|
GRAFT 6 X 40 CENTERFLEX VENAFLO CF4006C
|
Facility
|
IP
|
$8,503.00
|
|
| Hospital Charge Code |
2973736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,166.47 |
| Max. Negotiated Rate |
$7,822.76 |
| Rate for Payer: Aetna Commercial |
$7,652.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,312.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,506.59
|
| Rate for Payer: Cash Price |
$2,550.90
|
| Rate for Payer: Cigna Commercial |
$7,822.76
|
| Rate for Payer: Health EOS Commercial |
$7,567.67
|
| Rate for Payer: HFN Commercial |
$7,822.76
|
| Rate for Payer: Multiplan Commercial |
$6,802.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,101.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,822.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,166.47
|
| Rate for Payer: Quartz Commercial |
$5,101.80
|
| Rate for Payer: WEA Trust Commercial |
$4,676.65
|
| Rate for Payer: WPS Commercial |
$6,298.17
|
|
|
GRAFT 6 X 40 CENTERFLEX VENAFLO CF4006C
|
Facility
|
OP
|
$8,503.00
|
|
| Hospital Charge Code |
2973736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,380.84 |
| Max. Negotiated Rate |
$34,012.00 |
| Rate for Payer: Aetna Commercial |
$7,652.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,312.58
|
| Rate for Payer: Aetna Managed Medicare |
$2,380.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,526.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,251.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,081.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,506.59
|
| Rate for Payer: Cash Price |
$2,550.90
|
| Rate for Payer: Cigna Commercial |
$7,822.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,758.28
|
| Rate for Payer: Health EOS Commercial |
$7,567.67
|
| Rate for Payer: HFN Commercial |
$7,822.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,377.25
|
| Rate for Payer: Multiplan Commercial |
$6,802.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,101.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,822.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,166.47
|
| Rate for Payer: Quartz Commercial |
$5,526.95
|
| Rate for Payer: Quartz Medicare Advantage |
$5,101.80
|
| Rate for Payer: The Alliance Commercial |
$34,012.00
|
| Rate for Payer: WEA Trust Commercial |
$4,676.65
|
| Rate for Payer: WPS Commercial |
$6,298.17
|
|
|
GRAFT 6x50 CENTERFLEX CF5006
|
Facility
|
OP
|
$6,246.00
|
|
| Hospital Charge Code |
2973691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,748.88 |
| Max. Negotiated Rate |
$24,984.00 |
| Rate for Payer: Aetna Commercial |
$5,621.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,371.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,748.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,059.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,123.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,998.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,310.38
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,746.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,495.26
|
| Rate for Payer: Health EOS Commercial |
$5,558.94
|
| Rate for Payer: HFN Commercial |
$5,746.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,684.50
|
| Rate for Payer: Multiplan Commercial |
$4,996.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,747.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,746.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,060.54
|
| Rate for Payer: Quartz Commercial |
$4,059.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,747.60
|
| Rate for Payer: The Alliance Commercial |
$24,984.00
|
| Rate for Payer: WEA Trust Commercial |
$3,435.30
|
| Rate for Payer: WPS Commercial |
$4,626.41
|
|
|
GRAFT 6x50 CENTERFLEX CF5006
|
Facility
|
IP
|
$6,246.00
|
|
| Hospital Charge Code |
2973691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,060.54 |
| Max. Negotiated Rate |
$5,746.32 |
| Rate for Payer: Aetna Commercial |
$5,621.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,371.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,310.38
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,746.32
|
| Rate for Payer: Health EOS Commercial |
$5,558.94
|
