|
Graftmaster 3.0mm x 16mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162998
|
|
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 19mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163000
|
|
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 19mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163000
|
|
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 19mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163000
|
|
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 4.0mm x 16mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163002
|
|
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 4.0mm x 16mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163002
|
|
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 4.0mm x 16mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163002
|
|
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 4.0mm x 19mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163004
|
|
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 4.0mm x 19mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163004
|
|
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 4.0mm x 19mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163004
|
|
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 5.0mm x 26mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163006
|
|
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 5.0mm x 26mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163006
|
|
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 5.0mm x 26mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163006
|
|
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
|
|
|
GRAFT OPTIGRAFT HALF-MOON SPLIT THICKNESS V0129/V0137
|
Facility
|
OP
|
$3,197.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6171648
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$930.97 |
| Max. Negotiated Rate |
$3,058.89 |
| Rate for Payer: Aetna Commercial |
$2,992.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,859.40
|
| Rate for Payer: Aetna Managed Medicare |
$930.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,161.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,662.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,595.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,762.19
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$3,058.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,860.65
|
| Rate for Payer: Health EOS Commercial |
$2,959.14
|
| Rate for Payer: HFN Commercial |
$3,058.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,493.66
|
| Rate for Payer: Multiplan Commercial |
$2,659.90
|
| Rate for Payer: NAPHCARE Commercial |
$1,994.93
|
| Rate for Payer: Preferred Network Access Commercial |
$3,058.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,629.19
|
| Rate for Payer: Quartz Commercial |
$2,161.17
|
| Rate for Payer: Quartz Medicare Advantage |
$1,994.93
|
| Rate for Payer: The Alliance Commercial |
$1,662.44
|
| Rate for Payer: WEA Trust Commercial |
$1,828.68
|
| Rate for Payer: WPS Commercial |
$2,462.65
|
|
|
GRAFT OPTIGRAFT HALF-MOON SPLIT THICKNESS V0129/V0137
|
Facility
|
IP
|
$3,197.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6171648
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,629.19 |
| Max. Negotiated Rate |
$3,058.89 |
| Rate for Payer: Aetna Commercial |
$2,992.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,859.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,762.19
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$3,058.89
|
| Rate for Payer: Health EOS Commercial |
$2,959.14
|
| Rate for Payer: HFN Commercial |
$3,058.89
|
| Rate for Payer: Multiplan Commercial |
$2,659.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,058.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,629.19
|
| Rate for Payer: Quartz Commercial |
$1,994.93
|
| Rate for Payer: WEA Trust Commercial |
$1,828.68
|
| Rate for Payer: WPS Commercial |
$2,462.65
|
|
|
GRAFT PATCH VASCULAR 2X9CMX.4MM
|
Facility
|
OP
|
$2,893.00
|
|
| Hospital Charge Code |
2967379
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$842.44 |
| Max. Negotiated Rate |
$2,768.02 |
| Rate for Payer: Aetna Commercial |
$2,707.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,587.50
|
| Rate for Payer: Aetna Managed Medicare |
$842.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,955.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,504.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,444.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,594.62
|
| Rate for Payer: Cash Price |
$867.90
|
| Rate for Payer: Cigna Commercial |
$2,768.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,683.73
|
| Rate for Payer: Health EOS Commercial |
$2,677.76
|
| Rate for Payer: HFN Commercial |
$2,768.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,256.54
|
| Rate for Payer: Multiplan Commercial |
$2,406.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,805.23
|
| Rate for Payer: Preferred Network Access Commercial |
$2,768.02
|
| Rate for Payer: Quartz Beloit One Network |
$1,474.27
|
| Rate for Payer: Quartz Commercial |
$1,955.67
|
| Rate for Payer: Quartz Medicare Advantage |
