|
GRAFT AV ACUSEAL EARLY CANNULATION ECH060040A
|
Facility
|
IP
|
$7,807.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
4030006
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,978.45 |
| Max. Negotiated Rate |
$7,469.74 |
| Rate for Payer: Aetna Commercial |
$7,307.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,982.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,303.22
|
| Rate for Payer: Cash Price |
$2,342.10
|
| Rate for Payer: Cigna Commercial |
$7,469.74
|
| Rate for Payer: Health EOS Commercial |
$7,226.16
|
| Rate for Payer: HFN Commercial |
$7,469.74
|
| Rate for Payer: Multiplan Commercial |
$6,495.42
|
| Rate for Payer: Preferred Network Access Commercial |
$7,469.74
|
| Rate for Payer: Quartz Beloit One Network |
$3,978.45
|
| Rate for Payer: Quartz Commercial |
$4,871.57
|
| Rate for Payer: WEA Trust Commercial |
$4,465.60
|
| Rate for Payer: WPS Commercial |
$6,013.73
|
|
|
GRAFT AV ACUSEAL EARLY CANNULATION ECH060040A
|
Facility
|
OP
|
$7,807.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
4030006
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,273.40 |
| Max. Negotiated Rate |
$7,469.74 |
| Rate for Payer: Aetna Commercial |
$7,307.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,982.58
|
| Rate for Payer: Aetna Managed Medicare |
$2,273.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,277.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,059.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,897.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,303.22
|
| Rate for Payer: Cash Price |
$2,342.10
|
| Rate for Payer: Cigna Commercial |
$7,469.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,543.67
|
| Rate for Payer: Health EOS Commercial |
$7,226.16
|
| Rate for Payer: HFN Commercial |
$7,469.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,089.46
|
| Rate for Payer: Multiplan Commercial |
$6,495.42
|
| Rate for Payer: NAPHCARE Commercial |
$4,871.57
|
| Rate for Payer: Preferred Network Access Commercial |
$7,469.74
|
| Rate for Payer: Quartz Beloit One Network |
$3,978.45
|
| Rate for Payer: Quartz Commercial |
$5,277.53
|
| Rate for Payer: Quartz Medicare Advantage |
$4,871.57
|
| Rate for Payer: The Alliance Commercial |
$4,059.64
|
| Rate for Payer: WEA Trust Commercial |
$4,465.60
|
| Rate for Payer: WPS Commercial |
$6,013.73
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 0.4,0.6 ENT-OTO-0.4-0.6
|
Facility
|
IP
|
$2,007.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
5490704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,022.77 |
| Max. Negotiated Rate |
$1,920.30 |
| Rate for Payer: Aetna Commercial |
$1,878.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,795.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,106.26
|
| Rate for Payer: Cash Price |
$602.10
|
| Rate for Payer: Cigna Commercial |
$1,920.30
|
| Rate for Payer: Health EOS Commercial |
$1,857.68
|
| Rate for Payer: HFN Commercial |
$1,920.30
|
| Rate for Payer: Multiplan Commercial |
$1,669.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,920.30
|
| Rate for Payer: Quartz Beloit One Network |
$1,022.77
|
| Rate for Payer: Quartz Commercial |
$1,252.37
|
| Rate for Payer: WEA Trust Commercial |
$1,148.00
|
| Rate for Payer: WPS Commercial |
$1,545.99
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 0.4,0.6 ENT-OTO-0.4-0.6
|
Facility
|
OP
|
$2,007.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
5490704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.44 |
| Max. Negotiated Rate |
$1,920.30 |
| Rate for Payer: Aetna Commercial |
$1,878.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,795.06
|
| Rate for Payer: Aetna Managed Medicare |
$584.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,356.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,043.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,001.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,106.26
|
| Rate for Payer: Cash Price |
$602.10
|
| Rate for Payer: Cigna Commercial |
