|
GRAFT 8 X 8O FLEX PTFE #F8008
|
Facility
|
IP
|
$8,503.00
|
|
| Hospital Charge Code |
2969351
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,333.13 |
| Max. Negotiated Rate |
$8,135.67 |
| Rate for Payer: Aetna Commercial |
$7,958.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,605.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,686.85
|
| Rate for Payer: Cash Price |
$2,550.90
|
| Rate for Payer: Cigna Commercial |
$8,135.67
|
| Rate for Payer: Health EOS Commercial |
$7,870.38
|
| Rate for Payer: HFN Commercial |
$8,135.67
|
| Rate for Payer: Multiplan Commercial |
$7,074.50
|
| Rate for Payer: Preferred Network Access Commercial |
$8,135.67
|
| Rate for Payer: Quartz Beloit One Network |
$4,333.13
|
| Rate for Payer: Quartz Commercial |
$5,305.87
|
| Rate for Payer: WEA Trust Commercial |
$4,863.72
|
| Rate for Payer: WPS Commercial |
$6,549.86
|
|
|
GRAFT ACHILLES TENDON TENDON
|
Facility
|
IP
|
$14,094.00
|
|
| Hospital Charge Code |
2965943
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,182.30 |
| Max. Negotiated Rate |
$13,485.14 |
| Rate for Payer: Aetna Commercial |
$13,191.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,605.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,768.61
|
| Rate for Payer: Cash Price |
$4,228.20
|
| Rate for Payer: Cigna Commercial |
$13,485.14
|
| Rate for Payer: Health EOS Commercial |
$13,045.41
|
| Rate for Payer: HFN Commercial |
$13,485.14
|
| Rate for Payer: Multiplan Commercial |
$11,726.21
|
| Rate for Payer: Preferred Network Access Commercial |
$13,485.14
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.30
|
| Rate for Payer: Quartz Commercial |
$8,794.66
|
| Rate for Payer: WEA Trust Commercial |
$8,061.77
|
| Rate for Payer: WPS Commercial |
$10,856.61
|
|
|
GRAFT ACHILLES TENDON TENDON
|
Facility
|
OP
|
$14,094.00
|
|
| Hospital Charge Code |
2965943
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,104.17 |
| Max. Negotiated Rate |
$13,485.14 |
| Rate for Payer: Aetna Commercial |
$13,191.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,605.67
|
| Rate for Payer: Aetna Managed Medicare |
$4,104.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,527.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,328.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,035.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,768.61
|
| Rate for Payer: Cash Price |
$4,228.20
|
| Rate for Payer: Cigna Commercial |
$13,485.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,202.71
|
| Rate for Payer: Health EOS Commercial |
$13,045.41
|
| Rate for Payer: HFN Commercial |
$13,485.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,993.32
|
| Rate for Payer: Multiplan Commercial |
$11,726.21
|
| Rate for Payer: NAPHCARE Commercial |
$8,794.66
|
| Rate for Payer: Preferred Network Access Commercial |
$13,485.14
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.30
|
| Rate for Payer: Quartz Commercial |
$9,527.54
|
| Rate for Payer: Quartz Medicare Advantage |
$8,794.66
|
| Rate for Payer: The Alliance Commercial |
$7,328.88
|
| Rate for Payer: WEA Trust Commercial |
$8,061.77
|
| Rate for Payer: WPS Commercial |
$10,856.61
|
|
|
GRAFT ACL PRESHAPED BTB
|
Facility
|
IP
|
$19,476.00
|
|
| Hospital Charge Code |
2965271
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,924.97 |
| Max. Negotiated Rate |
$18,634.64 |
| Rate for Payer: Aetna Commercial |
$18,229.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,419.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,735.17
|
| Rate for Payer: Cash Price |
$5,842.80
|
| Rate for Payer: Cigna Commercial |
$18,634.64
|
| Rate for Payer: Health EOS Commercial |
$18,026.99
|
| Rate for Payer: HFN Commercial |
$18,634.64
|
| Rate for Payer: Multiplan Commercial |
$16,204.03
|
| Rate for Payer: Preferred Network Access Commercial |
$18,634.64
|
| Rate for Payer: Quartz Beloit One Network |
$9,924.97
|
| Rate for Payer: Quartz Commercial |
$12,153.02
|
| Rate for Payer: WEA Trust Commercial |
$11,140.27
|
| Rate for Payer: WPS Commercial |
$15,002.36
|
|
|
GRAFT ACL PRESHAPED BTB
|
Facility
|
OP