$1,805.23
|
| Rate for Payer: The Alliance Commercial |
$1,504.36
|
| Rate for Payer: WEA Trust Commercial |
$1,654.80
|
| Rate for Payer: WPS Commercial |
$2,228.48
|
|
|
GRAFT PATCH VASCULAR 2X9CMX.4MM
|
Facility
|
IP
|
$2,893.00
|
|
| Hospital Charge Code |
2967379
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,474.27 |
| Max. Negotiated Rate |
$2,768.02 |
| Rate for Payer: Aetna Commercial |
$2,707.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,587.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,594.62
|
| Rate for Payer: Cash Price |
$867.90
|
| Rate for Payer: Cigna Commercial |
$2,768.02
|
| Rate for Payer: Health EOS Commercial |
$2,677.76
|
| Rate for Payer: HFN Commercial |
$2,768.02
|
| Rate for Payer: Multiplan Commercial |
$2,406.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,768.02
|
| Rate for Payer: Quartz Beloit One Network |
$1,474.27
|
| Rate for Payer: Quartz Commercial |
$1,805.23
|
| Rate for Payer: WEA Trust Commercial |
$1,654.80
|
| Rate for Payer: WPS Commercial |
$2,228.48
|
|
|
GRAFT PRIMATRIX 6X6 MESH 607-005-660
|
Facility
|
IP
|
$4,302.00
|
|
| Hospital Charge Code |
3075851
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,192.30 |
| Max. Negotiated Rate |
$4,116.15 |
| Rate for Payer: Aetna Commercial |
$4,026.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,847.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,371.26
|
| Rate for Payer: Cash Price |
$1,290.60
|
| Rate for Payer: Cigna Commercial |
$4,116.15
|
| Rate for Payer: Health EOS Commercial |
$3,981.93
|
| Rate for Payer: HFN Commercial |
$4,116.15
|
| Rate for Payer: Multiplan Commercial |
$3,579.26
|
| Rate for Payer: Preferred Network Access Commercial |
$4,116.15
|
| Rate for Payer: Quartz Beloit One Network |
$2,192.30
|
| Rate for Payer: Quartz Commercial |
$2,684.45
|
| Rate for Payer: WEA Trust Commercial |
$2,460.74
|
| Rate for Payer: WPS Commercial |
$3,313.83
|
|
|
GRAFT PRIMATRIX 6X6 MESH 607-005-660
|
Facility
|
OP
|
$4,302.00
|
|
| Hospital Charge Code |
3075851
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,252.74 |
| Max. Negotiated Rate |
$4,116.15 |
| Rate for Payer: Aetna Commercial |
$4,026.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,847.71
|
| Rate for Payer: Aetna Managed Medicare |
$1,252.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,908.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,237.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,147.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,371.26
|
| Rate for Payer: Cash Price |
$1,290.60
|
| Rate for Payer: Cigna Commercial |
$4,116.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,503.76
|
| Rate for Payer: Health EOS Commercial |
$3,981.93
|
| Rate for Payer: HFN Commercial |
$4,116.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,355.56
|
| Rate for Payer: Multiplan Commercial |
$3,579.26
|
| Rate for Payer: NAPHCARE Commercial |
$2,684.45
|
| Rate for Payer: Preferred Network Access Commercial |
$4,116.15
|
| Rate for Payer: Quartz Beloit One Network |
$2,192.30
|
| Rate for Payer: Quartz Commercial |
$2,908.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,684.45
|
| Rate for Payer: The Alliance Commercial |
$2,237.04
|
| Rate for Payer: WEA Trust Commercial |
$2,460.74
|
| Rate for Payer: WPS Commercial |
$3,313.83
|
|
|
GRAFT PROCOL 6MM X 40CM VASCULAR BIOPROSTHESIS HJL016-40-N
|
Facility
|
OP
|
$11,202.00
|
|
| Hospital Charge Code |
5414997
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,262.02 |
| Max. Negotiated Rate |
$10,718.07 |
| Rate for Payer: Aetna Commercial |
$10,485.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,019.07
|
| Rate for Payer: Aetna Managed Medicare |
$3,262.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,572.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,825.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,592.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,174.54
|
| Rate for Payer: Cash Price |
$3,360.60
|
| Rate for Payer: Cigna Commercial |
$10,718.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,519.56
|
| Rate for Payer: Health EOS Commercial |
$10,368.57
|
| Rate for Payer: HFN Commercial |
$10,718.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,737.56
|
| Rate for Payer: Multiplan Commercial |
$9,320.06
|
| Rate for Payer: NAPHCARE Commercial |
$6,990.05
|
| Rate for Payer: Preferred Network Access Commercial |
$10,718.07
|
| Rate for Payer: Quartz Beloit One Network |
$5,708.54
|
| Rate for Payer: Quartz Commercial |
$7,572.55
|
| Rate for Payer: Quartz Medicare Advantage |
$6,990.05
|
| Rate for Payer: The Alliance Commercial |
$5,825.04
|
| Rate for Payer: WEA Trust Commercial |
$6,407.54
|
| Rate for Payer: WPS Commercial |
$8,628.90
|
|
|
GRAFT PROCOL 6MM X 40CM VASCULAR BIOPROSTHESIS HJL016-40-N
|
Facility
|
IP
|
$11,202.00
|
|
| Hospital Charge Code |
5414997
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,708.54 |
| Max. Negotiated Rate |
$10,718.07 |
| Rate for Payer: Aetna Commercial |
$10,485.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,019.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,174.54
|
| Rate for Payer: Cash Price |
