|
GOWN MICROCOOL XL
|
Facility
|
OP
|
$156.00
|
|
| Hospital Charge Code |
2963185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Aetna Managed Medicare |
$43.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$101.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$74.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.30
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.00
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.60
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$101.40
|
| Rate for Payer: Quartz Medicare Advantage |
$93.60
|
| Rate for Payer: The Alliance Commercial |
$624.00
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
GOWN MICROCOOL XL
|
Facility
|
IP
|
$156.00
|
|
| Hospital Charge Code |
2963185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.44 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.60
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
GOWN POLY XLRG REINFORCED 95221
|
Facility
|
IP
|
$123.00
|
|
| Hospital Charge Code |
2963221
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$60.27 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$73.80
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
GOWN POLY XLRG REINFORCED 95221
|
Facility
|
OP
|
$123.00
|
|
| Hospital Charge Code |
2963221
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.44 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Aetna Managed Medicare |
$34.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.83
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.25
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$79.95
|
| Rate for Payer: Quartz Medicare Advantage |
$73.80
|
| Rate for Payer: The Alliance Commercial |
$492.00
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
GOWN SURGICAL ULTRA XL 95121
|
Facility
|
OP
|
$98.00
|
|
| Hospital Charge Code |
2963301
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Aetna Managed Medicare |
$27.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.84
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.50
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$63.70
|
| Rate for Payer: Quartz Medicare Advantage |
$58.80
|
| Rate for Payer: The Alliance Commercial |
$392.00
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
GOWN SURGICAL ULTRA XL 95121
|
Facility
|
IP
|
$98.00
|
|
| Hospital Charge Code |
2963301
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.02 |
| Max. Negotiated Rate |
$90.16 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$58.80
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
G PROBE 15980
|
Facility
|
IP
|
$2,286.00
|
|
| Hospital Charge Code |
6202984
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,120.14 |
| Max. Negotiated Rate |
$2,103.12 |
| Rate for Payer: Aetna Commercial |
$2,057.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,965.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,211.58
|
| Rate for Payer: Cash Price |
$685.80
|
| Rate for Payer: Cigna Commercial |
$2,103.12
|
| Rate for Payer: Health EOS Commercial |
$2,034.54
|
| Rate for Payer: HFN Commercial |
$2,103.12
|
| Rate for Payer: Multiplan Commercial |
$1,828.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,371.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,103.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.14
|
| Rate for Payer: Quartz Commercial |
$1,371.60
|
| Rate for Payer: WEA Trust Commercial |
$1,257.30
|
| Rate for Payer: WPS Commercial |
$1,693.24
|
|
|
G PROBE 15980
|
Facility
|
OP
|
$2,286.00
|
|
| Hospital Charge Code |
6202984
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$640.08 |
| Max. Negotiated Rate |
$9,144.00 |
| Rate for Payer: Aetna Commercial |
$2,057.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,965.96
|
| Rate for Payer: Aetna Managed Medicare |
$640.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,485.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,143.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,097.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,211.58
|
| Rate for Payer: Cash Price |
$685.80
|
| Rate for Payer: Cigna Commercial |
$2,103.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,279.25
|
| Rate for Payer: Health EOS Commercial |
$2,034.54
|
| Rate for Payer: HFN Commercial |
$2,103.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,714.50
|
| Rate for Payer: Multiplan Commercial |
$1,828.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,371.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,103.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.14
|
| Rate for Payer: Quartz Commercial |
$1,485.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,371.60
|
| Rate for Payer: The Alliance Commercial |
$9,144.00
|
| Rate for Payer: WEA Trust Commercial |
$1,257.30
|
| Rate for Payer: WPS Commercial |
$1,693.24
|
|
|
GPS IMPLANT KIT V2 A10012
|
Facility
|
IP
|
$3,921.51
|
|
| Hospital Charge Code |
6240173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,921.54 |
| Max. Negotiated Rate |
$3,607.79 |
| Rate for Payer: Aetna Commercial |
$3,529.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,372.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,078.40
|
| Rate for Payer: Cash Price |
$1,176.45
|
| Rate for Payer: Cigna Commercial |
$3,607.79
|
| Rate for Payer: Health EOS Commercial |
$3,490.14
|
| Rate for Payer: HFN Commercial |
$3,607.79
|
| Rate for Payer: Multiplan Commercial |
$3,137.21
|
| Rate for Payer: NAPHCARE Commercial |
$2,352.91
|
| Rate for Payer: Preferred Network Access Commercial |
$3,607.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,921.54
|