|
$19,476.00
|
|
| Hospital Charge Code |
2965271
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,671.41 |
| Max. Negotiated Rate |
$18,634.64 |
| Rate for Payer: Aetna Commercial |
$18,229.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,419.33
|
| Rate for Payer: Aetna Managed Medicare |
$5,671.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,165.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,127.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,722.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,735.17
|
| Rate for Payer: Cash Price |
$5,842.80
|
| Rate for Payer: Cigna Commercial |
$18,634.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,335.03
|
| Rate for Payer: Health EOS Commercial |
$18,026.99
|
| Rate for Payer: HFN Commercial |
$18,634.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,191.28
|
| Rate for Payer: Multiplan Commercial |
$16,204.03
|
| Rate for Payer: NAPHCARE Commercial |
$12,153.02
|
| Rate for Payer: Preferred Network Access Commercial |
$18,634.64
|
| Rate for Payer: Quartz Beloit One Network |
$9,924.97
|
| Rate for Payer: Quartz Commercial |
$13,165.78
|
| Rate for Payer: Quartz Medicare Advantage |
$12,153.02
|
| Rate for Payer: The Alliance Commercial |
$10,127.52
|
| Rate for Payer: WEA Trust Commercial |
$11,140.27
|
| Rate for Payer: WPS Commercial |
$15,002.36
|
|
|
GRAFT ACL PRESHAPED BTB 11MM
|
Facility
|
OP
|
$19,476.00
|
|
| Hospital Charge Code |
2965272
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,671.41 |
| Max. Negotiated Rate |
$18,634.64 |
| Rate for Payer: Aetna Commercial |
$18,229.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,419.33
|
| Rate for Payer: Aetna Managed Medicare |
$5,671.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,165.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,127.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,722.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,735.17
|
| Rate for Payer: Cash Price |
$5,842.80
|
| Rate for Payer: Cigna Commercial |
$18,634.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,335.03
|
| Rate for Payer: Health EOS Commercial |
$18,026.99
|
| Rate for Payer: HFN Commercial |
$18,634.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,191.28
|
| Rate for Payer: Multiplan Commercial |
$16,204.03
|
| Rate for Payer: NAPHCARE Commercial |
$12,153.02
|
| Rate for Payer: Preferred Network Access Commercial |
$18,634.64
|
| Rate for Payer: Quartz Beloit One Network |
$9,924.97
|
| Rate for Payer: Quartz Commercial |
$13,165.78
|
| Rate for Payer: Quartz Medicare Advantage |
$12,153.02
|
| Rate for Payer: The Alliance Commercial |
$10,127.52
|
| Rate for Payer: WEA Trust Commercial |
$11,140.27
|
| Rate for Payer: WPS Commercial |
$15,002.36
|
|
|
GRAFT ACL PRESHAPED BTB 11MM
|
Facility
|
IP
|
$19,476.00
|
|
| Hospital Charge Code |
2965272
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,924.97 |
| Max. Negotiated Rate |
$18,634.64 |
| Rate for Payer: Aetna Commercial |
$18,229.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,419.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,735.17
|
| Rate for Payer: Cash Price |
$5,842.80
|
| Rate for Payer: Cigna Commercial |
$18,634.64
|
| Rate for Payer: Health EOS Commercial |
$18,026.99
|
| Rate for Payer: HFN Commercial |
$18,634.64
|
| Rate for Payer: Multiplan Commercial |
$16,204.03
|
| Rate for Payer: Preferred Network Access Commercial |
$18,634.64
|
| Rate for Payer: Quartz Beloit One Network |
$9,924.97
|
| Rate for Payer: Quartz Commercial |
$12,153.02
|
| Rate for Payer: WEA Trust Commercial |
$11,140.27
|
| Rate for Payer: WPS Commercial |
$15,002.36
|
|
|
GRAFT ALLODERM 16 X 20CM 102320
|
Facility
|
IP
|
$72,429.00
|
|
| Hospital Charge Code |
2965263
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$36,909.82 |
| Max. Negotiated Rate |
$69,300.07 |
| Rate for Payer: Aetna Commercial |
$67,793.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64,780.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39,922.86
|
| Rate for Payer: Cash Price |
$21,728.70
|
| Rate for Payer: Cigna Commercial |