$3,360.60
|
| Rate for Payer: Cigna Commercial |
$10,718.07
|
| Rate for Payer: Health EOS Commercial |
$10,368.57
|
| Rate for Payer: HFN Commercial |
$10,718.07
|
| Rate for Payer: Multiplan Commercial |
$9,320.06
|
| Rate for Payer: Preferred Network Access Commercial |
$10,718.07
|
| Rate for Payer: Quartz Beloit One Network |
$5,708.54
|
| Rate for Payer: Quartz Commercial |
$6,990.05
|
| Rate for Payer: WEA Trust Commercial |
$6,407.54
|
| Rate for Payer: WPS Commercial |
$8,628.90
|
|
|
GRAFT PROPATEN HEPARIN THIN WALL 5MM X 90CM 70CM RINGS HT057090A
|
Facility
|
OP
|
$18,210.00
|
|
| Hospital Charge Code |
3553515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,302.75 |
| Max. Negotiated Rate |
$17,423.33 |
| Rate for Payer: Aetna Commercial |
$17,044.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,287.02
|
| Rate for Payer: Aetna Managed Medicare |
$5,302.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,309.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,469.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,090.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,037.35
|
| Rate for Payer: Cash Price |
$5,463.00
|
| Rate for Payer: Cigna Commercial |
$17,423.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,598.22
|
| Rate for Payer: Health EOS Commercial |
$16,855.18
|
| Rate for Payer: HFN Commercial |
$17,423.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,203.80
|
| Rate for Payer: Multiplan Commercial |
$15,150.72
|
| Rate for Payer: NAPHCARE Commercial |
$11,363.04
|
| Rate for Payer: Preferred Network Access Commercial |
$17,423.33
|
| Rate for Payer: Quartz Beloit One Network |
$9,279.82
|
| Rate for Payer: Quartz Commercial |
$12,309.96
|
| Rate for Payer: Quartz Medicare Advantage |
$11,363.04
|
| Rate for Payer: The Alliance Commercial |
$9,469.20
|
| Rate for Payer: WEA Trust Commercial |
$10,416.12
|
| Rate for Payer: WPS Commercial |
$14,027.16
|
|
|
GRAFT PROPATEN HEPARIN THIN WALL 5MM X 90CM 70CM RINGS HT057090A
|
Facility
|
IP
|
$18,210.00
|
|
| Hospital Charge Code |
3553515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,279.82 |
| Max. Negotiated Rate |
$17,423.33 |
| Rate for Payer: Aetna Commercial |
$17,044.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,287.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,037.35
|
| Rate for Payer: Cash Price |
$5,463.00
|
| Rate for Payer: Cigna Commercial |
$17,423.33
|
| Rate for Payer: Health EOS Commercial |
$16,855.18
|
| Rate for Payer: HFN Commercial |
$17,423.33
|
| Rate for Payer: Multiplan Commercial |
$15,150.72
|
| Rate for Payer: Preferred Network Access Commercial |
$17,423.33
|
| Rate for Payer: Quartz Beloit One Network |
$9,279.82
|
| Rate for Payer: Quartz Commercial |
$11,363.04
|
| Rate for Payer: WEA Trust Commercial |
$10,416.12
|
| Rate for Payer: WPS Commercial |
$14,027.16
|
|
|
GRAFT RESTORE ORTHOBIOLOGIC
|
Facility
|
IP
|
$14,929.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2965011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,607.82 |
| Max. Negotiated Rate |
$14,284.07 |
| Rate for Payer: Aetna Commercial |
$13,973.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,352.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,228.86
|
| Rate for Payer: Cash Price |
$4,478.70
|
| Rate for Payer: Cigna Commercial |
$14,284.07
|
| Rate for Payer: Health EOS Commercial |
$13,818.28
|
| Rate for Payer: HFN Commercial |
$14,284.07
|
| Rate for Payer: Multiplan Commercial |
$12,420.93
|
| Rate for Payer: Preferred Network Access Commercial |
$14,284.07
|
| Rate for Payer: Quartz Beloit One Network |
$7,607.82
|
| Rate for Payer: Quartz Commercial |
$9,315.70
|
| Rate for Payer: WEA Trust Commercial |
$8,539.39
|
| Rate for Payer: WPS Commercial |
$11,499.81
|
|
|
GRAFT RESTORE ORTHOBIOLOGIC
|
Facility
|
OP
|
$14,929.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2965011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,347.32 |
| Max. Negotiated Rate |
$14,284.07 |
| Rate for Payer: Aetna Commercial |
$13,973.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,352.50
|
| Rate for Payer: Aetna Managed Medicare |
$4,347.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,092.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,763.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,452.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,228.86
|
| Rate for Payer: Cash Price |
$4,478.70
|
| Rate for Payer: Cigna Commercial |
$14,284.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,688.68
|
| Rate for Payer: Health EOS Commercial |
$13,818.28
|
| Rate for Payer: HFN Commercial |
$14,284.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,644.62
|
| Rate for Payer: Multiplan Commercial |
$12,420.93
|
| Rate for Payer: NAPHCARE Commercial |
$9,315.70
|
| Rate for Payer: Preferred Network Access Commercial |
$14,284.07
|
| Rate for Payer: Quartz Beloit One Network |
$7,607.82
|
| Rate for Payer: Quartz Commercial |
$10,092.00
|
| Rate for Payer: Quartz Medicare Advantage |
$9,315.70
|
| Rate for Payer: The Alliance Commercial |
$7,763.08
|
| Rate for Payer: WEA Trust Commercial |
$8,539.39
|
| Rate for Payer: WPS Commercial |
$11,499.81
|
|
