|
GRAFT DISTAFLO 7MM X 80CM DF8007SC
|
Facility
|
OP
|
$12,492.00
|
|
| Hospital Charge Code |
2969346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,637.67 |
| 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: Aetna Managed Medicare |
$3,637.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,444.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,495.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,236.01
|
| 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: Dean Health DHI/DHP/ASO |
$7,270.34
|
| Rate for Payer: Health EOS Commercial |
$11,562.60
|
| Rate for Payer: HFN Commercial |
$11,952.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,743.76
|
| Rate for Payer: Multiplan Commercial |
$10,393.34
|
| Rate for Payer: NAPHCARE Commercial |
$7,795.01
|
| 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 |
$8,444.59
|
| Rate for Payer: Quartz Medicare Advantage |
$7,795.01
|
| Rate for Payer: The Alliance Commercial |
$6,495.84
|
| Rate for Payer: WEA Trust Commercial |
$7,145.42
|
| Rate for Payer: WPS Commercial |
$9,622.59
|
|
|
GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)
|
Facility
|
OP
|
$24,919.86
|
|
|
Service Code
|
CPT 21235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,409.60 |
| Max. Negotiated Rate |
$24,919.86 |
| Rate for Payer: Aetna Managed Medicare |
$6,229.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,727.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,350.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,781.68
|
| Rate for Payer: Anthem Medicare Advantage |
$6,229.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,229.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,229.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,229.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,105.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,229.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,175.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,229.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,229.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,229.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,229.96
|
| Rate for Payer: NAPHCARE Commercial |
$9,344.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,229.96
|
| Rate for Payer: The Alliance Commercial |
$24,919.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,229.96
|
| Rate for Payer: United Healthcare PPO |
$4,409.60
|
| Rate for Payer: Wellcare Medicare |
$6,229.96
|
|
|
GRAFT HEPARIN STD WALL 6MM X 10CM H060010A
|
Facility
|
OP
|
$3,952.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,150.82 |
| Max. Negotiated Rate |
$3,781.27 |
| Rate for Payer: Aetna Commercial |
$3,699.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,534.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,150.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,671.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,055.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,972.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,178.34
|
| Rate for Payer: Cash Price |
$1,185.60
|
| Rate for Payer: Cigna Commercial |
$3,781.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,300.06
|
| Rate for Payer: Health EOS Commercial |
$3,657.97
|
| Rate for Payer: HFN Commercial |
$3,781.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,082.56
|
| Rate for Payer: Multiplan Commercial |
$3,288.06
|
| Rate for Payer: NAPHCARE Commercial |
$2,466.05
|
| Rate for Payer: Preferred Network Access Commercial |
$3,781.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,013.94
|
| Rate for Payer: Quartz Commercial |
$2,671.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,466.05
|
| Rate for Payer: The Alliance Commercial |
$2,055.04
|
| Rate for Payer: WEA Trust Commercial |
$2,260.54
|
| Rate for Payer: WPS Commercial |
$3,044.23
|
|
|
GRAFT HEPARIN STD WALL 6MM X 10CM H060010A
|
Facility
|
IP
|
$3,952.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,013.94 |
| Max. Negotiated Rate |
$3,781.27 |
| Rate for Payer: Aetna Commercial |
$3,699.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,534.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,178.34
|
| Rate for Payer: Cash Price |
$1,185.60
|
| Rate for Payer: Cigna Commercial |
$3,781.27
|
| Rate for Payer: Health EOS Commercial |
