|
GRAFT ALLODERM 6 X 12CM 102072
|
Facility
|
IP
|
$11,575.00
|
|
| Hospital Charge Code |
2965265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,671.75 |
| Max. Negotiated Rate |
$10,649.00 |
| Rate for Payer: Aetna Commercial |
$10,417.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,954.50
|
| 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: Health EOS Commercial |
$10,301.75
|
| Rate for Payer: HFN Commercial |
$10,649.00
|
| 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 |
$6,945.00
|
| Rate for Payer: WEA Trust Commercial |
$6,366.25
|
| Rate for Payer: WPS Commercial |
$8,573.60
|
|
|
GRAFT ALLODERM 8 X 16CM 102128
|
Facility
|
IP
|
$21,751.00
|
|
| Hospital Charge Code |
2965266
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,657.99 |
| Max. Negotiated Rate |
$20,010.92 |
| Rate for Payer: Aetna Commercial |
$19,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,705.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,528.03
|
| Rate for Payer: Cash Price |
$6,525.30
|
| Rate for Payer: Cigna Commercial |
$20,010.92
|
| Rate for Payer: Health EOS Commercial |
$19,358.39
|
| Rate for Payer: HFN Commercial |
$20,010.92
|
| Rate for Payer: Multiplan Commercial |
$17,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$13,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20,010.92
|
| Rate for Payer: Quartz Beloit One Network |
$10,657.99
|
| Rate for Payer: Quartz Commercial |
$13,050.60
|
| Rate for Payer: WEA Trust Commercial |
$11,963.05
|
| Rate for Payer: WPS Commercial |
$16,110.97
|
|
|
GRAFT ALLODERM 8 X 16CM 102128
|
Facility
|
OP
|
$21,751.00
|
|
| Hospital Charge Code |
2965266
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,090.28 |
| Max. Negotiated Rate |
$87,004.00 |
| Rate for Payer: Aetna Commercial |
$19,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,705.86
|
| Rate for Payer: Aetna Managed Medicare |
$6,090.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,138.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,875.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,440.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,528.03
|
| Rate for Payer: Cash Price |
$6,525.30
|
| Rate for Payer: Cigna Commercial |
$20,010.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,171.86
|
| Rate for Payer: Health EOS Commercial |
$19,358.39
|
| Rate for Payer: HFN Commercial |
$20,010.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,313.25
|
| Rate for Payer: Multiplan Commercial |
$17,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$13,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20,010.92
|
| Rate for Payer: Quartz Beloit One Network |
$10,657.99
|
| Rate for Payer: Quartz Commercial |
$14,138.15
|
| Rate for Payer: Quartz Medicare Advantage |
$13,050.60
|
| Rate for Payer: The Alliance Commercial |
$87,004.00
|
| Rate for Payer: WEA Trust Commercial |
$11,963.05
|
| Rate for Payer: WPS Commercial |
$16,110.97
|
|
|
GRAFT AMNIOTIC MEMBRANE AMBIODRY 1.5 X 2CM AD5120
|
Facility
|
OP
|
$5,793.00
|
|
| Hospital Charge Code |
3553503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,622.04 |
| Max. Negotiated Rate |
$23,172.00 |
| Rate for Payer: Aetna Commercial |
$5,213.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,981.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,622.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,765.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,896.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,780.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,070.29
|
| Rate for Payer: Cash Price |
$1,737.90
|
| Rate for Payer: Cigna Commercial |
$5,329.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,241.76
|
| Rate for Payer: Health EOS Commercial |
$5,155.77
|
| Rate for Payer: HFN Commercial |
$5,329.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,344.75
|
| Rate for Payer: Multiplan Commercial |
$4,634.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,475.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,329.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,838.57
|
| Rate for Payer: Quartz Commercial |
$3,765.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,475.80
|
| Rate for Payer: The Alliance Commercial |
$23,172.00
|
| Rate for Payer: WEA Trust Commercial |
$3,186.15
|
| Rate for Payer: WPS Commercial |
$4,290.88
|
|
|
GRAFT AMNIOTIC MEMBRANE AMBIODRY 1.5 X 2CM AD5120
|
Facility
|
IP
|
$5,793.00
|
|
| Hospital Charge Code |
3553503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,838.57 |
| Max. Negotiated Rate |
$5,329.56 |
| Rate for Payer: Aetna Commercial |
$5,213.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,981.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,070.29
|
| Rate for Payer: Cash Price |
$1,737.90
|
| Rate for Payer: Cigna Commercial |