$1,920.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,168.07
|
| Rate for Payer: Health EOS Commercial |
$1,857.68
|
| Rate for Payer: HFN Commercial |
$1,920.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,565.46
|
| Rate for Payer: Multiplan Commercial |
$1,669.82
|
| Rate for Payer: NAPHCARE Commercial |
$1,252.37
|
| Rate for Payer: Preferred Network Access Commercial |
$1,920.30
|
| Rate for Payer: Quartz Beloit One Network |
$1,022.77
|
| Rate for Payer: Quartz Commercial |
$1,356.73
|
| Rate for Payer: Quartz Medicare Advantage |
$1,252.37
|
| Rate for Payer: The Alliance Commercial |
$1,043.64
|
| Rate for Payer: WEA Trust Commercial |
$1,148.00
|
| Rate for Payer: WPS Commercial |
$1,545.99
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 0.6,0.9 ENT-OTO-0.6-0.9
|
Facility
|
IP
|
$2,845.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
5490702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,449.81 |
| Max. Negotiated Rate |
$2,722.10 |
| Rate for Payer: Aetna Commercial |
$2,662.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,544.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,568.16
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cigna Commercial |
$2,722.10
|
| Rate for Payer: Health EOS Commercial |
$2,633.33
|
| Rate for Payer: HFN Commercial |
$2,722.10
|
| Rate for Payer: Multiplan Commercial |
$2,367.04
|
| Rate for Payer: Preferred Network Access Commercial |
$2,722.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,449.81
|
| Rate for Payer: Quartz Commercial |
$1,775.28
|
| Rate for Payer: WEA Trust Commercial |
$1,627.34
|
| Rate for Payer: WPS Commercial |
$2,191.50
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 0.6,0.9 ENT-OTO-0.6-0.9
|
Facility
|
OP
|
$2,845.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
5490702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$828.46 |
| Max. Negotiated Rate |
$2,722.10 |
| Rate for Payer: Aetna Commercial |
$2,662.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,544.57
|
| Rate for Payer: Aetna Managed Medicare |
$828.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,923.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,479.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,420.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,568.16
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cigna Commercial |
$2,722.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,655.79
|
| Rate for Payer: Health EOS Commercial |
$2,633.33
|
| Rate for Payer: HFN Commercial |
$2,722.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,219.10
|
| Rate for Payer: Multiplan Commercial |
$2,367.04
|
| Rate for Payer: NAPHCARE Commercial |
$1,775.28
|
| Rate for Payer: Preferred Network Access Commercial |
$2,722.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,449.81
|
| Rate for Payer: Quartz Commercial |
$1,923.22
|
| Rate for Payer: Quartz Medicare Advantage |
$1,775.28
|
| Rate for Payer: The Alliance Commercial |
$1,479.40
|
| Rate for Payer: WEA Trust Commercial |
$1,627.34
|
| Rate for Payer: WPS Commercial |
$2,191.50
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 2.5X2.5 ENT-OTO-2.5X2.5 G44451
|
Facility
|
IP
|
$2,746.00
|
|
| Hospital Charge Code |
4858886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,399.36 |
| Max. Negotiated Rate |
$2,627.37 |
| Rate for Payer: Aetna Commercial |
$2,570.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,456.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,513.60
|
| Rate for Payer: Cash Price |
$823.80
|
| Rate for Payer: Cigna Commercial |
$2,627.37
|
| Rate for Payer: Health EOS Commercial |
$2,541.70
|
| Rate for Payer: HFN Commercial |
$2,627.37
|
| Rate for Payer: Multiplan Commercial |
$2,284.67
|
| Rate for Payer: Preferred Network Access Commercial |
$2,627.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,399.36
|
| Rate for Payer: Quartz Commercial |
$1,713.50
|
| Rate for Payer: WEA Trust Commercial |
$1,570.71
|
| Rate for Payer: WPS Commercial |
$2,115.24