$69,300.07
|
| Rate for Payer: Health EOS Commercial |
$67,040.28
|
| Rate for Payer: HFN Commercial |
$69,300.07
|
| Rate for Payer: Multiplan Commercial |
$60,260.93
|
| Rate for Payer: Preferred Network Access Commercial |
$69,300.07
|
| Rate for Payer: Quartz Beloit One Network |
$36,909.82
|
| Rate for Payer: Quartz Commercial |
$45,195.70
|
| Rate for Payer: WEA Trust Commercial |
$41,429.39
|
| Rate for Payer: WPS Commercial |
$55,792.06
|
|
|
GRAFT ALLODERM 16 X 20CM 102320
|
Facility
|
OP
|
$72,429.00
|
|
| Hospital Charge Code |
2965263
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,091.32 |
| Max. Negotiated Rate |
$69,300.07 |
| Rate for Payer: Aetna Commercial |
$67,793.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64,780.50
|
| Rate for Payer: Aetna Managed Medicare |
$21,091.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48,962.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37,663.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36,156.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39,922.86
|
| Rate for Payer: Cash Price |
$21,728.70
|
| Rate for Payer: Cigna Commercial |
$69,300.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42,153.68
|
| Rate for Payer: Health EOS Commercial |
$67,040.28
|
| Rate for Payer: HFN Commercial |
$69,300.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56,494.62
|
| Rate for Payer: Multiplan Commercial |
$60,260.93
|
| Rate for Payer: NAPHCARE Commercial |
$45,195.70
|
| Rate for Payer: Preferred Network Access Commercial |
$69,300.07
|
| Rate for Payer: Quartz Beloit One Network |
$36,909.82
|
| Rate for Payer: Quartz Commercial |
$48,962.00
|
| Rate for Payer: Quartz Medicare Advantage |
$45,195.70
|
| Rate for Payer: The Alliance Commercial |
$37,663.08
|
| Rate for Payer: WEA Trust Commercial |
$41,429.39
|
| Rate for Payer: WPS Commercial |
$55,792.06
|
|
|
GRAFT ALLODERM 4 X 7CM 102034
|
Facility
|
IP
|
$6,762.00
|
|
| Hospital Charge Code |
2965264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,445.92 |
| Max. Negotiated Rate |
$6,469.88 |
| Rate for Payer: Aetna Commercial |
$6,329.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,047.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,727.21
|
| Rate for Payer: Cash Price |
$2,028.60
|
| Rate for Payer: Cigna Commercial |
$6,469.88
|
| Rate for Payer: Health EOS Commercial |
$6,258.91
|
| Rate for Payer: HFN Commercial |
$6,469.88
|
| Rate for Payer: Multiplan Commercial |
$5,625.98
|
| Rate for Payer: Preferred Network Access Commercial |
$6,469.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,445.92
|
| Rate for Payer: Quartz Commercial |
$4,219.49
|
| Rate for Payer: WEA Trust Commercial |
$3,867.86
|
| Rate for Payer: WPS Commercial |
$5,208.77
|
|
|
GRAFT ALLODERM 4 X 7CM 102034
|
Facility
|
OP
|
$6,762.00
|
|
| Hospital Charge Code |
2965264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,969.09 |
| Max. Negotiated Rate |
$6,469.88 |
| Rate for Payer: Aetna Commercial |
$6,329.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,047.93
|
| Rate for Payer: Aetna Managed Medicare |
$1,969.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,571.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,516.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,375.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,727.21
|
| Rate for Payer: Cash Price |
$2,028.60
|
| Rate for Payer: Cigna Commercial |
$6,469.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,935.48
|
| Rate for Payer: Health EOS Commercial |
$6,258.91
|
| Rate for Payer: HFN Commercial |
$6,469.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,274.36
|
| Rate for Payer: Multiplan Commercial |
$5,625.98
|
| Rate for Payer: NAPHCARE Commercial |
$4,219.49
|
| Rate for Payer: Preferred Network Access Commercial |
$6,469.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,445.92
|
| Rate for Payer: Quartz Commercial |
$4,571.11
|
| Rate for Payer: Quartz Medicare Advantage |
$4,219.49
|
| Rate for Payer: The Alliance Commercial |
$3,516.24
|
| Rate for Payer: WEA Trust Commercial |