$5,329.56
|
| Rate for Payer: Health EOS Commercial |
$5,155.77
|
| Rate for Payer: HFN Commercial |
$5,329.56
|
| Rate for Payer: Multiplan Commercial |
$4,634.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,475.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,329.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,838.57
|
| Rate for Payer: Quartz Commercial |
$3,475.80
|
| Rate for Payer: WEA Trust Commercial |
$3,186.15
|
| Rate for Payer: WPS Commercial |
$4,290.88
|
|
|
GRAFT ANTERIOR TIBIAL TENDON FANT/TIB/T
|
Facility
|
OP
|
$13,808.00
|
|
| Hospital Charge Code |
5563550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,866.24 |
| Max. Negotiated Rate |
$55,232.00 |
| Rate for Payer: Aetna Commercial |
$12,427.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,874.88
|
| Rate for Payer: Aetna Managed Medicare |
$3,866.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,975.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,904.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,627.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,318.24
|
| Rate for Payer: Cash Price |
$4,142.40
|
| Rate for Payer: Cigna Commercial |
$12,703.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,726.96
|
| Rate for Payer: Health EOS Commercial |
$12,289.12
|
| Rate for Payer: HFN Commercial |
$12,703.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,356.00
|
| Rate for Payer: Multiplan Commercial |
$11,046.40
|
| Rate for Payer: NAPHCARE Commercial |
$8,284.80
|
| Rate for Payer: Preferred Network Access Commercial |
$12,703.36
|
| Rate for Payer: Quartz Beloit One Network |
$6,765.92
|
| Rate for Payer: Quartz Commercial |
$8,975.20
|
| Rate for Payer: Quartz Medicare Advantage |
$8,284.80
|
| Rate for Payer: The Alliance Commercial |
$55,232.00
|
| Rate for Payer: WEA Trust Commercial |
$7,594.40
|
| Rate for Payer: WPS Commercial |
$10,227.59
|
|
|
GRAFT ANTERIOR TIBIAL TENDON FANT/TIB/T
|
Facility
|
IP
|
$13,808.00
|
|
| Hospital Charge Code |
5563550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,765.92 |
| Max. Negotiated Rate |
$12,703.36 |
| Rate for Payer: Aetna Commercial |
$12,427.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,874.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,318.24
|
| Rate for Payer: Cash Price |
$4,142.40
|
| Rate for Payer: Cigna Commercial |
$12,703.36
|
| Rate for Payer: Health EOS Commercial |
$12,289.12
|
| Rate for Payer: HFN Commercial |
$12,703.36
|
| Rate for Payer: Multiplan Commercial |
$11,046.40
|
| Rate for Payer: NAPHCARE Commercial |
$8,284.80
|
| Rate for Payer: Preferred Network Access Commercial |
$12,703.36
|
| Rate for Payer: Quartz Beloit One Network |
$6,765.92
|
| Rate for Payer: Quartz Commercial |
$8,284.80
|
| Rate for Payer: WEA Trust Commercial |
$7,594.40
|
| Rate for Payer: WPS Commercial |
$10,227.59
|
|
|
GRAFT AV ACCESS HEPARIN TAPER 4 - 7MM X 80CM H470080A
|
Facility
|
OP
|
$13,441.00
|
|
| Hospital Charge Code |
3553536
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,763.48 |
| Max. Negotiated Rate |
$53,764.00 |
| Rate for Payer: Aetna Commercial |
$12,096.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,559.26
|
| Rate for Payer: Aetna Managed Medicare |
$3,763.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,736.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,720.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,451.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,123.73
|
| Rate for Payer: Cash Price |
$4,032.30
|
| Rate for Payer: Cigna Commercial |
$12,365.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,521.58
|
| Rate for Payer: Health EOS Commercial |
$11,962.49
|
| Rate for Payer: HFN Commercial |
$12,365.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,080.75
|
| Rate for Payer: Multiplan Commercial |
$10,752.80
|
| Rate for Payer: NAPHCARE Commercial |
$8,064.60
|
| Rate for Payer: Preferred Network Access Commercial |
$12,365.72
|
| Rate for Payer: Quartz Beloit One Network |
$6,586.09
|
| Rate for Payer: Quartz Commercial |
$8,736.65
|
| Rate for Payer: Quartz Medicare Advantage |
$8,064.60
|
| Rate for Payer: The Alliance Commercial |
$53,764.00
|
| Rate for Payer: WEA Trust Commercial |
$7,392.55
|
| Rate for Payer: WPS Commercial |
$9,955.75
|
|
|
GRAFT AV ACCESS HEPARIN TAPER 4 - 7MM X 80CM H470080A
|
Facility
|
IP
|
$13,441.00
|
|
| Hospital Charge Code |
3553536
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,586.09 |
| Max. Negotiated Rate |
$12,365.72 |
| Rate for Payer: Aetna Commercial |
$12,096.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,559.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,123.73
|
| Rate for Payer: Cash Price |
$4,032.30
|
| Rate for Payer: Cigna Commercial |
$12,365.72
|
| Rate for Payer: Health EOS Commercial |
$11,962.49
