|
GRAFT SPREADER AR-19007GS
|
Facility
|
OP
|
$3,580.55
|
|
| Hospital Charge Code |
6246219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,042.66 |
| Max. Negotiated Rate |
$3,425.87 |
| Rate for Payer: Aetna Commercial |
$3,351.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,202.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,042.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,420.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,861.89
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,787.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,973.60
|
| Rate for Payer: Cash Price |
$1,074.16
|
| Rate for Payer: Cigna Commercial |
$3,425.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,083.88
|
| Rate for Payer: Health EOS Commercial |
$3,314.16
|
| Rate for Payer: HFN Commercial |
$3,425.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,792.83
|
| Rate for Payer: Multiplan Commercial |
$2,979.02
|
| Rate for Payer: NAPHCARE Commercial |
$2,234.26
|
| Rate for Payer: Preferred Network Access Commercial |
$3,425.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,824.65
|
| Rate for Payer: Quartz Commercial |
$2,420.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,234.26
|
| Rate for Payer: The Alliance Commercial |
$1,861.89
|
| Rate for Payer: WEA Trust Commercial |
$2,048.07
|
| Rate for Payer: WPS Commercial |
$2,758.10
|
|
|
GRAFT SPREADER AR-19007GS
|
Facility
|
IP
|
$3,580.55
|
|
| Hospital Charge Code |
6246219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,824.65 |
| Max. Negotiated Rate |
$3,425.87 |
| Rate for Payer: Aetna Commercial |
$3,351.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,202.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,973.60
|
| Rate for Payer: Cash Price |
$1,074.16
|
| Rate for Payer: Cigna Commercial |
$3,425.87
|
| Rate for Payer: Health EOS Commercial |
$3,314.16
|
| Rate for Payer: HFN Commercial |
$3,425.87
|
| Rate for Payer: Multiplan Commercial |
$2,979.02
|
| Rate for Payer: Preferred Network Access Commercial |
$3,425.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,824.65
|
| Rate for Payer: Quartz Commercial |
$2,234.26
|
| Rate for Payer: WEA Trust Commercial |
$2,048.07
|
| Rate for Payer: WPS Commercial |
$2,758.10
|
|
|
GRAFT STRATTICE 10 X 10CM (100 SQ CM) 1010002
|
Facility
|
OP
|
$14,129.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3755521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$13,518.63 |
| Rate for Payer: Aetna Commercial |
$13,224.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,636.98
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,551.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,347.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,053.20
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,787.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$4,238.70
|
| Rate for Payer: Cash Price |
$4,238.70
|
| Rate for Payer: Cigna Commercial |
$13,518.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,223.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$13,077.80
|
| Rate for Payer: HFN Commercial |
$13,518.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$11,755.33
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$13,518.63
|
| Rate for Payer: Quartz Beloit One Network |
$7,200.14
|
| Rate for Payer: Quartz Commercial |
$9,551.20
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$8,081.79
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$10,883.57
|
|
|
GRAFT STRATTICE 10 X 10CM (100 SQ CM) 1010002
|
Facility
|
IP
|
$14,129.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3755521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,200.14 |
| Max. Negotiated Rate |
$13,518.63 |
| Rate for Payer: Aetna Commercial |
$13,224.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,636.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,787.90
|
| Rate for Payer: Cash Price |
$4,238.70
|
| Rate for Payer: Cigna Commercial |
$13,518.63
|
| Rate for Payer: Health EOS Commercial |
$13,077.80
|
| Rate for Payer: HFN Commercial |
$13,518.63
|
| Rate for Payer: Multiplan Commercial |
$11,755.33
|
| Rate for Payer: Preferred Network Access Commercial |
$13,518.63
|
| Rate for Payer: Quartz Beloit One Network |
$7,200.14
|
| Rate for Payer: Quartz Commercial |
$8,816.50
|
| Rate for Payer: WEA Trust Commercial |
$8,081.79
|
| Rate for Payer: WPS Commercial |
$10,883.57
|
|
|
GRAFT STRATTICE 10 X 16CM (160 SQ CM) 1016002
|
Facility
|
OP
|
$23,089.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965267
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$22,091.56 |
| Rate for Payer: Aetna Commercial |
$21,611.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,650.80
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,608.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,006.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,526.03
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,726.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$6,926.70
|
| Rate for Payer: Cash Price |
$6,926.70
|
| Rate for Payer: Cigna Commercial |
$22,091.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,437.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$21,371.18
|
| Rate for Payer: HFN Commercial |
