|
GRAFT 14 X 7 BIFORCATED HEMAGARD KNITTED HGK1407/IGK1407
|
Facility
|
OP
|
$8,460.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3204829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,368.80 |
| Max. Negotiated Rate |
$33,840.00 |
| Rate for Payer: Aetna Commercial |
$7,614.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,275.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,368.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,499.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,230.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,060.80
|
| 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: Dean Health DHI/DHP/ASO |
$4,734.22
|
| Rate for Payer: Health EOS Commercial |
$7,529.40
|
| Rate for Payer: HFN Commercial |
$7,783.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,345.00
|
| 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 |
$5,499.00
|
| Rate for Payer: Quartz Medicare Advantage |
$5,076.00
|
| Rate for Payer: The Alliance Commercial |
$33,840.00
|
| Rate for Payer: WEA Trust Commercial |
$4,653.00
|
| Rate for Payer: WPS Commercial |
$6,266.32
|
|
|
GRAFT 16 X 8 BIFORCATED HEMAGARD KNITTED HGK1608
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2964759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,069.85 |
| Max. Negotiated Rate |
$5,763.80 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$3,759.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 16 X 8 BIFORCATED HEMAGARD KNITTED HGK1608
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2964759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,754.20 |
| Max. Negotiated Rate |
$25,060.00 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,754.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,072.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,132.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,007.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,505.89
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,698.75
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$4,072.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,759.00
|
| Rate for Payer: The Alliance Commercial |
$25,060.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 18 X 9 BIFORCATED HEMAGARD KNITTED HGK1809
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2965278
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,754.20 |
| Max. Negotiated Rate |
$25,060.00 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,754.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,072.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,132.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,007.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,505.89
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,698.75
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$4,072.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,759.00
|
| Rate for Payer: The Alliance Commercial |
$25,060.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 18 X 9 BIFORCATED HEMAGARD KNITTED HGK1809
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2965278
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,069.85 |
| Max. Negotiated Rate |
$5,763.80 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$3,759.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 20 X 10 BIFORCATED HEMAGARD KNITTED HGK2010
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2965279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,069.85 |
| Max. Negotiated Rate |
$5,763.80 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$3,759.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 20 X 10 BIFORCATED HEMAGARD KNITTED HGK2010
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2965279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,754.20 |
| Max. Negotiated Rate |
$25,060.00 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,754.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,072.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,132.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,007.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,505.89
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,698.75
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$4,072.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,759.00
|
| Rate for Payer: The Alliance Commercial |
$25,060.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 22 X 11 BIFORCATED INTERGARD WOVEN IGW2211
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2964760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,754.20 |
| Max. Negotiated Rate |
$25,060.00 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,754.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,072.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,132.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,007.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,505.89
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,698.75
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$4,072.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,759.00
|
| Rate for Payer: The Alliance Commercial |
$25,060.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 22 X 11 BIFORCATED INTERGARD WOVEN IGW2211
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2964760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,069.85 |
| Max. Negotiated Rate |
$5,763.80 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$3,759.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 24 X 12 BIFORCATED HEMASHIELD WOVEN HGK2412
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2965280
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,069.85 |
| Max. Negotiated Rate |
$5,763.80 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$3,759.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 24 X 12 BIFORCATED HEMASHIELD WOVEN HGK2412
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2965280
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,754.20 |
| Max. Negotiated Rate |
$25,060.00 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,754.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,072.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,132.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,007.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,505.89
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,698.75
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$4,072.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,759.00
|
| Rate for Payer: The Alliance Commercial |
$25,060.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 26 X 30 INTERGARD WOVEN STRAIGHT IGW0026-30
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2969492
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,069.85 |
| Max. Negotiated Rate |
$5,763.80 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$3,759.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 26 X 30 INTERGARD WOVEN STRAIGHT IGW0026-30
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2969492
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,754.20 |
| Max. Negotiated Rate |
$25,060.00 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,754.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,072.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,132.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,007.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,505.89
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,698.75
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$4,072.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,759.00
|
| Rate for Payer: The Alliance Commercial |
$25,060.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 28 X 30 INTERGARD WOVEN STRAIGHT IGW0028-30
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2965281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,754.20 |
| Max. Negotiated Rate |
$25,060.00 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,754.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,072.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,132.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,007.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,505.89
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,698.75
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$4,072.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,759.00
|
| Rate for Payer: The Alliance Commercial |
$25,060.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 28 X 30 INTERGARD WOVEN STRAIGHT IGW0028-30
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2965281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,069.85 |
| Max. Negotiated Rate |
$5,763.80 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$3,759.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 30 X 15 INTERGARD WOVEN STRAIGHT IGW0030-15
|
Facility
|
IP
|
$6,265.00
|
|
| Hospital Charge Code |
2964761
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,069.85 |