| Rate for Payer: Quartz Commercial |
$2,352.91
|
| Rate for Payer: WEA Trust Commercial |
$2,156.83
|
| Rate for Payer: WPS Commercial |
$2,904.66
|
|
|
GPS IMPLANT KIT V2 A10012
|
Facility
|
OP
|
$3,921.51
|
|
| Hospital Charge Code |
6240173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,098.02 |
| Max. Negotiated Rate |
$15,686.04 |
| Rate for Payer: Aetna Commercial |
$3,529.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,372.50
|
| Rate for Payer: Aetna Managed Medicare |
$1,098.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,548.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,960.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,882.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,078.40
|
| Rate for Payer: Cash Price |
$1,176.45
|
| Rate for Payer: Cigna Commercial |
$3,607.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,194.48
|
| Rate for Payer: Health EOS Commercial |
$3,490.14
|
| Rate for Payer: HFN Commercial |
$3,607.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,941.13
|
| Rate for Payer: Multiplan Commercial |
$3,137.21
|
| Rate for Payer: NAPHCARE Commercial |
$2,352.91
|
| Rate for Payer: Preferred Network Access Commercial |
$3,607.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,921.54
|
| Rate for Payer: Quartz Commercial |
$2,548.98
|
| Rate for Payer: Quartz Medicare Advantage |
$2,352.91
|
| Rate for Payer: The Alliance Commercial |
$15,686.04
|
| Rate for Payer: WEA Trust Commercial |
$2,156.83
|
| Rate for Payer: WPS Commercial |
$2,904.66
|
|
|
Grafix Core per sq cm Q4132
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS Q4132
|
| Hospital Charge Code |
4506681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.16 |
| Max. Negotiated Rate |
$688.00 |
| Rate for Payer: Aetna Commercial |
$154.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Aetna Managed Medicare |
$48.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$86.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.16
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$158.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.11
|
| Rate for Payer: Health EOS Commercial |
$153.08
|
| Rate for Payer: HFN Commercial |
$158.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.00
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: NAPHCARE Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$158.24
|
| Rate for Payer: Quartz Beloit One Network |
$84.28
|
| Rate for Payer: Quartz Commercial |
$111.80
|
| Rate for Payer: Quartz Medicare Advantage |
$103.20
|
| Rate for Payer: The Alliance Commercial |
$688.00
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$276.10
|
|
|
Grafix Core per sq cm Q4132
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
HCPCS Q4132
|
| Hospital Charge Code |
4506681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.28 |
| Max. Negotiated Rate |
$158.24 |
| Rate for Payer: Aetna Commercial |
$154.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.16
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$158.24
|
| Rate for Payer: Health EOS Commercial |
$153.08
|
| Rate for Payer: HFN Commercial |
$158.24
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: NAPHCARE Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$158.24
|
| Rate for Payer: Quartz Beloit One Network |
$84.28
|
| Rate for Payer: Quartz Commercial |
$103.20
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$127.40
|
|
|
Grafix Core per sq cm Q4132
|
Professional
|
Both
|
$172.00
|
|
|
Service Code
|
HCPCS Q4132
|
| Hospital Charge Code |
4506681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.68 |
| Max. Negotiated Rate |
$411.56 |
| Rate for Payer: Aetna Commercial |
$163.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$163.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$170.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.44
|
| Rate for Payer: Health EOS Commercial |
$156.52
|
| Rate for Payer: HFN Commercial |
$163.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$411.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$411.56
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: Preferred Network Access Commercial |
$163.40
|
| Rate for Payer: Quartz Beloit One Network |
$75.68
|
| Rate for Payer: Quartz Commercial |
$98.04
|
| Rate for Payer: The Alliance Commercial |
$86.00
|
| Rate for Payer: United Healthcare Medicaid |
$170.56
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$276.10
|
|
|
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 |
$301.35 |
| Max. Negotiated Rate |
$565.80 |
| Rate for Payer: Aetna Commercial |
$553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.95
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$565.80
|
| Rate for Payer: Health EOS Commercial |
$547.35
|
| Rate for Payer: HFN Commercial |
$565.80
|
| Rate for Payer: Multiplan Commercial |
$492.00
|
| Rate for Payer: NAPHCARE Commercial |
$369.00
|
| Rate for Payer: Preferred Network Access Commercial |
$565.80
|
| Rate for Payer: Quartz Beloit One Network |
$301.35
|
| Rate for Payer: Quartz Commercial |
$369.00
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: WPS Commercial |
$455.53
|
|
|
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 |
$172.20 |
| Max. Negotiated Rate |
$2,460.00 |
| Rate for Payer: Aetna Commercial |
$553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.90
|
| Rate for Payer: Aetna Managed Medicare |
$172.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$399.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$295.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.95