| Rate for Payer: HFN Commercial |
$5,746.32
|
| Rate for Payer: Multiplan Commercial |
$4,996.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,747.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,746.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,060.54
|
| Rate for Payer: Quartz Commercial |
$3,747.60
|
| Rate for Payer: WEA Trust Commercial |
$3,435.30
|
| Rate for Payer: WPS Commercial |
$4,626.41
|
|
|
GRAFT 6x50 FLEX F5006
|
Facility
|
IP
|
$8,503.00
|
|
| Hospital Charge Code |
2969347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,166.47 |
| Max. Negotiated Rate |
$7,822.76 |
| Rate for Payer: Aetna Commercial |
$7,652.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,312.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,506.59
|
| Rate for Payer: Cash Price |
$2,550.90
|
| Rate for Payer: Cigna Commercial |
$7,822.76
|
| Rate for Payer: Health EOS Commercial |
$7,567.67
|
| Rate for Payer: HFN Commercial |
$7,822.76
|
| Rate for Payer: Multiplan Commercial |
$6,802.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,101.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,822.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,166.47
|
| Rate for Payer: Quartz Commercial |
$5,101.80
|
| Rate for Payer: WEA Trust Commercial |
$4,676.65
|
| Rate for Payer: WPS Commercial |
$6,298.17
|
|
|
GRAFT 6x50 FLEX F5006
|
Facility
|
OP
|
$8,503.00
|
|
| Hospital Charge Code |
2969347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,380.84 |
| Max. Negotiated Rate |
$34,012.00 |
| Rate for Payer: Aetna Commercial |
$7,652.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,312.58
|
| Rate for Payer: Aetna Managed Medicare |
$2,380.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,526.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,251.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,081.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,506.59
|
| Rate for Payer: Cash Price |
$2,550.90
|
| Rate for Payer: Cigna Commercial |
$7,822.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,758.28
|
| Rate for Payer: Health EOS Commercial |
$7,567.67
|
| Rate for Payer: HFN Commercial |
$7,822.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,377.25
|
| Rate for Payer: Multiplan Commercial |
$6,802.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,101.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,822.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,166.47
|
| Rate for Payer: Quartz Commercial |
$5,526.95
|
| Rate for Payer: Quartz Medicare Advantage |
$5,101.80
|
| Rate for Payer: The Alliance Commercial |
$34,012.00
|
| Rate for Payer: WEA Trust Commercial |
$4,676.65
|
| Rate for Payer: WPS Commercial |
$6,298.17
|
|
|
GRAFT 6x70 FLEX F7006
|
Facility
|
IP
|
$8,457.00
|
|
| Hospital Charge Code |
2969349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,143.93 |
| Max. Negotiated Rate |
$7,780.44 |
| Rate for Payer: Aetna Commercial |
$7,611.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,273.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,482.21
|
| Rate for Payer: Cash Price |
$2,537.10
|
| Rate for Payer: Cigna Commercial |
$7,780.44
|
| Rate for Payer: Health EOS Commercial |
$7,526.73
|
| Rate for Payer: HFN Commercial |
$7,780.44
|
| Rate for Payer: Multiplan Commercial |
$6,765.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,074.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,780.44
|
| Rate for Payer: Quartz Beloit One Network |
$4,143.93
|
| Rate for Payer: Quartz Commercial |
$5,074.20
|
| Rate for Payer: WEA Trust Commercial |
$4,651.35
|
| Rate for Payer: WPS Commercial |
$6,264.10
|
|
|
GRAFT 6x70 FLEX F7006
|
Facility
|
OP
|
$8,457.00
|
|
| Hospital Charge Code |
2969349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,367.96 |
| Max. Negotiated Rate |
$33,828.00 |
| Rate for Payer: Aetna Commercial |
$7,611.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,273.02
|
| Rate for Payer: Aetna Managed Medicare |
$2,367.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,497.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,228.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,059.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,482.21