$3,657.97
|
| Rate for Payer: HFN Commercial |
$3,781.27
|
| Rate for Payer: Multiplan Commercial |
$3,288.06
|
| Rate for Payer: Preferred Network Access Commercial |
$3,781.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,013.94
|
| Rate for Payer: Quartz Commercial |
$2,466.05
|
| Rate for Payer: WEA Trust Commercial |
$2,260.54
|
| Rate for Payer: WPS Commercial |
$3,044.23
|
|
|
GRAFT HEPARIN TAPER 4-7MM X 45CM H470045A
|
Facility
|
IP
|
$7,708.00
|
|
| Hospital Charge Code |
3525505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,928.00 |
| Max. Negotiated Rate |
$7,375.01 |
| Rate for Payer: Aetna Commercial |
$7,214.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,894.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,248.65
|
| Rate for Payer: Cash Price |
$2,312.40
|
| Rate for Payer: Cigna Commercial |
$7,375.01
|
| Rate for Payer: Health EOS Commercial |
$7,134.52
|
| Rate for Payer: HFN Commercial |
$7,375.01
|
| Rate for Payer: Multiplan Commercial |
$6,413.06
|
| Rate for Payer: Preferred Network Access Commercial |
$7,375.01
|
| Rate for Payer: Quartz Beloit One Network |
$3,928.00
|
| Rate for Payer: Quartz Commercial |
$4,809.79
|
| Rate for Payer: WEA Trust Commercial |
$4,408.98
|
| Rate for Payer: WPS Commercial |
$5,937.47
|
|
|
GRAFT HEPARIN TAPER 4-7MM X 45CM H470045A
|
Facility
|
OP
|
$7,708.00
|
|
| Hospital Charge Code |
3525505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,244.57 |
| Max. Negotiated Rate |
$7,375.01 |
| Rate for Payer: Aetna Commercial |
$7,214.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,894.04
|
| Rate for Payer: Aetna Managed Medicare |
$2,244.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,210.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,008.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,847.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,248.65
|
| Rate for Payer: Cash Price |
$2,312.40
|
| Rate for Payer: Cigna Commercial |
$7,375.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,486.06
|
| Rate for Payer: Health EOS Commercial |
$7,134.52
|
| Rate for Payer: HFN Commercial |
$7,375.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,012.24
|
| Rate for Payer: Multiplan Commercial |
$6,413.06
|
| Rate for Payer: NAPHCARE Commercial |
$4,809.79
|
| Rate for Payer: Preferred Network Access Commercial |
$7,375.01
|
| Rate for Payer: Quartz Beloit One Network |
$3,928.00
|
| Rate for Payer: Quartz Commercial |
$5,210.61
|
| Rate for Payer: Quartz Medicare Advantage |
$4,809.79
|
| Rate for Payer: The Alliance Commercial |
$4,008.16
|
| Rate for Payer: WEA Trust Commercial |
$4,408.98
|
| Rate for Payer: WPS Commercial |
$5,937.47
|
|
|
GRAFT HEPARIN THIN WALL 8MM X 50CM 40CM RINGS HT084050A
|
Facility
|
IP
|
$11,085.00
|
|
| Hospital Charge Code |
3553530
|
|
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 HEPARIN THIN WALL 8MM X 50CM 40CM RINGS HT084050A
|
Facility
|
OP
|
$11,085.00
|
|
| Hospital Charge Code |
3553530
|
|
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 HYBRID 6MM X 50CM 0650HYB0605A
|
Facility
|
IP
|
$15,313.00
|
|
| Hospital Charge Code |
3495528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,803.50 |
| Max. Negotiated Rate |
$14,651.48 |
| Rate for Payer: Aetna Commercial |
$14,332.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,695.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,440.53
|
| Rate for Payer: Cash Price |
$4,593.90
|
| Rate for Payer: Cigna Commercial |
$14,651.48
|
| Rate for Payer: Health EOS Commercial |
$14,173.71
|
| Rate for Payer: HFN Commercial |
$14,651.48
|
| Rate for Payer: Multiplan Commercial |
$12,740.42
|
| Rate for Payer: Preferred Network Access Commercial |
$14,651.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,803.50
|
| Rate for Payer: Quartz Commercial |
$9,555.31
|
| Rate for Payer: WEA Trust Commercial |
$8,759.04
|
| Rate for Payer: WPS Commercial |
$11,795.60
|
|
|
GRAFT HYBRID 6MM X 50CM 0650HYB0605A
|
Facility
|
OP
|
$15,313.00
|
|
| Hospital Charge Code |
3495528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,459.15 |
| Max. Negotiated Rate |
$14,651.48 |
| Rate for Payer: Aetna Commercial |
$14,332.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,695.95
|
| Rate for Payer: Aetna Managed Medicare |