$22,091.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$19,210.05
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$22,091.56
|
| Rate for Payer: Quartz Beloit One Network |
$11,766.15
|
| Rate for Payer: Quartz Commercial |
$15,608.16
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$13,206.91
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$17,785.46
|
|
|
GRAFT STRATTICE 10 X 16CM (160 SQ CM) 1016002
|
Facility
|
IP
|
$23,089.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965267
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,766.15 |
| Max. Negotiated Rate |
$22,091.56 |
| Rate for Payer: Aetna Commercial |
$21,611.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,650.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,726.66
|
| Rate for Payer: Cash Price |
$6,926.70
|
| Rate for Payer: Cigna Commercial |
$22,091.56
|
| Rate for Payer: Health EOS Commercial |
$21,371.18
|
| Rate for Payer: HFN Commercial |
$22,091.56
|
| Rate for Payer: Multiplan Commercial |
$19,210.05
|
| Rate for Payer: Preferred Network Access Commercial |
$22,091.56
|
| Rate for Payer: Quartz Beloit One Network |
$11,766.15
|
| Rate for Payer: Quartz Commercial |
$14,407.54
|
| Rate for Payer: WEA Trust Commercial |
$13,206.91
|
| Rate for Payer: WPS Commercial |
$17,785.46
|
|
|
GRAFT STRATTICE 10 X 20CM (200 SQ CM) 1020002
|
Facility
|
IP
|
$28,252.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
4174302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14,397.22 |
| Max. Negotiated Rate |
$27,031.51 |
| Rate for Payer: Aetna Commercial |
$26,443.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25,268.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15,572.50
|
| Rate for Payer: Cash Price |
$8,475.60
|
| Rate for Payer: Cigna Commercial |
$27,031.51
|
| Rate for Payer: Health EOS Commercial |
$26,150.05
|
| Rate for Payer: HFN Commercial |
$27,031.51
|
| Rate for Payer: Multiplan Commercial |
$23,505.66
|
| Rate for Payer: Preferred Network Access Commercial |
$27,031.51
|
| Rate for Payer: Quartz Beloit One Network |
$14,397.22
|
| Rate for Payer: Quartz Commercial |
$17,629.25
|
| Rate for Payer: WEA Trust Commercial |
$16,160.14
|
| Rate for Payer: WPS Commercial |
$21,762.52
|
|
|
GRAFT STRATTICE 10 X 20CM (200 SQ CM) 1020002
|
Facility
|
OP
|
$28,252.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
4174302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$27,031.51 |
| Rate for Payer: Aetna Commercial |
$26,443.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25,268.59
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,098.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,691.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,103.40
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15,572.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$8,475.60
|
| Rate for Payer: Cash Price |
$8,475.60
|
| Rate for Payer: Cigna Commercial |
$27,031.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16,442.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$26,150.05
|
| Rate for Payer: HFN Commercial |
$27,031.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$23,505.66
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$27,031.51
|
| Rate for Payer: Quartz Beloit One Network |
$14,397.22
|
| Rate for Payer: Quartz Commercial |
$19,098.35
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$16,160.14
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$21,762.52
|
|
|
GRAFT STRATTICE 15 X 25 FIRM (375 SQ CM) 1525002
|
Facility
|
IP
|
$52,984.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3153466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$27,000.65 |
| Max. Negotiated Rate |
$50,695.09 |
| Rate for Payer: Aetna Commercial |
$49,593.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47,388.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29,204.78
|
| Rate for Payer: Cash Price |
$15,895.20
|
| Rate for Payer: Cigna Commercial |
$50,695.09
|
| Rate for Payer: Health EOS Commercial |
$49,041.99
|
| Rate for Payer: HFN Commercial |
$50,695.09
|
| Rate for Payer: Multiplan Commercial |
$44,082.69
|
| Rate for Payer: Preferred Network Access Commercial |
$50,695.09
|
| Rate for Payer: Quartz Beloit One Network |
$27,000.65
|
| Rate for Payer: Quartz Commercial |
$33,062.02
|
| Rate for Payer: WEA Trust Commercial |
$30,306.85
|
| Rate for Payer: WPS Commercial |
$40,813.58
|
|
|
GRAFT STRATTICE 15 X 25 FIRM (375 SQ CM) 1525002
|
Facility
|
OP
|
$52,984.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3153466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$50,695.09 |
| Rate for Payer: Aetna Commercial |
$49,593.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47,388.89
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35,817.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27,551.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26,449.61
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29,204.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$15,895.20
|
| Rate for Payer: Cash Price |
$15,895.20
|
| Rate for Payer: Cigna Commercial |
$50,695.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30,836.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$49,041.99
|
| Rate for Payer: HFN Commercial |
$50,695.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$44,082.69