|
| Rate for Payer: HFN Commercial |
$12,365.72
|
| Rate for Payer: Multiplan Commercial |
$10,752.80
|
| Rate for Payer: NAPHCARE Commercial |
$8,064.60
|
| Rate for Payer: Preferred Network Access Commercial |
$12,365.72
|
| Rate for Payer: Quartz Beloit One Network |
$6,586.09
|
| Rate for Payer: Quartz Commercial |
$8,064.60
|
| Rate for Payer: WEA Trust Commercial |
$7,392.55
|
| Rate for Payer: WPS Commercial |
$9,955.75
|
|
|
GRAFT AV ACCESS PROPATEN HEPARIN THIN WALL 8MM X 80CM 70CM RINGS HT087080A
|
Facility
|
IP
|
$11,085.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3845345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,431.65 |
| Max. Negotiated Rate |
$10,198.20 |
| Rate for Payer: Aetna Commercial |
$9,976.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,533.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,875.05
|
| Rate for Payer: Cash Price |
$3,325.50
|
| Rate for Payer: Cigna Commercial |
$10,198.20
|
| Rate for Payer: Health EOS Commercial |
$9,865.65
|
| Rate for Payer: HFN Commercial |
$10,198.20
|
| Rate for Payer: Multiplan Commercial |
$8,868.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,651.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,198.20
|
| Rate for Payer: Quartz Beloit One Network |
$5,431.65
|
| Rate for Payer: Quartz Commercial |
$6,651.00
|
| Rate for Payer: WEA Trust Commercial |
$6,096.75
|
| Rate for Payer: WPS Commercial |
$8,210.66
|
|
|
GRAFT AV ACCESS PROPATEN HEPARIN THIN WALL 8MM X 80CM 70CM RINGS HT087080A
|
Facility
|
OP
|
$11,085.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3845345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,103.80 |
| Max. Negotiated Rate |
$44,340.00 |
| Rate for Payer: Aetna Commercial |
$9,976.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,533.10
|
| Rate for Payer: Aetna Managed Medicare |
$3,103.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,205.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,542.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,320.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,875.05
|
| Rate for Payer: Cash Price |
$3,325.50
|
| Rate for Payer: Cigna Commercial |
$10,198.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,203.17
|
| Rate for Payer: Health EOS Commercial |
$9,865.65
|
| Rate for Payer: HFN Commercial |
$10,198.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,313.75
|
| Rate for Payer: Multiplan Commercial |
$8,868.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,651.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,198.20
|
| Rate for Payer: Quartz Beloit One Network |
$5,431.65
|
| Rate for Payer: Quartz Commercial |
$7,205.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,651.00
|
| Rate for Payer: The Alliance Commercial |
$44,340.00
|
| Rate for Payer: WEA Trust Commercial |
$6,096.75
|
| Rate for Payer: WPS Commercial |
$8,210.66
|
|
|
GRAFT AV ACUSEAL 4-6MM X 45CM EARLY CANNULATION ECH460045A
|
Facility
|
OP
|
$7,667.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5349343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,146.76 |
| Max. Negotiated Rate |
$30,668.00 |
| Rate for Payer: Aetna Commercial |
$6,900.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,593.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,146.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,983.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,833.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,680.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,063.51
|
| Rate for Payer: Cash Price |
$2,300.10
|
| Rate for Payer: Cigna Commercial |
$7,053.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,290.45
|
| Rate for Payer: Health EOS Commercial |
$6,823.63
|
| Rate for Payer: HFN Commercial |
$7,053.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,750.25
|
| Rate for Payer: Multiplan Commercial |
$6,133.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,600.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,053.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,756.83
|
| Rate for Payer: Quartz Commercial |
$4,983.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4,600.20
|
| Rate for Payer: The Alliance Commercial |
$30,668.00
|
| Rate for Payer: WEA Trust Commercial |
$4,216.85
|
| Rate for Payer: WPS Commercial |
$5,678.95
|
|
|
GRAFT AV ACUSEAL 4-6MM X 45CM EARLY CANNULATION ECH460045A
|
Facility
|
IP
|
$7,667.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5349343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,756.83 |
| Max. Negotiated Rate |
$7,053.64 |
| Rate for Payer: Aetna Commercial |
$6,900.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,593.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,063.51
|
| Rate for Payer: Cash Price |
$2,300.10
|
| Rate for Payer: Cigna Commercial |