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 2.5X2.5 ENT-OTO-2.5X2.5 G44451
|
Facility
|
OP
|
$2,746.00
|
|
| Hospital Charge Code |
4858886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$799.64 |
| Max. Negotiated Rate |
$2,627.37 |
| Rate for Payer: Aetna Commercial |
$2,570.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,456.02
|
| Rate for Payer: Aetna Managed Medicare |
$799.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,856.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,427.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,370.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,513.60
|
| Rate for Payer: Cash Price |
$823.80
|
| Rate for Payer: Cigna Commercial |
$2,627.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,598.17
|
| Rate for Payer: Health EOS Commercial |
$2,541.70
|
| Rate for Payer: HFN Commercial |
$2,627.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,141.88
|
| Rate for Payer: Multiplan Commercial |
$2,284.67
|
| Rate for Payer: NAPHCARE Commercial |
$1,713.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,627.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,399.36
|
| Rate for Payer: Quartz Commercial |
$1,856.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,713.50
|
| Rate for Payer: The Alliance Commercial |
$1,427.92
|
| Rate for Payer: WEA Trust Commercial |
$1,570.71
|
| Rate for Payer: WPS Commercial |
$2,115.24
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 5X5 ENT-OTO-5X5 G44452
|
Facility
|
OP
|
$4,115.00
|
|
| Hospital Charge Code |
4858887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,198.29 |
| Max. Negotiated Rate |
$3,937.23 |
| Rate for Payer: Aetna Commercial |
$3,851.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,680.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,198.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,781.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,139.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,054.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,268.19
|
| Rate for Payer: Cash Price |
$1,234.50
|
| Rate for Payer: Cigna Commercial |
$3,937.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,394.93
|
| Rate for Payer: Health EOS Commercial |
$3,808.84
|
| Rate for Payer: HFN Commercial |
$3,937.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,209.70
|
| Rate for Payer: Multiplan Commercial |
$3,423.68
|
| Rate for Payer: NAPHCARE Commercial |
$2,567.76
|
| Rate for Payer: Preferred Network Access Commercial |
$3,937.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,097.00
|
| Rate for Payer: Quartz Commercial |
$2,781.74
|
| Rate for Payer: Quartz Medicare Advantage |
$2,567.76
|
| Rate for Payer: The Alliance Commercial |
$2,139.80
|
| Rate for Payer: WEA Trust Commercial |
$2,353.78
|
| Rate for Payer: WPS Commercial |
$3,169.78
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 5X5 ENT-OTO-5X5 G44452
|
Facility
|
IP
|
$4,115.00
|
|
| Hospital Charge Code |
4858887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,097.00 |
| Max. Negotiated Rate |
$3,937.23 |
| Rate for Payer: Aetna Commercial |
$3,851.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,680.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,268.19
|
| Rate for Payer: Cash Price |
$1,234.50
|
| Rate for Payer: Cigna Commercial |
$3,937.23
|
| Rate for Payer: Health EOS Commercial |
$3,808.84
|
| Rate for Payer: HFN Commercial |
$3,937.23
|
| Rate for Payer: Multiplan Commercial |
$3,423.68
|
| Rate for Payer: Preferred Network Access Commercial |
$3,937.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,097.00
|
| Rate for Payer: Quartz Commercial |
$2,567.76
|
| Rate for Payer: WEA Trust Commercial |
$2,353.78
|
| Rate for Payer: WPS Commercial |
$3,169.78
|
|
|
GRAFT; COMPOSITE (EG, FULL THICKNESS OF EXTERNAL EAR OR NASAL ALA), INCLUDING PRIMARY CLOSURE, DONOR AREA
|
Facility
|
OP
|
$8,685.50
|
|
|
Service Code
|
CPT 15760
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,171.37 |