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$50,695.09
|
| Rate for Payer: Quartz Beloit One Network |
$27,000.65
|
| Rate for Payer: Quartz Commercial |
$35,817.18
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$30,306.85
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$40,813.58
|
|
|
GRAFT STRATTICE 16 X 20 (320 SQ CM) FIRM 1620002
|
Facility
|
OP
|
$45,213.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3439505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$43,259.80 |
| Rate for Payer: Aetna Commercial |
$42,319.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40,438.51
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30,563.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23,510.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22,570.33
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24,921.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$13,563.90
|
| Rate for Payer: Cash Price |
$13,563.90
|
| Rate for Payer: Cigna Commercial |
$43,259.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26,313.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$41,849.15
|
| Rate for Payer: HFN Commercial |
$43,259.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$37,617.22
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$43,259.80
|
| Rate for Payer: Quartz Beloit One Network |
$23,040.54
|
| Rate for Payer: Quartz Commercial |
$30,563.99
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$25,861.84
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$34,827.57
|
|
|
GRAFT STRATTICE 16 X 20 (320 SQ CM) FIRM 1620002
|
Facility
|
IP
|
$45,213.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3439505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$23,040.54 |
| Max. Negotiated Rate |
$43,259.80 |
| Rate for Payer: Aetna Commercial |
$42,319.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40,438.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24,921.41
|
| Rate for Payer: Cash Price |
$13,563.90
|
| Rate for Payer: Cigna Commercial |
$43,259.80
|
| Rate for Payer: Health EOS Commercial |
$41,849.15
|
| Rate for Payer: HFN Commercial |
$43,259.80
|
| Rate for Payer: Multiplan Commercial |
$37,617.22
|
| Rate for Payer: Preferred Network Access Commercial |
$43,259.80
|
| Rate for Payer: Quartz Beloit One Network |
$23,040.54
|
| Rate for Payer: Quartz Commercial |
$28,212.91
|
| Rate for Payer: WEA Trust Commercial |
$25,861.84
|
| Rate for Payer: WPS Commercial |
$34,827.57
|
|
|
GRAFT STRATTICE 20 X 20CM (400 SQ CM) 2020002
|
Facility
|
IP
|
$56,516.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$28,800.55 |
| Max. Negotiated Rate |
$54,074.51 |
| Rate for Payer: Aetna Commercial |
$52,898.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50,547.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31,151.62
|
| Rate for Payer: Cash Price |
$16,954.80
|
| Rate for Payer: Cigna Commercial |
$54,074.51
|
| Rate for Payer: Health EOS Commercial |
$52,311.21
|
| Rate for Payer: HFN Commercial |
$54,074.51
|
| Rate for Payer: Multiplan Commercial |
$47,021.31
|
| Rate for Payer: Preferred Network Access Commercial |
$54,074.51
|
| Rate for Payer: Quartz Beloit One Network |
$28,800.55
|
| Rate for Payer: Quartz Commercial |
$35,265.98
|
| Rate for Payer: WEA Trust Commercial |
$32,327.15
|
| Rate for Payer: WPS Commercial |
$43,534.27
|
|
|
GRAFT STRATTICE 20 X 20CM (400 SQ CM) 2020002
|
Facility
|
OP
|
$56,516.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$54,074.51 |
| Rate for Payer: Aetna Commercial |
$52,898.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50,547.91
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38,204.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,388.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,212.79
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31,151.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$16,954.80
|
| Rate for Payer: Cash Price |
$16,954.80
|
| Rate for Payer: Cigna Commercial |
$54,074.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32,892.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$52,311.21
|
| Rate for Payer: HFN Commercial |
$54,074.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$47,021.31
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$54,074.51
|
| Rate for Payer: Quartz Beloit One Network |
$28,800.55
|
| Rate for Payer: Quartz Commercial |
$38,204.82
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$32,327.15
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$43,534.27
|
|
|
GRAFT STRATTICE 6 X 8CM PLIABLE (48 SQ CM) 0608001
|
Facility
|
OP
|
$7,042.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965269
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$6,737.79 |
| Rate for Payer: Aetna Commercial |
$6,591.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,298.36
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,760.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,661.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,515.37
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,881.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$2,112.60
|
| Rate for Payer: Cash Price |
$2,112.60
|
| Rate for Payer: Cigna Commercial |
$6,737.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,098.44