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$565.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.49
|
| Rate for Payer: Health EOS Commercial |
$547.35
|
| Rate for Payer: HFN Commercial |
$565.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$461.25
|
| Rate for Payer: Multiplan Commercial |
$492.00
|
| Rate for Payer: NAPHCARE Commercial |
$369.00
|
| Rate for Payer: Preferred Network Access Commercial |
$565.80
|
| Rate for Payer: Quartz Beloit One Network |
$301.35
|
| Rate for Payer: Quartz Commercial |
$399.75
|
| Rate for Payer: Quartz Medicare Advantage |
$369.00
|
| Rate for Payer: The Alliance Commercial |
$2,460.00
|
| Rate for Payer: WEA Trust Commercial |
$338.25
|
| Rate for Payer: WPS Commercial |
$358.06
|
|
|
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 |
$143.23 |
| Max. Negotiated Rate |
$613.70 |
| Rate for Payer: Aetna Commercial |
$613.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.56
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$613.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$170.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.23
|
| Rate for Payer: Health EOS Commercial |
$587.86
|
| Rate for Payer: HFN Commercial |
$613.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$474.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$474.33
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: Preferred Network Access Commercial |
$613.70
|
| Rate for Payer: Quartz Beloit One Network |
$284.24
|
| Rate for Payer: Quartz Commercial |
$368.22
|
| Rate for Payer: The Alliance Commercial |
$323.00
|
| Rate for Payer: United Healthcare Medicaid |
$170.56
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$358.06
|
|
|
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 |
$180.88 |
| Max. Negotiated Rate |
$2,584.00 |
| Rate for Payer: Aetna Commercial |
$581.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.56
|
| Rate for Payer: Aetna Managed Medicare |
$180.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$419.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$323.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$310.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.38
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$594.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.49
|
| Rate for Payer: Health EOS Commercial |
$574.94
|
| Rate for Payer: HFN Commercial |
$594.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$484.50
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: NAPHCARE Commercial |
$387.60
|
| Rate for Payer: Preferred Network Access Commercial |
$594.32
|
| Rate for Payer: Quartz Beloit One Network |
$316.54
|
| Rate for Payer: Quartz Commercial |
$419.90
|
| Rate for Payer: Quartz Medicare Advantage |
$387.60
|
| Rate for Payer: The Alliance Commercial |
$2,584.00
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$358.06
|
|
|
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 |
$316.54 |
| Max. Negotiated Rate |
$594.32 |
| Rate for Payer: Aetna Commercial |
$581.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.38
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$594.32
|
| Rate for Payer: Health EOS Commercial |
$574.94
|
| Rate for Payer: HFN Commercial |
$594.32
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: NAPHCARE Commercial |
$387.60
|
| Rate for Payer: Preferred Network Access Commercial |
$594.32
|
| Rate for Payer: Quartz Beloit One Network |
$316.54
|
| Rate for Payer: Quartz Commercial |
$387.60
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$478.49
|
|
|
GRAFT 10 X 50CM FLEX F5010
|
Facility
|
IP
|
$6,246.00
|
|
| Hospital Charge Code |
2969348
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,060.54 |
| Max. Negotiated Rate |
$5,746.32 |
| Rate for Payer: Aetna Commercial |
$5,621.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,371.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,310.38
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,746.32
|
| Rate for Payer: Health EOS Commercial |
$5,558.94
|
| Rate for Payer: HFN Commercial |
$5,746.32
|
| Rate for Payer: Multiplan Commercial |
$4,996.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,747.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,746.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,060.54
|
| Rate for Payer: Quartz Commercial |
$3,747.60
|
| Rate for Payer: WEA Trust Commercial |
$3,435.30
|
| Rate for Payer: WPS Commercial |
$4,626.41
|
|
|
GRAFT 10 X 50CM FLEX F5010
|
Facility
|
OP
|
$6,246.00
|
|
| Hospital Charge Code |
2969348
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,748.88 |
| Max. Negotiated Rate |
$24,984.00 |
| Rate for Payer: Aetna Commercial |
$5,621.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,371.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,748.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,059.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,123.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,998.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,310.38
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,746.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,495.26
|
| Rate for Payer: Health EOS Commercial |
$5,558.94
|
| Rate for Payer: HFN Commercial |
$5,746.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,684.50
|
| Rate for Payer: Multiplan Commercial |
$4,996.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,747.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,746.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,060.54
|
| Rate for Payer: Quartz Commercial |
$4,059.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,747.60