| Max. Negotiated Rate |
$8,685.50 |
| Rate for Payer: Aetna Managed Medicare |
$2,171.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$2,171.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,171.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,171.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,171.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,171.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,077.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,171.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,171.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,171.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,171.37
|
| Rate for Payer: NAPHCARE Commercial |
$3,257.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,171.37
|
| Rate for Payer: The Alliance Commercial |
$8,685.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,171.37
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$2,171.37
|
|
|
GRAFT COMPOSITE W/PRIMARY CLOSURE DONOR AREA 15760
|
Professional
|
Both
|
$3,461.00
|
|
|
Service Code
|
CPT 15760
|
| Hospital Charge Code |
6041658
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$592.98 |
| Max. Negotiated Rate |
$3,419.47 |
| Rate for Payer: Aetna Commercial |
$3,419.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,095.52
|
| Rate for Payer: Aetna Managed Medicare |
$592.98
|
| Rate for Payer: Anthem Medicare Advantage |
$592.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$592.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$592.98
|
| Rate for Payer: Cash Price |
$1,038.30
|
| Rate for Payer: Cash Price |
$1,038.30
|
| Rate for Payer: Cash Price |
$1,038.30
|
| Rate for Payer: Cigna Commercial |
$3,419.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$685.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$592.98
|
| Rate for Payer: Health EOS Commercial |
$3,275.49
|
| Rate for Payer: HFN Commercial |
$3,419.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,421.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,421.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$592.98
|
| Rate for Payer: Multiplan Commercial |
$2,879.55
|
| Rate for Payer: NAPHCARE Commercial |
$889.47
|
| Rate for Payer: Preferred Network Access Commercial |
$3,419.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,583.75
|
| Rate for Payer: Quartz Commercial |
$2,051.68
|
| Rate for Payer: Quartz Medicare Advantage |
$592.98
|
| Rate for Payer: The Alliance Commercial |
$2,520.15
|
| Rate for Payer: United Healthcare Medicaid |
$685.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$592.98
|
| Rate for Payer: WEA Trust Commercial |
$1,979.69
|
| Rate for Payer: WPS Commercial |
$2,668.40
|
|
|
GRAFT DERMIS DECELLULARIZED 3.5 X 3.5CM (12.25 SQ CM) AFLEX200
|
Facility
|
IP
|
$1,325.00
|
|
|
Service Code
|
HCPCS Q4125
|
| Hospital Charge Code |
5787662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$675.22 |
| Max. Negotiated Rate |
$1,267.76 |
| Rate for Payer: Aetna Commercial |
$1,240.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,185.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$730.34
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$1,267.76
|
| Rate for Payer: Health EOS Commercial |
$1,226.42
|
| Rate for Payer: HFN Commercial |
$1,267.76
|
| Rate for Payer: Multiplan Commercial |
$1,102.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,267.76
|
| Rate for Payer: Quartz Beloit One Network |
$675.22
|
| Rate for Payer: Quartz Commercial |
$826.80
|
| Rate for Payer: WEA Trust Commercial |
$757.90
|
| Rate for Payer: WPS Commercial |
$1,020.65
|
|
|
GRAFT DERMIS DECELLULARIZED 3.5 X 3.5CM (12.25 SQ CM) AFLEX200
|
Facility
|
OP
|
$1,325.00
|
|
|
Service Code
|
HCPCS Q4125
|
| Hospital Charge Code |
5787662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$1,267.76 |
| Rate for Payer: Aetna Commercial |
$1,240.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,185.08
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$895.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$661.44