$3,867.86
|
| Rate for Payer: WPS Commercial |
$5,208.77
|
|
|
GRAFT ALLODERM 6 X 12CM 102072
|
Facility
|
IP
|
$11,575.00
|
|
| Hospital Charge Code |
2965265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,898.62 |
| Max. Negotiated Rate |
$11,074.96 |
| Rate for Payer: Aetna Commercial |
$10,834.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,352.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,380.14
|
| Rate for Payer: Cash Price |
$3,472.50
|
| Rate for Payer: Cigna Commercial |
$11,074.96
|
| Rate for Payer: Health EOS Commercial |
$10,713.82
|
| Rate for Payer: HFN Commercial |
$11,074.96
|
| Rate for Payer: Multiplan Commercial |
$9,630.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,074.96
|
| Rate for Payer: Quartz Beloit One Network |
$5,898.62
|
| Rate for Payer: Quartz Commercial |
$7,222.80
|
| Rate for Payer: WEA Trust Commercial |
$6,620.90
|
| Rate for Payer: WPS Commercial |
$8,916.22
|
|
|
GRAFT ALLODERM 6 X 12CM 102072
|
Facility
|
OP
|
$11,575.00
|
|
| Hospital Charge Code |
2965265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,370.64 |
| Max. Negotiated Rate |
$11,074.96 |
| Rate for Payer: Aetna Commercial |
$10,834.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,352.68
|
| Rate for Payer: Aetna Managed Medicare |
$3,370.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,824.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,019.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,778.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,380.14
|
| Rate for Payer: Cash Price |
$3,472.50
|
| Rate for Payer: Cigna Commercial |
$11,074.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,736.65
|
| Rate for Payer: Health EOS Commercial |
$10,713.82
|
| Rate for Payer: HFN Commercial |
$11,074.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,028.50
|
| Rate for Payer: Multiplan Commercial |
$9,630.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,222.80
|
| Rate for Payer: Preferred Network Access Commercial |
$11,074.96
|
| Rate for Payer: Quartz Beloit One Network |
$5,898.62
|
| Rate for Payer: Quartz Commercial |
$7,824.70
|
| Rate for Payer: Quartz Medicare Advantage |
$7,222.80
|
| Rate for Payer: The Alliance Commercial |
$6,019.00
|
| Rate for Payer: WEA Trust Commercial |
$6,620.90
|
| Rate for Payer: WPS Commercial |
$8,916.22
|
|
|
GRAFT ALLODERM 8 X 16CM 102128
|
Facility
|
OP
|
$21,751.00
|
|
| Hospital Charge Code |
2965266
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,333.89 |
| Max. Negotiated Rate |
$20,811.36 |
| Rate for Payer: Aetna Commercial |
$20,358.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,454.09
|
| Rate for Payer: Aetna Managed Medicare |
$6,333.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,703.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,310.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,858.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,989.15
|
| Rate for Payer: Cash Price |
$6,525.30
|
| Rate for Payer: Cigna Commercial |
$20,811.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,659.08
|
| Rate for Payer: Health EOS Commercial |
$20,132.73
|
| Rate for Payer: HFN Commercial |
$20,811.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,965.78
|
| Rate for Payer: Multiplan Commercial |
$18,096.83
|
| Rate for Payer: NAPHCARE Commercial |
$13,572.62
|
| Rate for Payer: Preferred Network Access Commercial |
$20,811.36
|
| Rate for Payer: Quartz Beloit One Network |
$11,084.31
|
| Rate for Payer: Quartz Commercial |
$14,703.68
|
| Rate for Payer: Quartz Medicare Advantage |
$13,572.62
|
| Rate for Payer: The Alliance Commercial |
$11,310.52
|
| Rate for Payer: WEA Trust Commercial |
$12,441.57
|
| Rate for Payer: WPS Commercial |
$16,754.80
|
|
|
GRAFT ALLODERM 8 X 16CM 102128
|
Facility
|
IP
|
$21,751.00
|
|
| Hospital Charge Code |
2965266
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,084.31 |
| Max. Negotiated Rate |
$20,811.36 |
| Rate for Payer: Aetna Commercial |
$20,358.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,454.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,989.15