$4,459.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,351.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,962.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,644.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,440.53
|
| Rate for Payer: Cash Price |
$4,593.90
|
| Rate for Payer: Cigna Commercial |
$14,651.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,912.17
|
| Rate for Payer: Health EOS Commercial |
$14,173.71
|
| Rate for Payer: HFN Commercial |
$14,651.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,944.14
|
| Rate for Payer: Multiplan Commercial |
$12,740.42
|
| Rate for Payer: NAPHCARE Commercial |
$9,555.31
|
| Rate for Payer: Preferred Network Access Commercial |
$14,651.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,803.50
|
| Rate for Payer: Quartz Commercial |
$10,351.59
|
| Rate for Payer: Quartz Medicare Advantage |
$9,555.31
|
| Rate for Payer: The Alliance Commercial |
$7,962.76
|
| Rate for Payer: WEA Trust Commercial |
$8,759.04
|
| Rate for Payer: WPS Commercial |
$11,795.60
|
|
|
GRAFT HYBRID 9MM X 50CM 0650HYB0905A
|
Facility
|
IP
|
$15,313.00
|
|
| Hospital Charge Code |
3525504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,803.50 |
| Max. Negotiated Rate |
$14,651.48 |
| Rate for Payer: Aetna Commercial |
$14,332.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,695.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,440.53
|
| Rate for Payer: Cash Price |
$4,593.90
|
| Rate for Payer: Cigna Commercial |
$14,651.48
|
| Rate for Payer: Health EOS Commercial |
$14,173.71
|
| Rate for Payer: HFN Commercial |
$14,651.48
|
| Rate for Payer: Multiplan Commercial |
$12,740.42
|
| Rate for Payer: Preferred Network Access Commercial |
$14,651.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,803.50
|
| Rate for Payer: Quartz Commercial |
$9,555.31
|
| Rate for Payer: WEA Trust Commercial |
$8,759.04
|
| Rate for Payer: WPS Commercial |
$11,795.60
|
|
|
GRAFT HYBRID 9MM X 50CM 0650HYB0905A
|
Facility
|
OP
|
$15,313.00
|
|
| Hospital Charge Code |
3525504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,459.15 |
| Max. Negotiated Rate |
$14,651.48 |
| Rate for Payer: Aetna Commercial |
$14,332.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,695.95
|
| Rate for Payer: Aetna Managed Medicare |
$4,459.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,351.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,962.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,644.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,440.53
|
| Rate for Payer: Cash Price |
$4,593.90
|
| Rate for Payer: Cigna Commercial |
$14,651.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,912.17
|
| Rate for Payer: Health EOS Commercial |
$14,173.71
|
| Rate for Payer: HFN Commercial |
$14,651.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,944.14
|
| Rate for Payer: Multiplan Commercial |
$12,740.42
|
| Rate for Payer: NAPHCARE Commercial |
$9,555.31
|
| Rate for Payer: Preferred Network Access Commercial |
$14,651.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,803.50
|
| Rate for Payer: Quartz Commercial |
$10,351.59
|
| Rate for Payer: Quartz Medicare Advantage |
$9,555.31
|
| Rate for Payer: The Alliance Commercial |
$7,962.76
|
| Rate for Payer: WEA Trust Commercial |
$8,759.04
|
| Rate for Payer: WPS Commercial |
$11,795.60
|
|
|
GRAFT JACKET MAX FORCE 5 X 5CM 86MX-5X05
|
Facility
|
OP
|
$18,946.00
|
|
| Hospital Charge Code |
2967397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,517.08 |
| Max. Negotiated Rate |
$18,127.53 |
| Rate for Payer: Aetna Commercial |
$17,733.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,945.30
|
| Rate for Payer: Aetna Managed Medicare |
$5,517.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,807.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,851.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,457.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,443.04
|
| Rate for Payer: Cash Price |
$5,683.80
|
| Rate for Payer: Cigna Commercial |
$18,127.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,026.57
|
| Rate for Payer: Health EOS Commercial |
$17,536.42
|
| Rate for Payer: HFN Commercial |
$18,127.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,777.88
|
| Rate for Payer: Multiplan Commercial |
$15,763.07
|
| Rate for Payer: NAPHCARE Commercial |
