.24
|
| Rate for Payer: HFN Commercial |
$588.43
|
| Rate for Payer: Multiplan Commercial |
$511.68
|
| Rate for Payer: Preferred Network Access Commercial |
$588.43
|
| Rate for Payer: Quartz Beloit One Network |
$313.40
|
| Rate for Payer: Quartz Commercial |
$383.76
|
| Rate for Payer: WEA Trust Commercial |
$351.78
|
| Rate for Payer: WPS Commercial |
$473.73
|
|
|
GRAFIXPL PRIME 3 X 3CM (9 SQ CM) PS13033
|
Facility
|
OP
|
$615.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5415978
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$588.43 |
| Rate for Payer: Aetna Commercial |
$575.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$550.06
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$415.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$319.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$307.01
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$338.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$588.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$569.24
|
| Rate for Payer: HFN Commercial |
$588.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$511.68
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$588.43
|
| Rate for Payer: Quartz Beloit One Network |
$313.40
|
| Rate for Payer: Quartz Commercial |
$415.74
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$351.78
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$372.39
|
|
|
Grafix Prime per sq cm Q4133
|
Facility
|
IP
|
$646.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
4494917
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$329.20 |
| Max. Negotiated Rate |
$618.09 |
| Rate for Payer: Aetna Commercial |
$604.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$356.08
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$618.09
|
| Rate for Payer: Health EOS Commercial |
$597.94
|
| Rate for Payer: HFN Commercial |
$618.09
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: Preferred Network Access Commercial |
$618.09
|
| Rate for Payer: Quartz Beloit One Network |
$329.20
|
| Rate for Payer: Quartz Commercial |
$403.10
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: WPS Commercial |
$497.61
|
|
|
Grafix Prime per sq cm Q4133
|
Professional
|
Both
|
$646.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
4494917
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.79 |
| Max. Negotiated Rate |
$638.25 |
| Rate for Payer: Aetna Commercial |
$638.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| Rate for Payer: Aetna Managed Medicare |
$126.79
|
| Rate for Payer: Anthem Medicare Advantage |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.79
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$638.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$177.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.96
|
| Rate for Payer: Health EOS Commercial |
$611.37
|
| Rate for Payer: HFN Commercial |
$638.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$493.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$493.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: NAPHCARE Commercial |
$190.18
|
| Rate for Payer: Preferred Network Access Commercial |
$638.25
|
| Rate for Payer: Quartz Beloit One Network |
$295.61
|
| Rate for Payer: Quartz Commercial |
$382.95
|
| Rate for Payer: Quartz Medicare Advantage |
$126.79
|
| Rate for Payer: The Alliance Commercial |
$348.66
|
| Rate for Payer: United Healthcare Medicaid |
$177.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.79
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: WPS Commercial |
$372.39
|
|
|
Grafix Prime per sq cm Q4133
|
Facility
|
OP
|
$646.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
4494917
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$618.09 |
| Rate for Payer: Aetna Commercial |
$604.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$436.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$335.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.48
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$356.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$618.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$597.94
|
| Rate for Payer: HFN Commercial |
$618.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$618.09
|
| Rate for Payer: Quartz Beloit One Network |
$329.20
|
| Rate for Payer: Quartz Commercial |
$436.70
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$372.39
|
|
|
GRAFT 10 X 50CM FLEX F5010
|
Facility
|
IP
|
$6,246.00
|
|
| Hospital Charge Code |
2969348
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,182.96 |
| Max. Negotiated Rate |
$5,976.17 |
| Rate for Payer: Aetna Commercial |
$5,846.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,586.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,442.80
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,976.17
|
| Rate for Payer: Health EOS Commercial |
$5,781.30
|
| Rate for Payer: HFN Commercial |
$5,976.17
|
| Rate for Payer: Multiplan Commercial |
$5,196.67
|
| Rate for Payer: Preferred Network Access Commercial |
$5,976.17
|
| Rate for Payer: Quartz Beloit One Network |
$3,182.96
|
| Rate for Payer: Quartz Commercial |
$3,897.50
|
| Rate for Payer: WEA Trust Commercial |