|
| Rate for Payer: Cash Price |
$6,525.30
|
| Rate for Payer: Cigna Commercial |
$20,811.36
|
| Rate for Payer: Health EOS Commercial |
$20,132.73
|
| Rate for Payer: HFN Commercial |
$20,811.36
|
| Rate for Payer: Multiplan Commercial |
$18,096.83
|
| Rate for Payer: Preferred Network Access Commercial |
$20,811.36
|
| Rate for Payer: Quartz Beloit One Network |
$11,084.31
|
| Rate for Payer: Quartz Commercial |
$13,572.62
|
| Rate for Payer: WEA Trust Commercial |
$12,441.57
|
| Rate for Payer: WPS Commercial |
$16,754.80
|
|
|
GRAFT AMNIOTIC MEMBRANE AMBIODRY 1.5 X 2CM AD5120
|
Facility
|
IP
|
$5,793.00
|
|
| Hospital Charge Code |
3553503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,952.11 |
| Max. Negotiated Rate |
$5,542.74 |
| Rate for Payer: Aetna Commercial |
$5,422.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,181.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,193.10
|
| Rate for Payer: Cash Price |
$1,737.90
|
| Rate for Payer: Cigna Commercial |
$5,542.74
|
| Rate for Payer: Health EOS Commercial |
$5,362.00
|
| Rate for Payer: HFN Commercial |
$5,542.74
|
| Rate for Payer: Multiplan Commercial |
$4,819.78
|
| Rate for Payer: Preferred Network Access Commercial |
$5,542.74
|
| Rate for Payer: Quartz Beloit One Network |
$2,952.11
|
| Rate for Payer: Quartz Commercial |
$3,614.83
|
| Rate for Payer: WEA Trust Commercial |
$3,313.60
|
| Rate for Payer: WPS Commercial |
$4,462.35
|
|
|
GRAFT AMNIOTIC MEMBRANE AMBIODRY 1.5 X 2CM AD5120
|
Facility
|
OP
|
$5,793.00
|
|
| Hospital Charge Code |
3553503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,686.92 |
| Max. Negotiated Rate |
$5,542.74 |
| Rate for Payer: Aetna Commercial |
$5,422.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,181.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,686.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,916.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,012.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,891.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,193.10
|
| Rate for Payer: Cash Price |
$1,737.90
|
| Rate for Payer: Cigna Commercial |
$5,542.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,371.53
|
| Rate for Payer: Health EOS Commercial |
$5,362.00
|
| Rate for Payer: HFN Commercial |
$5,542.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,518.54
|
| Rate for Payer: Multiplan Commercial |
$4,819.78
|
| Rate for Payer: NAPHCARE Commercial |
$3,614.83
|
| Rate for Payer: Preferred Network Access Commercial |
$5,542.74
|
| Rate for Payer: Quartz Beloit One Network |
$2,952.11
|
| Rate for Payer: Quartz Commercial |
$3,916.07
|
| Rate for Payer: Quartz Medicare Advantage |
$3,614.83
|
| Rate for Payer: The Alliance Commercial |
$3,012.36
|
| Rate for Payer: WEA Trust Commercial |
$3,313.60
|
| Rate for Payer: WPS Commercial |
$4,462.35
|
|
|
GRAFT ANTERIOR TIBIAL TENDON FANT/TIB/T
|
Facility
|
OP
|
$13,808.00
|
|
| Hospital Charge Code |
5563550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,020.89 |
| Max. Negotiated Rate |
$13,211.49 |
| Rate for Payer: Aetna Commercial |
$12,924.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,349.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,020.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,334.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,180.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,892.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,610.97
|
| Rate for Payer: Cash Price |
$4,142.40
|
| Rate for Payer: Cigna Commercial |
$13,211.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,036.26
|
| Rate for Payer: Health EOS Commercial |
$12,780.68
|
| Rate for Payer: HFN Commercial |
$13,211.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,770.24
|
| Rate for Payer: Multiplan Commercial |
$11,488.26
|
| Rate for Payer: NAPHCARE Commercial |
$8,616.19
|
| Rate for Payer: Preferred Network Access Commercial |
$13,211.49
|
| Rate for Payer: Quartz Beloit One Network |
$7,036.56
|
| Rate for Payer: Quartz Commercial |
$9,334.21
|
| Rate for Payer: Quartz Medicare Advantage |