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$730.34
|
| 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 |
$397.50
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$1,267.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$771.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$1,226.42
|
| Rate for Payer: HFN Commercial |
$1,267.76
|
| 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 |
$1,102.40
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$1,267.76
|
| Rate for Payer: Quartz Beloit One Network |
$675.22
|
| Rate for Payer: Quartz Commercial |
$895.70
|
| 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 |
$757.90
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$1,020.65
|
|
|
GRAFT DERMIS DECELLULARIZED AFLEX100
|
Facility
|
OP
|
$13,840.00
|
|
| Hospital Charge Code |
3901338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,030.21 |
| Max. Negotiated Rate |
$13,242.11 |
| Rate for Payer: Aetna Commercial |
$12,954.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,378.50
|
| Rate for Payer: Aetna Managed Medicare |
$4,030.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,355.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,196.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,908.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,628.61
|
| Rate for Payer: Cash Price |
$4,152.00
|
| Rate for Payer: Cigna Commercial |
$13,242.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,054.88
|
| Rate for Payer: Health EOS Commercial |
$12,810.30
|
| Rate for Payer: HFN Commercial |
$13,242.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,795.20
|
| Rate for Payer: Multiplan Commercial |
$11,514.88
|
| Rate for Payer: NAPHCARE Commercial |
$8,636.16
|
| Rate for Payer: Preferred Network Access Commercial |
$13,242.11
|
| Rate for Payer: Quartz Beloit One Network |
$7,052.86
|
| Rate for Payer: Quartz Commercial |
$9,355.84
|
| Rate for Payer: Quartz Medicare Advantage |
$8,636.16
|
| Rate for Payer: The Alliance Commercial |
$7,196.80
|
| Rate for Payer: WEA Trust Commercial |
$7,916.48
|
| Rate for Payer: WPS Commercial |
$10,660.95
|
|
|
GRAFT DERMIS DECELLULARIZED AFLEX100
|
Facility
|
IP
|
$13,840.00
|
|
| Hospital Charge Code |
3901338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,052.86 |
| Max. Negotiated Rate |
$13,242.11 |
| Rate for Payer: Aetna Commercial |
$12,954.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,378.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,628.61
|
| Rate for Payer: Cash Price |
$4,152.00
|
| Rate for Payer: Cigna Commercial |
$13,242.11
|
| Rate for Payer: Health EOS Commercial |
$12,810.30
|
| Rate for Payer: HFN Commercial |
$13,242.11
|
| Rate for Payer: Multiplan Commercial |
$11,514.88
|
| Rate for Payer: Preferred Network Access Commercial |
$13,242.11
|
| Rate for Payer: Quartz Beloit One Network |
$7,052.86
|
| Rate for Payer: Quartz Commercial |
$8,636.16
|
| Rate for Payer: WEA Trust Commercial |
$7,916.48
|
| Rate for Payer: WPS Commercial |
$10,660.95
|
|
|
GRAFT DERMIS DECELLULARIZED ARTHROFLEX 40 X 70 X 3.0 AFLEX301
|
Facility
|
OP
|
$20,187.00
|
|
|
Service Code
|
HCPCS Q4125
|
| Hospital Charge Code |
5611576
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$19,314.92 |
| Rate for Payer: Aetna Commercial |
$18,895.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,055.25
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,646.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,497.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,077.35
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,127.07
|
| 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 |
$6,056.10
|
| Rate for Payer: Cash Price |
$6,056.10
|
| Rate for Payer: Cigna Commercial |
$19,314.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,748.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$18,685.09
|
| Rate for Payer: HFN Commercial |
$19,314.92
|
| 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 |