$7,053.64
|
| Rate for Payer: Health EOS Commercial |
$6,823.63
|
| Rate for Payer: HFN Commercial |
$7,053.64
|
| Rate for Payer: Multiplan Commercial |
$6,133.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,600.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,053.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,756.83
|
| Rate for Payer: Quartz Commercial |
$4,600.20
|
| Rate for Payer: WEA Trust Commercial |
$4,216.85
|
| Rate for Payer: WPS Commercial |
$5,678.95
|
|
|
GRAFT AV ACUSEAL EARLY CANNULATION ECH060040A
|
Facility
|
OP
|
$7,807.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
4030006
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,185.96 |
| Max. Negotiated Rate |
$31,228.00 |
| Rate for Payer: Aetna Commercial |
$7,026.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,714.02
|
| Rate for Payer: Aetna Managed Medicare |
$2,185.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,074.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,903.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,747.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,137.71
|
| Rate for Payer: Cash Price |
$2,342.10
|
| Rate for Payer: Cigna Commercial |
$7,182.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,368.80
|
| Rate for Payer: Health EOS Commercial |
$6,948.23
|
| Rate for Payer: HFN Commercial |
$7,182.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,855.25
|
| Rate for Payer: Multiplan Commercial |
$6,245.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,684.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,182.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,825.43
|
| Rate for Payer: Quartz Commercial |
$5,074.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4,684.20
|
| Rate for Payer: The Alliance Commercial |
$31,228.00
|
| Rate for Payer: WEA Trust Commercial |
$4,293.85
|
| Rate for Payer: WPS Commercial |
$5,782.64
|
|
|
GRAFT AV ACUSEAL EARLY CANNULATION ECH060040A
|
Facility
|
IP
|
$7,807.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
4030006
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,825.43 |
| Max. Negotiated Rate |
$7,182.44 |
| Rate for Payer: Aetna Commercial |
$7,026.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,714.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,137.71
|
| Rate for Payer: Cash Price |
$2,342.10
|
| Rate for Payer: Cigna Commercial |
$7,182.44
|
| Rate for Payer: Health EOS Commercial |
$6,948.23
|
| Rate for Payer: HFN Commercial |
$7,182.44
|
| Rate for Payer: Multiplan Commercial |
$6,245.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,684.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,182.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,825.43
|
| Rate for Payer: Quartz Commercial |
$4,684.20
|
| Rate for Payer: WEA Trust Commercial |
$4,293.85
|
| Rate for Payer: WPS Commercial |
$5,782.64
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 0.4,0.6 ENT-OTO-0.4-0.6
|
Facility
|
OP
|
$2,007.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
5490704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.96 |
| Max. Negotiated Rate |
$8,028.00 |
| Rate for Payer: Aetna Commercial |
$1,806.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,726.02
|
| Rate for Payer: Aetna Managed Medicare |
$561.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,304.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,003.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$963.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,063.71
|
| Rate for Payer: Cash Price |
$602.10
|
| Rate for Payer: Cigna Commercial |
$1,846.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,123.12
|
| Rate for Payer: Health EOS Commercial |
$1,786.23
|
| Rate for Payer: HFN Commercial |
$1,846.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,505.25
|
| Rate for Payer: Multiplan Commercial |
$1,605.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,204.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,846.44
|
| Rate for Payer: Quartz Beloit One Network |
$983.43
|
| Rate for Payer: Quartz Commercial |
$1,304.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,204.20
|
| Rate for Payer: The Alliance Commercial |
$8,028.00
|
| Rate for Payer: WEA Trust Commercial |
$1,103.85
|
| Rate for Payer: WPS Commercial |
$1,486.58
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 0.4,0.6 ENT-OTO-0.4-0.6
|
Facility
|
IP
|
$2,007.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
5490704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$983.43 |
| Max. Negotiated Rate |
$1,846.44 |
| Rate for Payer: Aetna Commercial |
$1,806.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,726.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,063.71
|
| Rate for Payer: Cash Price |
$602.10
|