|
| Rate for Payer: Cash Price |
$2,537.10
|
| Rate for Payer: Cigna Commercial |
$7,780.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,732.54
|
| Rate for Payer: Health EOS Commercial |
$7,526.73
|
| Rate for Payer: HFN Commercial |
$7,780.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,342.75
|
| Rate for Payer: Multiplan Commercial |
$6,765.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,074.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,780.44
|
| Rate for Payer: Quartz Beloit One Network |
$4,143.93
|
| Rate for Payer: Quartz Commercial |
$5,497.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5,074.20
|
| Rate for Payer: The Alliance Commercial |
$33,828.00
|
| Rate for Payer: WEA Trust Commercial |
$4,651.35
|
| Rate for Payer: WPS Commercial |
$6,264.10
|
|
|
GRAFT 7-4 X 70CM FLEX TAPER F70T74TWS
|
Facility
|
IP
|
$6,246.00
|
|
| Hospital Charge Code |
2969350
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,060.54 |
| Max. Negotiated Rate |
$5,746.32 |
| Rate for Payer: Aetna Commercial |
$5,621.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,371.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,310.38
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,746.32
|
| Rate for Payer: Health EOS Commercial |
$5,558.94
|
| Rate for Payer: HFN Commercial |
$5,746.32
|
| Rate for Payer: Multiplan Commercial |
$4,996.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,747.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,746.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,060.54
|
| Rate for Payer: Quartz Commercial |
$3,747.60
|
| Rate for Payer: WEA Trust Commercial |
$3,435.30
|
| Rate for Payer: WPS Commercial |
$4,626.41
|
|
|
GRAFT 7-4 X 70CM FLEX TAPER F70T74TWS
|
Facility
|
OP
|
$6,246.00
|
|
| Hospital Charge Code |
2969350
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,748.88 |
| Max. Negotiated Rate |
$24,984.00 |
| Rate for Payer: Aetna Commercial |
$5,621.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,371.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,748.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,059.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,123.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,998.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,310.38
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,746.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,495.26
|
| Rate for Payer: Health EOS Commercial |
$5,558.94
|
| Rate for Payer: HFN Commercial |
$5,746.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,684.50
|
| Rate for Payer: Multiplan Commercial |
$4,996.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,747.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,746.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,060.54
|
| Rate for Payer: Quartz Commercial |
$4,059.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,747.60
|
| Rate for Payer: The Alliance Commercial |
$24,984.00
|
| Rate for Payer: WEA Trust Commercial |
$3,435.30
|
| Rate for Payer: WPS Commercial |
$4,626.41
|
|
|
GRAFT 8 X 50CM CENTERFLEX CF5008
|
Facility
|
OP
|
$6,246.00
|
|
| Hospital Charge Code |
2973693
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,748.88 |
| Max. Negotiated Rate |
$24,984.00 |
| Rate for Payer: Aetna Commercial |
$5,621.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,371.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,748.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,059.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,123.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,998.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,310.38
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,746.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,495.26
|
| Rate for Payer: Health EOS Commercial |
$5,558.94
|
| Rate for Payer: HFN Commercial |
$5,746.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,684.50
|
| Rate for Payer: Multiplan Commercial |
$4,996.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,747.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,746.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,060.54