$3,572.71
|
| Rate for Payer: WPS Commercial |
$4,811.29
|
|
|
GRAFT 10 X 50CM FLEX F5010
|
Facility
|
OP
|
$6,246.00
|
|
| Hospital Charge Code |
2969348
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,818.84 |
| Max. Negotiated Rate |
$5,976.17 |
| Rate for Payer: Aetna Commercial |
$5,846.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,586.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,818.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,222.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,247.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,118.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,442.80
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,976.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,635.17
|
| Rate for Payer: Health EOS Commercial |
$5,781.30
|
| Rate for Payer: HFN Commercial |
$5,976.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,871.88
|
| Rate for Payer: Multiplan Commercial |
$5,196.67
|
| Rate for Payer: NAPHCARE Commercial |
$3,897.50
|
| Rate for Payer: Preferred Network Access Commercial |
$5,976.17
|
| Rate for Payer: Quartz Beloit One Network |
$3,182.96
|
| Rate for Payer: Quartz Commercial |
$4,222.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,897.50
|
| Rate for Payer: The Alliance Commercial |
$3,247.92
|
| Rate for Payer: WEA Trust Commercial |
$3,572.71
|
| Rate for Payer: WPS Commercial |
$4,811.29
|
|
|
GRAFT 10 X 80CM FLEX F8010
|
Facility
|
IP
|
$6,246.00
|
|
| Hospital Charge Code |
2969352
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,182.96 |
| Max. Negotiated Rate |
$5,976.17 |
| Rate for Payer: Aetna Commercial |
$5,846.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,586.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,442.80
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,976.17
|
| Rate for Payer: Health EOS Commercial |
$5,781.30
|
| Rate for Payer: HFN Commercial |
$5,976.17
|
| Rate for Payer: Multiplan Commercial |
$5,196.67
|
| Rate for Payer: Preferred Network Access Commercial |
$5,976.17
|
| Rate for Payer: Quartz Beloit One Network |
$3,182.96
|
| Rate for Payer: Quartz Commercial |
$3,897.50
|
| Rate for Payer: WEA Trust Commercial |
$3,572.71
|
| Rate for Payer: WPS Commercial |
$4,811.29
|
|
|
GRAFT 10 X 80CM FLEX F8010
|
Facility
|
OP
|
$6,246.00
|
|
| Hospital Charge Code |
2969352
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,818.84 |
| Max. Negotiated Rate |
$5,976.17 |
| Rate for Payer: Aetna Commercial |
$5,846.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,586.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,818.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,222.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,247.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,118.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,442.80
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,976.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,635.17
|
| Rate for Payer: Health EOS Commercial |
$5,781.30
|
| Rate for Payer: HFN Commercial |
$5,976.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,871.88
|
| Rate for Payer: Multiplan Commercial |
$5,196.67
|
| Rate for Payer: NAPHCARE Commercial |
$3,897.50
|
| Rate for Payer: Preferred Network Access Commercial |
$5,976.17
|
| Rate for Payer: Quartz Beloit One Network |
$3,182.96
|
| Rate for Payer: Quartz Commercial |
$4,222.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,897.50
|
| Rate for Payer: The Alliance Commercial |
$3,247.92
|
| Rate for Payer: WEA Trust Commercial |
$3,572.71
|
| Rate for Payer: WPS Commercial |
$4,811.29
|
|
|
GRAFT 12 X 6 BIFORCATED HEMAGARD KNITTED HGK1206
|
Facility
|
OP
|
$6,117.00
|
|
| Hospital Charge Code |
2965276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,781.27 |
| Max. Negotiated Rate |
$5,852.75 |
| Rate for Payer: Aetna Commercial |
$5,725.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,471.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,781.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,135.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,180.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,053.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,371.69
|
| Rate for Payer: Cash Price |
$1,835.10
|
| Rate for Payer: Cigna Commercial |
$5,852.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,560.09
|
| Rate for Payer: Health EOS Commercial |
$5,661.90
|
| Rate for Payer: HFN Commercial |
$5,852.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,771.26
|
| Rate for Payer: Multiplan Commercial |
$5,089.34
|
| Rate for Payer: NAPHCARE Commercial |
$3,817.01
|
| Rate for Payer: Preferred Network Access Commercial |
$5,852.75
|
| Rate for Payer: Quartz Beloit One Network |
$3,117.22
|
| Rate for Payer: Quartz Commercial |
$4,135.09
|
| Rate for Payer: Quartz Medicare Advantage |
$3,817.01
|
| Rate for Payer: The Alliance Commercial |
$3,180.84
|
| Rate for Payer: WEA Trust Commercial |
$3,498.92
|
| Rate for Payer: WPS Commercial |
$4,711.93
|
|
|
GRAFT 12 X 6 BIFORCATED HEMAGARD KNITTED HGK1206
|
Facility
|
IP
|
$6,117.00
|
|
| Hospital Charge Code |
2965276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,117.22 |