|
| Rate for Payer: The Alliance Commercial |
$24,984.00
|
| Rate for Payer: WEA Trust Commercial |
$3,435.30
|
| Rate for Payer: WPS Commercial |
$4,626.41
|
|
|
GRAFT 10 X 80CM FLEX F8010
|
Facility
|
OP
|
$6,246.00
|
|
| Hospital Charge Code |
2969352
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,748.88 |
| Max. Negotiated Rate |
$24,984.00 |
| Rate for Payer: Aetna Commercial |
$5,621.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,371.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,748.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,059.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,123.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,998.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,310.38
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,746.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,495.26
|
| Rate for Payer: Health EOS Commercial |
$5,558.94
|
| Rate for Payer: HFN Commercial |
$5,746.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,684.50
|
| Rate for Payer: Multiplan Commercial |
$4,996.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,747.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,746.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,060.54
|
| Rate for Payer: Quartz Commercial |
$4,059.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,747.60
|
| Rate for Payer: The Alliance Commercial |
$24,984.00
|
| Rate for Payer: WEA Trust Commercial |
$3,435.30
|
| Rate for Payer: WPS Commercial |
$4,626.41
|
|
|
GRAFT 10 X 80CM FLEX F8010
|
Facility
|
IP
|
$6,246.00
|
|
| Hospital Charge Code |
2969352
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,060.54 |
| Max. Negotiated Rate |
$5,746.32 |
| Rate for Payer: Aetna Commercial |
$5,621.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,371.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,310.38
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,746.32
|
| Rate for Payer: Health EOS Commercial |
$5,558.94
|
| Rate for Payer: HFN Commercial |
$5,746.32
|
| Rate for Payer: Multiplan Commercial |
$4,996.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,747.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,746.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,060.54
|
| Rate for Payer: Quartz Commercial |
$3,747.60
|
| Rate for Payer: WEA Trust Commercial |
$3,435.30
|
| Rate for Payer: WPS Commercial |
$4,626.41
|
|
|
GRAFT 12 X 6 BIFORCATED HEMAGARD KNITTED HGK1206
|
Facility
|
OP
|
$6,117.00
|
|
| Hospital Charge Code |
2965276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,712.76 |
| Max. Negotiated Rate |
$24,468.00 |
| Rate for Payer: Aetna Commercial |
$5,505.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,260.62
|
| Rate for Payer: Aetna Managed Medicare |
$1,712.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,976.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,058.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,936.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,242.01
|
| Rate for Payer: Cash Price |
$1,835.10
|
| Rate for Payer: Cigna Commercial |
$5,627.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,423.07
|
| Rate for Payer: Health EOS Commercial |
$5,444.13
|
| Rate for Payer: HFN Commercial |
$5,627.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,587.75
|
| Rate for Payer: Multiplan Commercial |
$4,893.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,670.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,627.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,997.33
|
| Rate for Payer: Quartz Commercial |
$3,976.05
|
| Rate for Payer: Quartz Medicare Advantage |
$3,670.20
|
| Rate for Payer: The Alliance Commercial |
$24,468.00
|
| Rate for Payer: WEA Trust Commercial |
$3,364.35
|
| Rate for Payer: WPS Commercial |
$4,530.86
|
|
|
GRAFT 12 X 6 BIFORCATED HEMAGARD KNITTED HGK1206
|
Facility
|
IP
|
$6,117.00
|
|
| Hospital Charge Code |
2965276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,997.33 |
| Max. Negotiated Rate |
$5,627.64 |
| Rate for Payer: Aetna Commercial |
$5,505.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,260.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,242.01
|
| Rate for Payer: Cash Price |
$1,835.10
|
| Rate for Payer: Cigna Commercial |
$5,627.64
|
| Rate for Payer: Health EOS Commercial |
$5,444.13
|
| Rate for Payer: HFN Commercial |
$5,627.64
|
| Rate for Payer: Multiplan Commercial |
$4,893.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,670.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,627.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,997.33
|
| Rate for Payer: Quartz Commercial |
$3,670.20
|
| Rate for Payer: WEA Trust Commercial |
$3,364.35
|
| Rate for Payer: WPS Commercial |
$4,530.86
|
|
|
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 |
$4,145.40 |
| Max. Negotiated Rate |
$7,783.20 |
| Rate for Payer: Aetna Commercial |
$7,614.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,275.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,483.80
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna Commercial |
$7,783.20
|
| Rate for Payer: Health EOS Commercial |
$7,529.40
|
| Rate for Payer: HFN Commercial |
$7,783.20
|
| Rate for Payer: Multiplan Commercial |
$6,768.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,076.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,783.20
|
| Rate for Payer: Quartz Beloit One Network |
$4,145.40
|
| Rate for Payer: Quartz Commercial |
$5,076.00
|
| Rate for Payer: WEA Trust Commercial |
$4,653.00
|
| Rate for Payer: WPS Commercial |
$6,266.32
|
|