$11,822.30
|
| Rate for Payer: Preferred Network Access Commercial |
$18,127.53
|
| Rate for Payer: Quartz Beloit One Network |
$9,654.88
|
| Rate for Payer: Quartz Commercial |
$12,807.50
|
| Rate for Payer: Quartz Medicare Advantage |
$11,822.30
|
| Rate for Payer: The Alliance Commercial |
$9,851.92
|
| Rate for Payer: WEA Trust Commercial |
$10,837.11
|
| Rate for Payer: WPS Commercial |
$14,594.10
|
|
|
GRAFT JACKET MAX FORCE 5 X 5CM 86MX-5X05
|
Facility
|
IP
|
$18,946.00
|
|
| Hospital Charge Code |
2967397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,654.88 |
| Max. Negotiated Rate |
$18,127.53 |
| Rate for Payer: Aetna Commercial |
$17,733.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,945.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,443.04
|
| Rate for Payer: Cash Price |
$5,683.80
|
| Rate for Payer: Cigna Commercial |
$18,127.53
|
| Rate for Payer: Health EOS Commercial |
$17,536.42
|
| Rate for Payer: HFN Commercial |
$18,127.53
|
| Rate for Payer: Multiplan Commercial |
$15,763.07
|
| Rate for Payer: Preferred Network Access Commercial |
$18,127.53
|
| Rate for Payer: Quartz Beloit One Network |
$9,654.88
|
| Rate for Payer: Quartz Commercial |
$11,822.30
|
| Rate for Payer: WEA Trust Commercial |
$10,837.11
|
| Rate for Payer: WPS Commercial |
$14,594.10
|
|
|
GRAFT KNIFE 10MM 232110
|
Facility
|
OP
|
$1,772.00
|
|
| Hospital Charge Code |
2965024
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$516.01 |
| Max. Negotiated Rate |
$1,695.45 |
| Rate for Payer: Aetna Commercial |
$1,658.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,584.88
|
| Rate for Payer: Aetna Managed Medicare |
$516.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,197.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$921.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$884.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$976.73
|
| Rate for Payer: Cash Price |
$531.60
|
| Rate for Payer: Cigna Commercial |
$1,695.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,031.30
|
| Rate for Payer: Health EOS Commercial |
$1,640.16
|
| Rate for Payer: HFN Commercial |
$1,695.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,382.16
|
| Rate for Payer: Multiplan Commercial |
$1,474.30
|
| Rate for Payer: NAPHCARE Commercial |
$1,105.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,695.45
|
| Rate for Payer: Quartz Beloit One Network |
$903.01
|
| Rate for Payer: Quartz Commercial |
$1,197.87
|
| Rate for Payer: Quartz Medicare Advantage |
$1,105.73
|
| Rate for Payer: The Alliance Commercial |
$921.44
|
| Rate for Payer: WEA Trust Commercial |
$1,013.58
|
| Rate for Payer: WPS Commercial |
$1,364.97
|
|
|
GRAFT KNIFE 10MM 232110
|
Facility
|
IP
|
$1,772.00
|
|
| Hospital Charge Code |
2965024
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$903.01 |
| Max. Negotiated Rate |
$1,695.45 |
| Rate for Payer: Aetna Commercial |
$1,658.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,584.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$976.73
|
| Rate for Payer: Cash Price |
$531.60
|
| Rate for Payer: Cigna Commercial |
$1,695.45
|
| Rate for Payer: Health EOS Commercial |
$1,640.16
|
| Rate for Payer: HFN Commercial |
$1,695.45
|
| Rate for Payer: Multiplan Commercial |
$1,474.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,695.45
|
| Rate for Payer: Quartz Beloit One Network |
$903.01
|
| Rate for Payer: Quartz Commercial |
$1,105.73
|
| Rate for Payer: WEA Trust Commercial |
$1,013.58
|
| Rate for Payer: WPS Commercial |
$1,364.97
|
|
|
GRAFT KNIFE 11MM 232111
|
Facility
|
OP
|
$1,706.00
|
|
| Hospital Charge Code |
2965025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$496.79 |
| Max. Negotiated Rate |
$1,632.30 |
| Rate for Payer: Aetna Commercial |
$1,596.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,525.85
|
| Rate for Payer: Aetna Managed Medicare |
$496.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,153.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$887.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$851.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$940.35
|
| Rate for Payer: Cash Price |
$511.80
|
| Rate for Payer: Cigna Commercial |
$1,632.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$992.89
|
| Rate for Payer: Health EOS Commercial |
$1,579.07
|