| Max. Negotiated Rate |
$5,763.80 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$3,759.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 30 X 15 INTERGARD WOVEN STRAIGHT IGW0030-15
|
Facility
|
OP
|
$6,265.00
|
|
| Hospital Charge Code |
2964761
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,754.20 |
| Max. Negotiated Rate |
$25,060.00 |
| Rate for Payer: Aetna Commercial |
$5,638.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,387.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,754.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,072.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,132.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,007.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,320.45
|
| Rate for Payer: Cash Price |
$1,879.50
|
| Rate for Payer: Cigna Commercial |
$5,763.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,505.89
|
| Rate for Payer: Health EOS Commercial |
$5,575.85
|
| Rate for Payer: HFN Commercial |
$5,763.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,698.75
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,759.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,763.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,069.85
|
| Rate for Payer: Quartz Commercial |
$4,072.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,759.00
|
| Rate for Payer: The Alliance Commercial |
$25,060.00
|
| Rate for Payer: WEA Trust Commercial |
$3,445.75
|
| Rate for Payer: WPS Commercial |
$4,640.49
|
|
|
GRAFT 30 X 30 INTERGARD WOVEN STRAIGHT IGW0030-30
|
Facility
|
OP
|
$5,887.00
|
|
| Hospital Charge Code |
3167477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,648.36 |
| Max. Negotiated Rate |
$23,548.00 |
| Rate for Payer: Aetna Commercial |
$5,298.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,062.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,648.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,826.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,943.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,825.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,120.11
|
| Rate for Payer: Cash Price |
$1,766.10
|
| Rate for Payer: Cigna Commercial |
$5,416.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,294.37
|
| Rate for Payer: Health EOS Commercial |
$5,239.43
|
| Rate for Payer: HFN Commercial |
$5,416.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,415.25
|
| Rate for Payer: Multiplan Commercial |
$4,709.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,532.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,416.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,884.63
|
| Rate for Payer: Quartz Commercial |
$3,826.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,532.20
|
| Rate for Payer: The Alliance Commercial |
$23,548.00
|
| Rate for Payer: WEA Trust Commercial |
$3,237.85
|
| Rate for Payer: WPS Commercial |
$4,360.50
|
|
|
GRAFT 30 X 30 INTERGARD WOVEN STRAIGHT IGW0030-30
|
Facility
|
IP
|
$5,887.00
|
|
| Hospital Charge Code |
3167477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,884.63 |
| Max. Negotiated Rate |
$5,416.04 |
| Rate for Payer: Aetna Commercial |
$5,298.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,062.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,120.11
|
| Rate for Payer: Cash Price |
$1,766.10
|
| Rate for Payer: Cigna Commercial |
$5,416.04
|
| Rate for Payer: Health EOS Commercial |
$5,239.43
|
| Rate for Payer: HFN Commercial |
$5,416.04
|
| Rate for Payer: Multiplan Commercial |
$4,709.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,532.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,416.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,884.63
|
| Rate for Payer: Quartz Commercial |
$3,532.20
|
| Rate for Payer: WEA Trust Commercial |
$3,237.85
|
| Rate for Payer: WPS Commercial |
$4,360.50
|
|
|
GRAFT 4 X 10CM SEGMENT STR 10S04
|
Facility
|
OP
|
$2,162.00
|
|
| Hospital Charge Code |
2972892
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$605.36 |
| Max. Negotiated Rate |
$8,648.00 |
| Rate for Payer: Aetna Commercial |
$1,945.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,859.32
|
| Rate for Payer: Aetna Managed Medicare |
$605.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,405.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,081.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,037.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.86
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$1,989.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,209.86
|
| Rate for Payer: Health EOS Commercial |
$1,924.18
|
| Rate for Payer: HFN Commercial |
$1,989.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,621.50
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,297.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,989.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.38
|
| Rate for Payer: Quartz Commercial |
$1,405.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,297.20
|
| Rate for Payer: The Alliance Commercial |
$8,648.00
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
GRAFT 4 X 10CM SEGMENT STR 10S04
|
Facility
|
IP
|
$2,162.00
|
|
| Hospital Charge Code |
2972892
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,059.38 |
| Max. Negotiated Rate |
$1,989.04 |
| Rate for Payer: Aetna Commercial |
$1,945.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,859.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.86
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$1,989.04
|
| Rate for Payer: Health EOS Commercial |
$1,924.18
|
| Rate for Payer: HFN Commercial |
$1,989.04
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,297.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,989.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.38
|
| Rate for Payer: Quartz Commercial |
$1,297.20
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
GRAFT 5.0 x 26mm JOS #12748-26
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973909
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,239.04 |
| Max. Negotiated Rate |
$19,224.32 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$12,537.60
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
GRAFT 5.0 x 26mm JOS #12748-26
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973909
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.88 |
| Max. Negotiated Rate |
$83,584.00 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,582.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,448.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,030.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,693.40
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,672.00
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$13,582.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.60
|
| Rate for Payer: The Alliance Commercial |
$83,584.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
GRAFT 6 X 10CM SEGMENT STR 10S06
|
Facility
|
OP
|
$2,162.00
|
|
| Hospital Charge Code |
2972893
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$605.36 |
| Max. Negotiated Rate |
$8,648.00 |
| Rate for Payer: Aetna Commercial |
$1,945.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,859.32
|
| Rate for Payer: Aetna Managed Medicare |
$605.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,405.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,081.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,037.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.86
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$1,989.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,209.86
|
| Rate for Payer: Health EOS Commercial |
$1,924.18
|
| Rate for Payer: HFN Commercial |
$1,989.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,621.50
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,297.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,989.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.38
|
| Rate for Payer: Quartz Commercial |
$1,405.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,297.20
|
| Rate for Payer: The Alliance Commercial |
$8,648.00
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
GRAFT 6 X 10CM SEGMENT STR 10S06
|
Facility
|
IP
|
$2,162.00
|
|
| Hospital Charge Code |
2972893
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,059.38 |
| Max. Negotiated Rate |
$1,989.04 |
| Rate for Payer: Aetna Commercial |
$1,945.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,859.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.86
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$1,989.04
|
| Rate for Payer: Health EOS Commercial |
$1,924.18
|
| Rate for Payer: HFN Commercial |
$1,989.04
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,297.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,989.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.38
|
| Rate for Payer: Quartz Commercial |
$1,297.20
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