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$6,518.08
|
| Rate for Payer: HFN Commercial |
$6,737.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$5,858.94
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$6,737.79
|
| Rate for Payer: Quartz Beloit One Network |
$3,588.60
|
| Rate for Payer: Quartz Commercial |
$4,760.39
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$4,028.02
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$5,424.45
|
|
|
GRAFT STRATTICE 6 X 8CM PLIABLE (48 SQ CM) 0608001
|
Facility
|
IP
|
$7,042.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965269
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,588.60 |
| Max. Negotiated Rate |
$6,737.79 |
| Rate for Payer: Aetna Commercial |
$6,591.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,298.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,881.55
|
| Rate for Payer: Cash Price |
$2,112.60
|
| Rate for Payer: Cigna Commercial |
$6,737.79
|
| Rate for Payer: Health EOS Commercial |
$6,518.08
|
| Rate for Payer: HFN Commercial |
$6,737.79
|
| Rate for Payer: Multiplan Commercial |
$5,858.94
|
| Rate for Payer: Preferred Network Access Commercial |
$6,737.79
|
| Rate for Payer: Quartz Beloit One Network |
$3,588.60
|
| Rate for Payer: Quartz Commercial |
$4,394.21
|
| Rate for Payer: WEA Trust Commercial |
$4,028.02
|
| Rate for Payer: WPS Commercial |
$5,424.45
|
|
|
GRAFT STRATTICE 8 X 16CM PLIABLE (128 SQ CM) 0816001
|
Facility
|
IP
|
$18,086.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965270
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,216.63 |
| Max. Negotiated Rate |
$17,304.68 |
| Rate for Payer: Aetna Commercial |
$16,928.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,176.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,969.00
|
| Rate for Payer: Cash Price |
$5,425.80
|
| Rate for Payer: Cigna Commercial |
$17,304.68
|
| Rate for Payer: Health EOS Commercial |
$16,740.40
|
| Rate for Payer: HFN Commercial |
$17,304.68
|
| Rate for Payer: Multiplan Commercial |
$15,047.55
|
| Rate for Payer: Preferred Network Access Commercial |
$17,304.68
|
| Rate for Payer: Quartz Beloit One Network |
$9,216.63
|
| Rate for Payer: Quartz Commercial |
$11,285.66
|
| Rate for Payer: WEA Trust Commercial |
$10,345.19
|
| Rate for Payer: WPS Commercial |
$13,931.65
|
|
|
GRAFT STRATTICE 8 X 16CM PLIABLE (128 SQ CM) 0816001
|
Facility
|
OP
|
$18,086.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965270
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$17,304.68 |
| Rate for Payer: Aetna Commercial |
$16,928.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,176.12
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,226.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,404.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,028.53
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,969.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$5,425.80
|
| Rate for Payer: Cash Price |
$5,425.80
|
| Rate for Payer: Cigna Commercial |
$17,304.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,526.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$16,740.40
|
| Rate for Payer: HFN Commercial |
$17,304.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$15,047.55
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$17,304.68
|
| Rate for Payer: Quartz Beloit One Network |
$9,216.63
|
| Rate for Payer: Quartz Commercial |
$12,226.14
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$10,345.19
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$13,931.65
|
|
|
GRAFT STRAVIX 2CM X 2CM (4 SQ CM) FROZEN PS60006
|
Facility
|
IP
|
$1,560.08
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
6252143
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$795.02 |
| Max. Negotiated Rate |
$1,492.68 |
| Rate for Payer: Aetna Commercial |
$1,460.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,395.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.92
|
| Rate for Payer: Cash Price |
$468.02
|
| Rate for Payer: Cigna Commercial |
$1,492.68
|
| Rate for Payer: Health EOS Commercial |
$1,444.01
|
| Rate for Payer: HFN Commercial |
$1,492.68
|
| Rate for Payer: Multiplan Commercial |
$1,297.99
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.68
|
| Rate for Payer: Quartz Beloit One Network |
$795.02
|
| Rate for Payer: Quartz Commercial |
$973.49
|
| Rate for Payer: WEA Trust Commercial |
$892.37
|
| Rate for Payer: WPS Commercial |
$1,201.73
|
|
|
GRAFT STRAVIX 2CM X 2CM (4 SQ CM) FROZEN PS60006
|
Facility
|
OP
|
$1,560.08
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
6252143
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$1,492.68 |
| Rate for Payer: Aetna Commercial |
$1,460.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,395.34
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,054.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$811.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$778.79
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$468.02
|
| Rate for Payer: Cash Price |
$468.02
|
| Rate for Payer: Cigna Commercial |
$1,492.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$1,444.01
|
| Rate for Payer: HFN Commercial |
$1,492.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$1,297.99