|
| Rate for Payer: Quartz Commercial |
$4,059.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,747.60
|
| Rate for Payer: The Alliance Commercial |
$24,984.00
|
| Rate for Payer: WEA Trust Commercial |
$3,435.30
|
| Rate for Payer: WPS Commercial |
$4,626.41
|
|
|
GRAFT 8 X 50CM CENTERFLEX CF5008
|
Facility
|
IP
|
$6,246.00
|
|
| Hospital Charge Code |
2973693
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,060.54 |
| Max. Negotiated Rate |
$5,746.32 |
| Rate for Payer: Aetna Commercial |
$5,621.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,371.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,310.38
|
| Rate for Payer: Cash Price |
$1,873.80
|
| Rate for Payer: Cigna Commercial |
$5,746.32
|
| Rate for Payer: Health EOS Commercial |
$5,558.94
|
| Rate for Payer: HFN Commercial |
$5,746.32
|
| Rate for Payer: Multiplan Commercial |
$4,996.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,747.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,746.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,060.54
|
| Rate for Payer: Quartz Commercial |
$3,747.60
|
| Rate for Payer: WEA Trust Commercial |
$3,435.30
|
| Rate for Payer: WPS Commercial |
$4,626.41
|
|
|
GRAFT 8 X 8O FLEX PTFE #F8008
|
Facility
|
OP
|
$8,503.00
|
|
| Hospital Charge Code |
2969351
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,380.84 |
| Max. Negotiated Rate |
$34,012.00 |
| Rate for Payer: Aetna Commercial |
$7,652.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,312.58
|
| Rate for Payer: Aetna Managed Medicare |
$2,380.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,526.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,251.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,081.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,506.59
|
| Rate for Payer: Cash Price |
$2,550.90
|
| Rate for Payer: Cigna Commercial |
$7,822.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,758.28
|
| Rate for Payer: Health EOS Commercial |
$7,567.67
|
| Rate for Payer: HFN Commercial |
$7,822.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,377.25
|
| Rate for Payer: Multiplan Commercial |
$6,802.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,101.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,822.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,166.47
|
| Rate for Payer: Quartz Commercial |
$5,526.95
|
| Rate for Payer: Quartz Medicare Advantage |
$5,101.80
|
| Rate for Payer: The Alliance Commercial |
$34,012.00
|
| Rate for Payer: WEA Trust Commercial |
$4,676.65
|
| Rate for Payer: WPS Commercial |
$6,298.17
|
|
|
GRAFT 8 X 8O FLEX PTFE #F8008
|
Facility
|
IP
|
$8,503.00
|
|
| Hospital Charge Code |
2969351
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,166.47 |
| Max. Negotiated Rate |
$7,822.76 |
| Rate for Payer: Aetna Commercial |
$7,652.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,312.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,506.59
|
| Rate for Payer: Cash Price |
$2,550.90
|
| Rate for Payer: Cigna Commercial |
$7,822.76
|
| Rate for Payer: Health EOS Commercial |
$7,567.67
|
| Rate for Payer: HFN Commercial |
$7,822.76
|
| Rate for Payer: Multiplan Commercial |
$6,802.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,101.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,822.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,166.47
|
| Rate for Payer: Quartz Commercial |
$5,101.80
|
| Rate for Payer: WEA Trust Commercial |
$4,676.65
|
| Rate for Payer: WPS Commercial |
$6,298.17
|
|
|
GRAFT ACHILLES TENDON TENDON
|
Facility
|
OP
|
$14,094.00
|
|
| Hospital Charge Code |
2965943
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,946.32 |
| Max. Negotiated Rate |
$56,376.00 |
| Rate for Payer: Aetna Commercial |
$12,684.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,120.84
|
| Rate for Payer: Aetna Managed Medicare |
$3,946.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,161.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,047.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,765.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,469.82
|