$16,795.58
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$19,314.92
|
| Rate for Payer: Quartz Beloit One Network |
$10,287.30
|
| Rate for Payer: Quartz Commercial |
$13,646.41
|
| 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 |
$11,546.96
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$15,550.05
|
|
|
GRAFT DERMIS DECELLULARIZED ARTHROFLEX 40 X 70 X 3.0 AFLEX301
|
Facility
|
IP
|
$20,187.00
|
|
|
Service Code
|
HCPCS Q4125
|
| Hospital Charge Code |
5611576
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,287.30 |
| Max. Negotiated Rate |
$19,314.92 |
| Rate for Payer: Aetna Commercial |
$18,895.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,055.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,127.07
|
| Rate for Payer: Cash Price |
$6,056.10
|
| Rate for Payer: Cigna Commercial |
$19,314.92
|
| Rate for Payer: Health EOS Commercial |
$18,685.09
|
| Rate for Payer: HFN Commercial |
$19,314.92
|
| Rate for Payer: Multiplan Commercial |
$16,795.58
|
| Rate for Payer: Preferred Network Access Commercial |
$19,314.92
|
| Rate for Payer: Quartz Beloit One Network |
$10,287.30
|
| Rate for Payer: Quartz Commercial |
$12,596.69
|
| Rate for Payer: WEA Trust Commercial |
$11,546.96
|
| Rate for Payer: WPS Commercial |
$15,550.05
|
|
|
GRAFT DISTAFLO 4MM X 10CM CVL4006C
|
Facility
|
IP
|
$8,503.00
|
|
| Hospital Charge Code |
2969345
|
|
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 DISTAFLO 4MM X 10CM CVL4006C
|
Facility
|
OP
|
$8,503.00
|
|
| Hospital Charge Code |
2969345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,476.07 |
| 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: Aetna Managed Medicare |
$2,476.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,748.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,421.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,244.70
|
| 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: Dean Health DHI/DHP/ASO |
$4,948.75
|
| Rate for Payer: Health EOS Commercial |
$7,870.38
|
| Rate for Payer: HFN Commercial |
$8,135.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,632.34
|
| Rate for Payer: Multiplan Commercial |
$7,074.50
|
| Rate for Payer: NAPHCARE Commercial |
$5,305.87
|
| 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 |
$5,748.03
|
| Rate for Payer: Quartz Medicare Advantage |
$5,305.87
|
| Rate for Payer: The Alliance Commercial |
$4,421.56
|
| Rate for Payer: WEA Trust Commercial |
$4,863.72
|
| Rate for Payer: WPS Commercial |
$6,549.86
|
|
|
GRAFT DISTAFLO 6MM X 70CM DF7006SC
|
Facility
|
OP
|
$12,119.00
|
|
| Hospital Charge Code |
5384692
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,529.05 |
| Max. Negotiated Rate |
$11,595.46 |
| Rate for Payer: Aetna Commercial |
$11,343.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,839.23
|
| Rate for Payer: Aetna Managed Medicare |
$3,529.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,192.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,301.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,049.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,679.99
|
| Rate for Payer: Cash Price |
$3,635.70
|
| Rate for Payer: Cigna Commercial |
$11,595.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,053.26
|
| Rate for Payer: Health EOS Commercial |
$11,217.35
|
| Rate for Payer: HFN Commercial |
$11,595.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,452.82
|
| Rate for Payer: Multiplan Commercial |
$10,083.01
|
| Rate for Payer: NAPHCARE Commercial |
$7,562.26
|
| Rate for Payer: Preferred Network Access Commercial |
$11,595.46
|
| Rate for Payer: Quartz Beloit One Network |
$6,175.84
|
| Rate for Payer: Quartz Commercial |
$8,192.44
|
| Rate for Payer: Quartz Medicare Advantage |
$7,562.26
|
| Rate for Payer: The Alliance Commercial |
$6,301.88
|
| Rate for Payer: WEA Trust Commercial |
$6,932.07
|
| Rate for Payer: WPS Commercial |
$9,335.27
|
|
|
GRAFT DISTAFLO 6MM X 70CM DF7006SC
|
Facility
|
IP
|
$12,119.00
|
|