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.68
|
| Rate for Payer: Quartz Beloit One Network |
$795.02
|
| Rate for Payer: Quartz Commercial |
$1,054.61
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$892.37
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$372.39
|
|
|
GRAFT STRAVIX 2CM X 4CM (8 SQ CM) FROZEN PS60005
|
Facility
|
IP
|
$9,974.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5415470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,082.75 |
| Max. Negotiated Rate |
$9,543.12 |
| Rate for Payer: Aetna Commercial |
$9,335.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,920.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,497.67
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cigna Commercial |
$9,543.12
|
| Rate for Payer: Health EOS Commercial |
$9,231.93
|
| Rate for Payer: HFN Commercial |
$9,543.12
|
| Rate for Payer: Multiplan Commercial |
$8,298.37
|
| Rate for Payer: Preferred Network Access Commercial |
$9,543.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,082.75
|
| Rate for Payer: Quartz Commercial |
$6,223.78
|
| Rate for Payer: WEA Trust Commercial |
$5,705.13
|
| Rate for Payer: WPS Commercial |
$7,682.97
|
|
|
GRAFT STRAVIX 2CM X 4CM (8 SQ CM) FROZEN PS60005
|
Facility
|
OP
|
$9,974.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5415470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$9,543.12 |
| Rate for Payer: Aetna Commercial |
$9,335.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,920.75
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,742.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,186.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,979.02
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,497.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cigna Commercial |
$9,543.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$9,231.93
|
| Rate for Payer: HFN Commercial |
$9,543.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$8,298.37
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$9,543.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,082.75
|
| Rate for Payer: Quartz Commercial |
$6,742.42
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$5,705.13
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$372.39
|
|
|
GRAFT STRAVIX 3CM X 6CM (18 SQ CM) FROZEN PS60008
|
Facility
|
OP
|
$17,819.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5415471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$17,049.22 |
| Rate for Payer: Aetna Commercial |
$16,678.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,937.31
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,045.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,265.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,895.24
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,821.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$5,345.70
|
| Rate for Payer: Cash Price |
$5,345.70
|
| Rate for Payer: Cigna Commercial |
$17,049.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$16,493.27
|
| Rate for Payer: HFN Commercial |
$17,049.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$14,825.41
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$17,049.22
|
| Rate for Payer: Quartz Beloit One Network |
$9,080.56
|
| Rate for Payer: Quartz Commercial |
$12,045.64
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$10,192.47
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$372.39
|
|
|
GRAFT STRAVIX 3CM X 6CM (18 SQ CM) FROZEN PS60008
|
Facility
|
IP
|
$17,819.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5415471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,080.56 |
| Max. Negotiated Rate |
$17,049.22 |
| Rate for Payer: Aetna Commercial |
$16,678.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,937.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,821.83
|
| Rate for Payer: Cash Price |
$5,345.70
|
| Rate for Payer: Cigna Commercial |
$17,049.22
|
| Rate for Payer: Health EOS Commercial |
$16,493.27
|
| Rate for Payer: HFN Commercial |
$17,049.22
|
| Rate for Payer: Multiplan Commercial |
$14,825.41
|
| Rate for Payer: Preferred Network Access Commercial |
$17,049.22
|
| Rate for Payer: Quartz Beloit One Network |
$9,080.56
|
| Rate for Payer: Quartz Commercial |
$11,119.06
|
| Rate for Payer: WEA Trust Commercial |
$10,192.47
|
| Rate for Payer: WPS Commercial |
$13,725.98
|
|
|
GRAFT STRAVIX MESHED 3CM X 6CM (18 SQ CM) FROZEN PS60036
|
Facility
|
IP
|
$15,841.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5885642
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,072.57 |
| Max. Negotiated Rate |
$15,156.67 |
| Rate for Payer: Aetna Commercial |
$14,827.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,168.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,731.56
|
| Rate for Payer: Cash Price |
$4,752.30
|
| Rate for Payer: Cigna Commercial |
$15,156.67
|
| Rate for Payer: Health EOS Commercial |
$14,662.43
|
| Rate for Payer: HFN Commercial |
$15,156.67
|
| Rate for Payer: Multiplan Commercial |
$13,179.71
|
| Rate for Payer: Preferred Network Access Commercial |
$15,156.67
|
| Rate for Payer: Quartz Beloit One Network |
$8,072.57
|
| Rate for Payer: Quartz Commercial |
$9,884.78
|
| Rate for Payer: WEA Trust Commercial |
$9,061.05
|
| Rate for Payer: WPS Commercial |
$12,202.32
|
|