$8,616.19
|
| Rate for Payer: The Alliance Commercial |
$7,180.16
|
| Rate for Payer: WEA Trust Commercial |
$7,898.18
|
| Rate for Payer: WPS Commercial |
$10,636.30
|
|
|
GRAFT ANTERIOR TIBIAL TENDON FANT/TIB/T
|
Facility
|
IP
|
$13,808.00
|
|
| Hospital Charge Code |
5563550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,036.56 |
| Max. Negotiated Rate |
$13,211.49 |
| Rate for Payer: Aetna Commercial |
$12,924.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,349.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,610.97
|
| Rate for Payer: Cash Price |
$4,142.40
|
| Rate for Payer: Cigna Commercial |
$13,211.49
|
| Rate for Payer: Health EOS Commercial |
$12,780.68
|
| Rate for Payer: HFN Commercial |
$13,211.49
|
| Rate for Payer: Multiplan Commercial |
$11,488.26
|
| Rate for Payer: Preferred Network Access Commercial |
$13,211.49
|
| Rate for Payer: Quartz Beloit One Network |
$7,036.56
|
| Rate for Payer: Quartz Commercial |
$8,616.19
|
| Rate for Payer: WEA Trust Commercial |
$7,898.18
|
| Rate for Payer: WPS Commercial |
$10,636.30
|
|
|
GRAFT AV ACCESS HEPARIN TAPER 4 - 7MM X 80CM H470080A
|
Facility
|
OP
|
$13,441.00
|
|
| Hospital Charge Code |
3553536
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,914.02 |
| Max. Negotiated Rate |
$12,860.35 |
| Rate for Payer: Aetna Commercial |
$12,580.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,021.63
|
| Rate for Payer: Aetna Managed Medicare |
$3,914.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,086.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,989.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,709.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,408.68
|
| Rate for Payer: Cash Price |
$4,032.30
|
| Rate for Payer: Cigna Commercial |
$12,860.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,822.66
|
| Rate for Payer: Health EOS Commercial |
$12,440.99
|
| Rate for Payer: HFN Commercial |
$12,860.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,483.98
|
| Rate for Payer: Multiplan Commercial |
$11,182.91
|
| Rate for Payer: NAPHCARE Commercial |
$8,387.18
|
| Rate for Payer: Preferred Network Access Commercial |
$12,860.35
|
| Rate for Payer: Quartz Beloit One Network |
$6,849.53
|
| Rate for Payer: Quartz Commercial |
$9,086.12
|
| Rate for Payer: Quartz Medicare Advantage |
$8,387.18
|
| Rate for Payer: The Alliance Commercial |
$6,989.32
|
| Rate for Payer: WEA Trust Commercial |
$7,688.25
|
| Rate for Payer: WPS Commercial |
$10,353.60
|
|
|
GRAFT AV ACCESS HEPARIN TAPER 4 - 7MM X 80CM H470080A
|
Facility
|
IP
|
$13,441.00
|
|
| Hospital Charge Code |
3553536
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,849.53 |
| Max. Negotiated Rate |
$12,860.35 |
| Rate for Payer: Aetna Commercial |
$12,580.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,021.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,408.68
|
| Rate for Payer: Cash Price |
$4,032.30
|
| Rate for Payer: Cigna Commercial |
$12,860.35
|
| Rate for Payer: Health EOS Commercial |
$12,440.99
|
| Rate for Payer: HFN Commercial |
$12,860.35
|
| Rate for Payer: Multiplan Commercial |
$11,182.91
|
| Rate for Payer: Preferred Network Access Commercial |
$12,860.35
|
| Rate for Payer: Quartz Beloit One Network |
$6,849.53
|
| Rate for Payer: Quartz Commercial |
$8,387.18
|
| Rate for Payer: WEA Trust Commercial |
$7,688.25
|
| Rate for Payer: WPS Commercial |
$10,353.60
|
|
|
GRAFT AV ACCESS PROPATEN HEPARIN THIN WALL 8MM X 80CM 70CM RINGS HT087080A
|
Facility
|
IP
|
$11,085.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3845345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,648.92 |
| Max. Negotiated Rate |
$10,606.13 |
| Rate for Payer: Aetna Commercial |
$10,375.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,914.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,110.05
|
| Rate for Payer: Cash Price |
$3,325.50
|
| Rate for Payer: Cigna Commercial |
$10,606.13
|
| Rate for Payer: Health EOS Commercial |
$10,260.28
|
| Rate for Payer: HFN Commercial |
$10,606.13
|
| Rate for Payer: Multiplan Commercial |
$9,222.72
|