| Hospital Charge Code |
5384692
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,175.84 |
| Max. Negotiated Rate |
$11,595.46 |
| Rate for Payer: Aetna Commercial |
$11,343.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,839.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,679.99
|
| Rate for Payer: Cash Price |
$3,635.70
|
| Rate for Payer: Cigna Commercial |
$11,595.46
|
| Rate for Payer: Health EOS Commercial |
$11,217.35
|
| Rate for Payer: HFN Commercial |
$11,595.46
|
| Rate for Payer: Multiplan Commercial |
$10,083.01
|
| Rate for Payer: Preferred Network Access Commercial |
$11,595.46
|
| Rate for Payer: Quartz Beloit One Network |
$6,175.84
|
| Rate for Payer: Quartz Commercial |
$7,562.26
|
| Rate for Payer: WEA Trust Commercial |
$6,932.07
|
| Rate for Payer: WPS Commercial |
$9,335.27
|
|
|
GRAFT DISTAFLO 7MM X 70CM DF7007SC
|
Facility
|
OP
|
$12,586.00
|
|
| Hospital Charge Code |
5384693
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,665.04 |
| Max. Negotiated Rate |
$12,042.28 |
| Rate for Payer: Aetna Commercial |
$11,780.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,256.92
|
| Rate for Payer: Aetna Managed Medicare |
$3,665.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,508.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,544.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,282.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,937.40
|
| Rate for Payer: Cash Price |
$3,775.80
|
| Rate for Payer: Cigna Commercial |
$12,042.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,325.05
|
| Rate for Payer: Health EOS Commercial |
$11,649.60
|
| Rate for Payer: HFN Commercial |
$12,042.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,817.08
|
| Rate for Payer: Multiplan Commercial |
$10,471.55
|
| Rate for Payer: NAPHCARE Commercial |
$7,853.66
|
| Rate for Payer: Preferred Network Access Commercial |
$12,042.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,413.83
|
| Rate for Payer: Quartz Commercial |
$8,508.14
|
| Rate for Payer: Quartz Medicare Advantage |
$7,853.66
|
| Rate for Payer: The Alliance Commercial |
$6,544.72
|
| Rate for Payer: WEA Trust Commercial |
$7,199.19
|
| Rate for Payer: WPS Commercial |
$9,695.00
|
|
|
GRAFT DISTAFLO 7MM X 70CM DF7007SC
|
Facility
|
IP
|
$12,586.00
|
|
| Hospital Charge Code |
5384693
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,413.83 |
| Max. Negotiated Rate |
$12,042.28 |
| Rate for Payer: Aetna Commercial |
$11,780.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,256.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,937.40
|
| Rate for Payer: Cash Price |
$3,775.80
|
| Rate for Payer: Cigna Commercial |
$12,042.28
|
| Rate for Payer: Health EOS Commercial |
$11,649.60
|
| Rate for Payer: HFN Commercial |
$12,042.28
|
| Rate for Payer: Multiplan Commercial |
$10,471.55
|
| Rate for Payer: Preferred Network Access Commercial |
$12,042.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,413.83
|
| Rate for Payer: Quartz Commercial |
$7,853.66
|
| Rate for Payer: WEA Trust Commercial |
$7,199.19
|
| Rate for Payer: WPS Commercial |
$9,695.00
|
|
|
GRAFT DISTAFLO 7MM X 80CM DF8007SC
|
Facility
|
IP
|
$12,492.00
|
|
| Hospital Charge Code |
2969346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,365.92 |
| Max. Negotiated Rate |
$11,952.35 |
| Rate for Payer: Aetna Commercial |
$11,692.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,172.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,885.59
|
| Rate for Payer: Cash Price |
$3,747.60
|
| Rate for Payer: Cigna Commercial |
$11,952.35
|
| Rate for Payer: Health EOS Commercial |
$11,562.60
|
| Rate for Payer: HFN Commercial |
$11,952.35
|
| Rate for Payer: Multiplan Commercial |
$10,393.34
|
| Rate for Payer: Preferred Network Access Commercial |
$11,952.35
|
| Rate for Payer: Quartz Beloit One Network |
$6,365.92
|
| Rate for Payer: Quartz Commercial |
$7,795.01
|
| Rate for Payer: WEA Trust Commercial |
$7,145.42
|
| Rate for Payer: WPS Commercial |
$9,622.59
|
|