| Rate for Payer: Cash Price |
$4,228.20
|
| Rate for Payer: Cigna Commercial |
$12,966.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,887.00
|
| Rate for Payer: Health EOS Commercial |
$12,543.66
|
| Rate for Payer: HFN Commercial |
$12,966.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,570.50
|
| Rate for Payer: Multiplan Commercial |
$11,275.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,456.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,966.48
|
| Rate for Payer: Quartz Beloit One Network |
$6,906.06
|
| Rate for Payer: Quartz Commercial |
$9,161.10
|
| Rate for Payer: Quartz Medicare Advantage |
$8,456.40
|
| Rate for Payer: The Alliance Commercial |
$56,376.00
|
| Rate for Payer: WEA Trust Commercial |
$7,751.70
|
| Rate for Payer: WPS Commercial |
$10,439.43
|
|
|
GRAFT ACHILLES TENDON TENDON
|
Facility
|
IP
|
$14,094.00
|
|
| Hospital Charge Code |
2965943
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,906.06 |
| Max. Negotiated Rate |
$12,966.48 |
| Rate for Payer: Aetna Commercial |
$12,684.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,120.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,469.82
|
| Rate for Payer: Cash Price |
$4,228.20
|
| Rate for Payer: Cigna Commercial |
$12,966.48
|
| Rate for Payer: Health EOS Commercial |
$12,543.66
|
| Rate for Payer: HFN Commercial |
$12,966.48
|
| Rate for Payer: Multiplan Commercial |
$11,275.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,456.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,966.48
|
| Rate for Payer: Quartz Beloit One Network |
$6,906.06
|
| Rate for Payer: Quartz Commercial |
$8,456.40
|
| Rate for Payer: WEA Trust Commercial |
$7,751.70
|
| Rate for Payer: WPS Commercial |
$10,439.43
|
|
|
GRAFT ACL PRESHAPED BTB
|
Facility
|
OP
|
$19,476.00
|
|
| Hospital Charge Code |
2965271
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,453.28 |
| Max. Negotiated Rate |
$77,904.00 |
| Rate for Payer: Aetna Commercial |
$17,528.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,749.36
|
| Rate for Payer: Aetna Managed Medicare |
$5,453.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,659.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,738.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,348.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,322.28
|
| Rate for Payer: Cash Price |
$5,842.80
|
| Rate for Payer: Cigna Commercial |
$17,917.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,898.77
|
| Rate for Payer: Health EOS Commercial |
$17,333.64
|
| Rate for Payer: HFN Commercial |
$17,917.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,607.00
|
| Rate for Payer: Multiplan Commercial |
$15,580.80
|
| Rate for Payer: NAPHCARE Commercial |
$11,685.60
|
| Rate for Payer: Preferred Network Access Commercial |
$17,917.92
|
| Rate for Payer: Quartz Beloit One Network |
$9,543.24
|
| Rate for Payer: Quartz Commercial |
$12,659.40
|
| Rate for Payer: Quartz Medicare Advantage |
$11,685.60
|
| Rate for Payer: The Alliance Commercial |
$77,904.00
|
| Rate for Payer: WEA Trust Commercial |
$10,711.80
|
| Rate for Payer: WPS Commercial |
$14,425.87
|
|
|
GRAFT ACL PRESHAPED BTB
|
Facility
|
IP
|
$19,476.00
|
|
| Hospital Charge Code |
2965271
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,543.24 |
| Max. Negotiated Rate |
$17,917.92 |
| Rate for Payer: Aetna Commercial |
$17,528.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,749.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,322.28
|
| Rate for Payer: Cash Price |
$5,842.80
|
| Rate for Payer: Cigna Commercial |
$17,917.92
|
| Rate for Payer: Health EOS Commercial |
$17,333.64
|
| Rate for Payer: HFN Commercial |
$17,917.92
|
| Rate for Payer: Multiplan Commercial |
$15,580.80
|
| Rate for Payer: NAPHCARE Commercial |
$11,685.60
|
| Rate for Payer: Preferred Network Access Commercial |
$17,917.92
|
| Rate for Payer: Quartz Beloit One Network |
$9,543.24
|
| Rate for Payer: Quartz Commercial |
$11,685.60
|
| Rate for Payer: WEA Trust Commercial |
$10,711.80
|
| Rate for Payer: WPS Commercial |
$14,425.87
|
|
|
GRAFT ACL PRESHAPED BTB 11MM
|
Facility
|
OP
|
$19,476.00
|
|
| Hospital Charge Code |
2965272