| Rate for Payer: Preferred Network Access Commercial |
$10,606.13
|
| Rate for Payer: Quartz Beloit One Network |
$5,648.92
|
| Rate for Payer: Quartz Commercial |
$6,917.04
|
| Rate for Payer: WEA Trust Commercial |
$6,340.62
|
| Rate for Payer: WPS Commercial |
$8,538.78
|
|
|
GRAFT AV ACCESS PROPATEN HEPARIN THIN WALL 8MM X 80CM 70CM RINGS HT087080A
|
Facility
|
OP
|
$11,085.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3845345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,227.95 |
| Max. Negotiated Rate |
$10,606.13 |
| Rate for Payer: Aetna Commercial |
$10,375.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,914.42
|
| Rate for Payer: Aetna Managed Medicare |
$3,227.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,493.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,764.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,533.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,110.05
|
| Rate for Payer: Cash Price |
$3,325.50
|
| Rate for Payer: Cigna Commercial |
$10,606.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,451.47
|
| Rate for Payer: Health EOS Commercial |
$10,260.28
|
| Rate for Payer: HFN Commercial |
$10,606.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,646.30
|
| Rate for Payer: Multiplan Commercial |
$9,222.72
|
| Rate for Payer: NAPHCARE Commercial |
$6,917.04
|
| Rate for Payer: Preferred Network Access Commercial |
$10,606.13
|
| Rate for Payer: Quartz Beloit One Network |
$5,648.92
|
| Rate for Payer: Quartz Commercial |
$7,493.46
|
| Rate for Payer: Quartz Medicare Advantage |
$6,917.04
|
| Rate for Payer: The Alliance Commercial |
$5,764.20
|
| Rate for Payer: WEA Trust Commercial |
$6,340.62
|
| Rate for Payer: WPS Commercial |
$8,538.78
|
|
|
GRAFT AV ACUSEAL 4-6MM X 45CM EARLY CANNULATION ECH460045A
|
Facility
|
OP
|
$7,667.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5349343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,232.63 |
| Max. Negotiated Rate |
$7,335.79 |
| Rate for Payer: Aetna Commercial |
$7,176.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,857.36
|
| Rate for Payer: Aetna Managed Medicare |
$2,232.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,182.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,986.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,827.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,226.05
|
| Rate for Payer: Cash Price |
$2,300.10
|
| Rate for Payer: Cigna Commercial |
$7,335.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,462.19
|
| Rate for Payer: Health EOS Commercial |
$7,096.58
|
| Rate for Payer: HFN Commercial |
$7,335.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,980.26
|
| Rate for Payer: Multiplan Commercial |
$6,378.94
|
| Rate for Payer: NAPHCARE Commercial |
$4,784.21
|
| Rate for Payer: Preferred Network Access Commercial |
$7,335.79
|
| Rate for Payer: Quartz Beloit One Network |
$3,907.10
|
| Rate for Payer: Quartz Commercial |
$5,182.89
|
| Rate for Payer: Quartz Medicare Advantage |
$4,784.21
|
| Rate for Payer: The Alliance Commercial |
$3,986.84
|
| Rate for Payer: WEA Trust Commercial |
$4,385.52
|
| Rate for Payer: WPS Commercial |
$5,905.89
|
|
|
GRAFT AV ACUSEAL 4-6MM X 45CM EARLY CANNULATION ECH460045A
|
Facility
|
IP
|
$7,667.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5349343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,907.10 |
| Max. Negotiated Rate |
$7,335.79 |
| Rate for Payer: Aetna Commercial |
$7,176.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,857.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,226.05
|
| Rate for Payer: Cash Price |
$2,300.10
|
| Rate for Payer: Cigna Commercial |
$7,335.79
|
| Rate for Payer: Health EOS Commercial |
$7,096.58
|
| Rate for Payer: HFN Commercial |
$7,335.79
|
| Rate for Payer: Multiplan Commercial |
$6,378.94
|
| Rate for Payer: Preferred Network Access Commercial |
$7,335.79
|
| Rate for Payer: Quartz Beloit One Network |
$3,907.10
|
| Rate for Payer: Quartz Commercial |
$4,784.21
|
| Rate for Payer: WEA Trust Commercial |
$4,385.52
|
| Rate for Payer: WPS Commercial |
$5,905.89
|
|