| Max. Negotiated Rate |
$5,852.75 |
| Rate for Payer: Aetna Commercial |
$5,725.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,471.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,371.69
|
| Rate for Payer: Cash Price |
$1,835.10
|
| Rate for Payer: Cigna Commercial |
$5,852.75
|
| Rate for Payer: Health EOS Commercial |
$5,661.90
|
| Rate for Payer: HFN Commercial |
$5,852.75
|
| Rate for Payer: Multiplan Commercial |
$5,089.34
|
| Rate for Payer: Preferred Network Access Commercial |
$5,852.75
|
| Rate for Payer: Quartz Beloit One Network |
$3,117.22
|
| Rate for Payer: Quartz Commercial |
$3,817.01
|
| Rate for Payer: WEA Trust Commercial |
$3,498.92
|
| Rate for Payer: WPS Commercial |
$4,711.93
|
|
|
GRAFT 14 X 7 BIFORCATED HEMAGARD KNITTED HGK1407/IGK1407
|
Facility
|
OP
|
$8,460.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3204829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,463.55 |
| Max. Negotiated Rate |
$8,094.53 |
| Rate for Payer: Aetna Commercial |
$7,918.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,566.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,463.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,718.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,399.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,223.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,663.15
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna Commercial |
$8,094.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,923.72
|
| Rate for Payer: Health EOS Commercial |
$7,830.58
|
| Rate for Payer: HFN Commercial |
$8,094.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,598.80
|
| Rate for Payer: Multiplan Commercial |
$7,038.72
|
| Rate for Payer: NAPHCARE Commercial |
$5,279.04
|
| Rate for Payer: Preferred Network Access Commercial |
$8,094.53
|
| Rate for Payer: Quartz Beloit One Network |
$4,311.22
|
| Rate for Payer: Quartz Commercial |
$5,718.96
|
| Rate for Payer: Quartz Medicare Advantage |
$5,279.04
|
| Rate for Payer: The Alliance Commercial |
$4,399.20
|
| Rate for Payer: WEA Trust Commercial |
$4,839.12
|
| Rate for Payer: WPS Commercial |
$6,516.74
|
|
|
GRAFT 14 X 7 BIFORCATED HEMAGARD KNITTED HGK1407/IGK1407
|
Facility
|
IP
|
$8,460.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3204829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,311.22 |
| Max. Negotiated Rate |
$8,094.53 |
| Rate for Payer: Aetna Commercial |
$7,918.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,566.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,663.15
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna Commercial |
$8,094.53
|
| Rate for Payer: Health EOS Commercial |
$7,830.58
|
| Rate for Payer: HFN Commercial |
$8,094.53
|
| Rate for Payer: Multiplan Commercial |
$7,038.72
|
| Rate for Payer: Preferred Network Access Commercial |
$8,094.53
|
| Rate for Payer: Quartz Beloit One Network |
$4,311.22
|
| Rate for Payer: Quartz Commercial |
$5,279.04
|
| Rate for Payer: WEA Trust Commercial |
$4,839.12
|
| Rate for Payer: WPS Commercial |
$6,516.74
|
|
|
GRAFT 16 X 8 BIFORCATED HEMAGARD KNITTED HGK1608
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2964759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,192.64 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$3,909.36
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
|
GRAFT 16 X 8 BIFORCATED HEMAGARD KNITTED HGK1608
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2964759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,824.37 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,824.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,235.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,257.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,127.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,646.23
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,886.70
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: NAPHCARE Commercial |
$3,909.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$4,235.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,909.36
|
| Rate for Payer: The Alliance Commercial |
$3,257.80
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
|
GRAFT 18 X 9 BIFORCATED HEMAGARD KNITTED HGK1809
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2965278
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,192.64 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$3,909.36
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
|
GRAFT 18 X 9 BIFORCATED HEMAGARD KNITTED HGK1809
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2965278
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,824.37 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,824.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,235.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,257.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,127.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,646.23
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,886.70
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: NAPHCARE Commercial |
$3,909.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$4,235.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,909.36