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,453.28 |
| Max. Negotiated Rate |
$77,904.00 |
| Rate for Payer: Aetna Commercial |
$17,528.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,749.36
|
| Rate for Payer: Aetna Managed Medicare |
$5,453.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,659.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,738.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,348.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,322.28
|
| Rate for Payer: Cash Price |
$5,842.80
|
| Rate for Payer: Cigna Commercial |
$17,917.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,898.77
|
| Rate for Payer: Health EOS Commercial |
$17,333.64
|
| Rate for Payer: HFN Commercial |
$17,917.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,607.00
|
| Rate for Payer: Multiplan Commercial |
$15,580.80
|
| Rate for Payer: NAPHCARE Commercial |
$11,685.60
|
| Rate for Payer: Preferred Network Access Commercial |
$17,917.92
|
| Rate for Payer: Quartz Beloit One Network |
$9,543.24
|
| Rate for Payer: Quartz Commercial |
$12,659.40
|
| Rate for Payer: Quartz Medicare Advantage |
$11,685.60
|
| Rate for Payer: The Alliance Commercial |
$77,904.00
|
| Rate for Payer: WEA Trust Commercial |
$10,711.80
|
| Rate for Payer: WPS Commercial |
$14,425.87
|
|
|
GRAFT ACL PRESHAPED BTB 11MM
|
Facility
|
IP
|
$19,476.00
|
|
| Hospital Charge Code |
2965272
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,543.24 |
| Max. Negotiated Rate |
$17,917.92 |
| Rate for Payer: Aetna Commercial |
$17,528.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,749.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,322.28
|
| Rate for Payer: Cash Price |
$5,842.80
|
| Rate for Payer: Cigna Commercial |
$17,917.92
|
| Rate for Payer: Health EOS Commercial |
$17,333.64
|
| Rate for Payer: HFN Commercial |
$17,917.92
|
| Rate for Payer: Multiplan Commercial |
$15,580.80
|
| Rate for Payer: NAPHCARE Commercial |
$11,685.60
|
| Rate for Payer: Preferred Network Access Commercial |
$17,917.92
|
| Rate for Payer: Quartz Beloit One Network |
$9,543.24
|
| Rate for Payer: Quartz Commercial |
$11,685.60
|
| Rate for Payer: WEA Trust Commercial |
$10,711.80
|
| Rate for Payer: WPS Commercial |
$14,425.87
|
|
|
GRAFT ALLODERM 16 X 20CM 102320
|
Facility
|
OP
|
$72,429.00
|
|
| Hospital Charge Code |
2965263
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,280.12 |
| Max. Negotiated Rate |
$289,716.00 |
| Rate for Payer: Aetna Commercial |
$65,186.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62,288.94
|
| Rate for Payer: Aetna Managed Medicare |
$20,280.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47,078.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36,214.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34,765.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38,387.37
|
| Rate for Payer: Cash Price |
$21,728.70
|
| Rate for Payer: Cigna Commercial |
$66,634.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40,531.27
|
| Rate for Payer: Health EOS Commercial |
$64,461.81
|
| Rate for Payer: HFN Commercial |
$66,634.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54,321.75
|
| Rate for Payer: Multiplan Commercial |
$57,943.20
|
| Rate for Payer: NAPHCARE Commercial |
$43,457.40
|
| Rate for Payer: Preferred Network Access Commercial |
$66,634.68
|
| Rate for Payer: Quartz Beloit One Network |
$35,490.21
|
| Rate for Payer: Quartz Commercial |
$47,078.85
|
| Rate for Payer: Quartz Medicare Advantage |
$43,457.40
|
| Rate for Payer: The Alliance Commercial |
$289,716.00
|
| Rate for Payer: WEA Trust Commercial |
$39,835.95
|
| Rate for Payer: WPS Commercial |
$53,648.16
|
|
|
GRAFT ALLODERM 16 X 20CM 102320
|
Facility
|
IP
|
$72,429.00
|
|
| Hospital Charge Code |
2965263
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$35,490.21 |
| Max. Negotiated Rate |
$66,634.68 |
| Rate for Payer: Aetna Commercial |
$65,186.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62,288.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38,387.37
|
| Rate for Payer: Cash Price |
$21,728.70
|
| Rate for Payer: Cigna Commercial |
$66,634.68
|
| Rate for Payer: Health EOS Commercial |