| Rate for Payer: HFN Commercial |
$1,632.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,330.68
|
| Rate for Payer: Multiplan Commercial |
$1,419.39
|
| Rate for Payer: NAPHCARE Commercial |
$1,064.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,632.30
|
| Rate for Payer: Quartz Beloit One Network |
$869.38
|
| Rate for Payer: Quartz Commercial |
$1,153.26
|
| Rate for Payer: Quartz Medicare Advantage |
$1,064.54
|
| Rate for Payer: The Alliance Commercial |
$887.12
|
| Rate for Payer: WEA Trust Commercial |
$975.83
|
| Rate for Payer: WPS Commercial |
$1,314.13
|
|
|
GRAFT KNIFE 11MM 232111
|
Facility
|
IP
|
$1,706.00
|
|
| Hospital Charge Code |
2965025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$869.38 |
| Max. Negotiated Rate |
$1,632.30 |
| Rate for Payer: Aetna Commercial |
$1,596.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,525.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$940.35
|
| Rate for Payer: Cash Price |
$511.80
|
| Rate for Payer: Cigna Commercial |
$1,632.30
|
| Rate for Payer: Health EOS Commercial |
$1,579.07
|
| Rate for Payer: HFN Commercial |
$1,632.30
|
| Rate for Payer: Multiplan Commercial |
$1,419.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,632.30
|
| Rate for Payer: Quartz Beloit One Network |
$869.38
|
| Rate for Payer: Quartz Commercial |
$1,064.54
|
| Rate for Payer: WEA Trust Commercial |
$975.83
|
| Rate for Payer: WPS Commercial |
$1,314.13
|
|
|
GRAFT KNIFE 9MM 232109
|
Facility
|
IP
|
$1,706.00
|
|
| Hospital Charge Code |
2965026
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$869.38 |
| Max. Negotiated Rate |
$1,632.30 |
| Rate for Payer: Aetna Commercial |
$1,596.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,525.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$940.35
|
| Rate for Payer: Cash Price |
$511.80
|
| Rate for Payer: Cigna Commercial |
$1,632.30
|
| Rate for Payer: Health EOS Commercial |
$1,579.07
|
| Rate for Payer: HFN Commercial |
$1,632.30
|
| Rate for Payer: Multiplan Commercial |
$1,419.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,632.30
|
| Rate for Payer: Quartz Beloit One Network |
$869.38
|
| Rate for Payer: Quartz Commercial |
$1,064.54
|
| Rate for Payer: WEA Trust Commercial |
$975.83
|
| Rate for Payer: WPS Commercial |
$1,314.13
|
|
|
GRAFT KNIFE 9MM 232109
|
Facility
|
OP
|
$1,706.00
|
|
| Hospital Charge Code |
2965026
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$496.79 |
| Max. Negotiated Rate |
$1,632.30 |
| Rate for Payer: Aetna Commercial |
$1,596.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,525.85
|
| Rate for Payer: Aetna Managed Medicare |
$496.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,153.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$887.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$851.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$940.35
|
| Rate for Payer: Cash Price |
$511.80
|
| Rate for Payer: Cigna Commercial |
$1,632.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$992.89
|
| Rate for Payer: Health EOS Commercial |
$1,579.07
|
| Rate for Payer: HFN Commercial |
$1,632.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,330.68
|
| Rate for Payer: Multiplan Commercial |
$1,419.39
|
| Rate for Payer: NAPHCARE Commercial |
$1,064.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,632.30
|
| Rate for Payer: Quartz Beloit One Network |
$869.38
|
| Rate for Payer: Quartz Commercial |
$1,153.26
|
| Rate for Payer: Quartz Medicare Advantage |
$1,064.54
|
| Rate for Payer: The Alliance Commercial |
$887.12
|
| Rate for Payer: WEA Trust Commercial |
$975.83
|
| Rate for Payer: WPS Commercial |
$1,314.13
|
|
|
Graftmaster 3.0mm x 12mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162996
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,672.01 |
| Max. Negotiated Rate |
$15,350.90 |
| Rate for Payer: Aetna Commercial |
$15,017.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,349.75
|
| Rate for Payer: Aetna Managed Medicare |
$4,672.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,845.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,342.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,009.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,843.45
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$15,350.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,337.61