|
| Rate for Payer: The Alliance Commercial |
$3,257.80
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
|
GRAFT 20 X 10 BIFORCATED HEMAGARD KNITTED HGK2010
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2965279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,824.37 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,824.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,235.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,257.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,127.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,646.23
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,886.70
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: NAPHCARE Commercial |
$3,909.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$4,235.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,909.36
|
| Rate for Payer: The Alliance Commercial |
$3,257.80
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
|
GRAFT 20 X 10 BIFORCATED HEMAGARD KNITTED HGK2010
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2965279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,192.64 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$3,909.36
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
|
GRAFT 22 X 11 BIFORCATED INTERGARD WOVEN IGW2211
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2964760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,192.64 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$3,909.36
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
|
GRAFT 22 X 11 BIFORCATED INTERGARD WOVEN IGW2211
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2964760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,824.37 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,824.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,235.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,257.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,127.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,646.23
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,886.70
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: NAPHCARE Commercial |
$3,909.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$4,235.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,909.36
|
| Rate for Payer: The Alliance Commercial |
$3,257.80
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
|
GRAFT 24 X 12 BIFORCATED HEMASHIELD WOVEN HGK2412
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2965280
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,192.64 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$3,909.36
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
|
GRAFT 24 X 12 BIFORCATED HEMASHIELD WOVEN HGK2412
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2965280
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,824.37 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,824.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,235.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,257.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,127.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,646.23
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,886.70
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: NAPHCARE Commercial |
$3,909.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$4,235.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,909.36
|
| Rate for Payer: The Alliance Commercial |
$3,257.80
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
|
GRAFT 26 X 30 INTERGARD WOVEN STRAIGHT IGW0026-30
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2969492
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,192.64 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$3,909.36
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
|
GRAFT 26 X 30 INTERGARD WOVEN STRAIGHT IGW0026-30
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2969492
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,824.37 |
| Max. Negotiated Rate |
$5,994.35 |
| Rate for Payer: Aetna Commercial |
$5,864.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,603.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,824.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,235.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,257.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,127.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,453.27
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,994.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,646.23
|
| Rate for Payer: Health EOS Commercial |
$5,798.88
|
| Rate for Payer: HFN Commercial |
$5,994.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,886.70
|
| Rate for Payer: Multiplan Commercial |
$5,212.48
|
| Rate for Payer: NAPHCARE Commercial |
$3,909.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,994.35
|
| Rate for Payer: Quartz Beloit One Network |
$3,192.64
|
| Rate for Payer: Quartz Commercial |
$4,235.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,909.36
|
| Rate for Payer: The Alliance Commercial |
$3,257.80
|
| Rate for Payer: WEA Trust Commercial |
$3,583.58
|
| Rate for Payer: WPS Commercial |
$4,825.93
|
|