$64,461.81
|
| Rate for Payer: HFN Commercial |
$66,634.68
|
| Rate for Payer: Multiplan Commercial |
$57,943.20
|
| Rate for Payer: NAPHCARE Commercial |
$43,457.40
|
| Rate for Payer: Preferred Network Access Commercial |
$66,634.68
|
| Rate for Payer: Quartz Beloit One Network |
$35,490.21
|
| Rate for Payer: Quartz Commercial |
$43,457.40
|
| Rate for Payer: WEA Trust Commercial |
$39,835.95
|
| Rate for Payer: WPS Commercial |
$53,648.16
|
|
|
GRAFT ALLODERM 4 X 7CM 102034
|
Facility
|
OP
|
$6,762.00
|
|
| Hospital Charge Code |
2965264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,893.36 |
| Max. Negotiated Rate |
$27,048.00 |
| Rate for Payer: Aetna Commercial |
$6,085.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,815.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,893.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,395.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,381.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,245.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,583.86
|
| Rate for Payer: Cash Price |
$2,028.60
|
| Rate for Payer: Cigna Commercial |
$6,221.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,784.02
|
| Rate for Payer: Health EOS Commercial |
$6,018.18
|
| Rate for Payer: HFN Commercial |
$6,221.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,071.50
|
| Rate for Payer: Multiplan Commercial |
$5,409.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,057.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,221.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,313.38
|
| Rate for Payer: Quartz Commercial |
$4,395.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,057.20
|
| Rate for Payer: The Alliance Commercial |
$27,048.00
|
| Rate for Payer: WEA Trust Commercial |
$3,719.10
|
| Rate for Payer: WPS Commercial |
$5,008.61
|
|
|
GRAFT ALLODERM 4 X 7CM 102034
|
Facility
|
IP
|
$6,762.00
|
|
| Hospital Charge Code |
2965264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,313.38 |
| Max. Negotiated Rate |
$6,221.04 |
| Rate for Payer: Aetna Commercial |
$6,085.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,815.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,583.86
|
| Rate for Payer: Cash Price |
$2,028.60
|
| Rate for Payer: Cigna Commercial |
$6,221.04
|
| Rate for Payer: Health EOS Commercial |
$6,018.18
|
| Rate for Payer: HFN Commercial |
$6,221.04
|
| Rate for Payer: Multiplan Commercial |
$5,409.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,057.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,221.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,313.38
|
| Rate for Payer: Quartz Commercial |
$4,057.20
|
| Rate for Payer: WEA Trust Commercial |
$3,719.10
|
| Rate for Payer: WPS Commercial |
$5,008.61
|
|
|
GRAFT ALLODERM 6 X 12CM 102072
|
Facility
|
OP
|
$11,575.00
|
|
| Hospital Charge Code |
2965265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,241.00 |
| Max. Negotiated Rate |
$46,300.00 |
| Rate for Payer: Aetna Commercial |
$10,417.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,954.50
|
| Rate for Payer: Aetna Managed Medicare |
$3,241.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,523.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,787.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,556.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,134.75
|
| Rate for Payer: Cash Price |
$3,472.50
|
| Rate for Payer: Cigna Commercial |
$10,649.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,477.37
|
| Rate for Payer: Health EOS Commercial |
$10,301.75
|
| Rate for Payer: HFN Commercial |
$10,649.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,681.25
|
| Rate for Payer: Multiplan Commercial |
$9,260.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,945.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,649.00
|
| Rate for Payer: Quartz Beloit One Network |
$5,671.75
|
| Rate for Payer: Quartz Commercial |
$7,523.75
|
| Rate for Payer: Quartz Medicare Advantage |
$6,945.00
|
| Rate for Payer: The Alliance Commercial |
$46,300.00
|
| Rate for Payer: WEA Trust Commercial |
$6,366.25
|
| Rate for Payer: WPS Commercial |
$8,573.60
|
|