|
| Rate for Payer: Health EOS Commercial |
$14,850.33
|
| Rate for Payer: HFN Commercial |
$15,350.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,514.32
|
| Rate for Payer: Multiplan Commercial |
$13,348.61
|
| Rate for Payer: NAPHCARE Commercial |
$10,011.46
|
| Rate for Payer: Preferred Network Access Commercial |
$15,350.90
|
| Rate for Payer: Quartz Beloit One Network |
$8,176.02
|
| Rate for Payer: Quartz Commercial |
$10,845.74
|
| Rate for Payer: Quartz Medicare Advantage |
$10,011.46
|
| Rate for Payer: The Alliance Commercial |
$8,342.88
|
| Rate for Payer: WEA Trust Commercial |
$9,177.17
|
| Rate for Payer: WPS Commercial |
$12,358.69
|
|
|
Graftmaster 3.0mm x 12mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162996
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,341.73 |
| Max. Negotiated Rate |
$15,851.47 |
| Rate for Payer: Aetna Commercial |
$15,851.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,349.75
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$15,851.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,342.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,011.46
|
| Rate for Payer: Health EOS Commercial |
$15,184.04
|
| Rate for Payer: HFN Commercial |
$15,851.47
|
| Rate for Payer: Multiplan Commercial |
$13,348.61
|
| Rate for Payer: Preferred Network Access Commercial |
$15,851.47
|
| Rate for Payer: Quartz Beloit One Network |
$7,341.73
|
| Rate for Payer: Quartz Commercial |
$9,510.88
|
| Rate for Payer: The Alliance Commercial |
$8,342.88
|
| Rate for Payer: WEA Trust Commercial |
$9,177.17
|
| Rate for Payer: WPS Commercial |
$12,358.69
|
|
|
Graftmaster 3.0mm x 12mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162996
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,176.02 |
| Max. Negotiated Rate |
$15,350.90 |
| Rate for Payer: Aetna Commercial |
$15,017.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,349.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,843.45
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$15,350.90
|
| Rate for Payer: Health EOS Commercial |
$14,850.33
|
| Rate for Payer: HFN Commercial |
$15,350.90
|
| Rate for Payer: Multiplan Commercial |
$13,348.61
|
| Rate for Payer: Preferred Network Access Commercial |
$15,350.90
|
| Rate for Payer: Quartz Beloit One Network |
$8,176.02
|
| Rate for Payer: Quartz Commercial |
$10,011.46
|
| Rate for Payer: WEA Trust Commercial |
$9,177.17
|
| Rate for Payer: WPS Commercial |
$12,358.69
|
|
|
Graftmaster 3.0mm x 16mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162998
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,176.02 |
| Max. Negotiated Rate |
$15,350.90 |
| Rate for Payer: Aetna Commercial |
$15,017.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,349.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,843.45
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$15,350.90
|
| Rate for Payer: Health EOS Commercial |
$14,850.33
|
| Rate for Payer: HFN Commercial |
$15,350.90
|
| Rate for Payer: Multiplan Commercial |
$13,348.61
|
| Rate for Payer: Preferred Network Access Commercial |
$15,350.90
|
| Rate for Payer: Quartz Beloit One Network |
$8,176.02
|
| Rate for Payer: Quartz Commercial |
$10,011.46
|
| Rate for Payer: WEA Trust Commercial |
$9,177.17
|
| Rate for Payer: WPS Commercial |
$12,358.69
|
|
|
Graftmaster 3.0mm x 16mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162998
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,341.73 |
| Max. Negotiated Rate |
$15,851.47 |
| Rate for Payer: Aetna Commercial |
$15,851.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,349.75
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$15,851.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,342.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,011.46
|
| Rate for Payer: Health EOS Commercial |
$15,184.04
|
| Rate for Payer: HFN Commercial |
$15,851.47
|
| Rate for Payer: Multiplan Commercial |
$13,348.61
|
| Rate for Payer: Preferred Network Access Commercial |
$15,851.47
|
| Rate for Payer: Quartz Beloit One Network |
$7,341.73
|
| Rate for Payer: Quartz Commercial |
$9,510.88
|
| Rate for Payer: The Alliance Commercial |
$8,342.88
|
| Rate for Payer: WEA Trust Commercial |
$9,177.17
|
| Rate for Payer: WPS Commercial |
$12,358.69
|
|