| Rate for Payer: Cigna Commercial |
$1,846.44
|
| Rate for Payer: Health EOS Commercial |
$1,786.23
|
| Rate for Payer: HFN Commercial |
$1,846.44
|
| Rate for Payer: Multiplan Commercial |
$1,605.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,204.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,846.44
|
| Rate for Payer: Quartz Beloit One Network |
$983.43
|
| Rate for Payer: Quartz Commercial |
$1,204.20
|
| Rate for Payer: WEA Trust Commercial |
$1,103.85
|
| Rate for Payer: WPS Commercial |
$1,486.58
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 0.6,0.9 ENT-OTO-0.6-0.9
|
Facility
|
OP
|
$2,845.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
5490702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$796.60 |
| Max. Negotiated Rate |
$11,380.00 |
| Rate for Payer: Aetna Commercial |
$2,560.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,446.70
|
| Rate for Payer: Aetna Managed Medicare |
$796.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,849.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,422.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,365.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,507.85
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cigna Commercial |
$2,617.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,592.06
|
| Rate for Payer: Health EOS Commercial |
$2,532.05
|
| Rate for Payer: HFN Commercial |
$2,617.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,133.75
|
| Rate for Payer: Multiplan Commercial |
$2,276.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,707.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,617.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,394.05
|
| Rate for Payer: Quartz Commercial |
$1,849.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,707.00
|
| Rate for Payer: The Alliance Commercial |
$11,380.00
|
| Rate for Payer: WEA Trust Commercial |
$1,564.75
|
| Rate for Payer: WPS Commercial |
$2,107.29
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 0.6,0.9 ENT-OTO-0.6-0.9
|
Facility
|
IP
|
$2,845.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
5490702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,394.05 |
| Max. Negotiated Rate |
$2,617.40 |
| Rate for Payer: Aetna Commercial |
$2,560.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,446.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,507.85
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cigna Commercial |
$2,617.40
|
| Rate for Payer: Health EOS Commercial |
$2,532.05
|
| Rate for Payer: HFN Commercial |
$2,617.40
|
| Rate for Payer: Multiplan Commercial |
$2,276.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,707.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,617.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,394.05
|
| Rate for Payer: Quartz Commercial |
$1,707.00
|
| Rate for Payer: WEA Trust Commercial |
$1,564.75
|
| Rate for Payer: WPS Commercial |
$2,107.29
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 2.5X2.5 ENT-OTO-2.5X2.5 G44451
|
Facility
|
OP
|
$2,746.00
|
|
| Hospital Charge Code |
4858886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$768.88 |
| Max. Negotiated Rate |
$10,984.00 |
| Rate for Payer: Aetna Commercial |
$2,471.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,361.56
|
| Rate for Payer: Aetna Managed Medicare |
$768.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,784.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,373.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,318.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,455.38
|
| Rate for Payer: Cash Price |
$823.80
|
| Rate for Payer: Cigna Commercial |
$2,526.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,536.66
|
| Rate for Payer: Health EOS Commercial |
$2,443.94
|
| Rate for Payer: HFN Commercial |
$2,526.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,059.50
|
| Rate for Payer: Multiplan Commercial |
$2,196.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,647.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,526.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,345.54
|
| Rate for Payer: Quartz Commercial |
$1,784.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,647.60
|
| Rate for Payer: The Alliance Commercial |
$10,984.00
|
| Rate for Payer: WEA Trust Commercial |
$1,510.30
|
| Rate for Payer: WPS Commercial |
$2,033.96
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 2.5X2.5 ENT-OTO-2.5X2.5 G44451
|
Facility
|
IP
|
$2,746.00
|
|
| Hospital Charge Code |
4858886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,345.54 |
| Max. Negotiated Rate |
$2,526.32 |
| Rate for Payer: Aetna Commercial |
$2,471.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,361.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,455.38
|
| Rate for Payer: Cash Price |
$823.80
|
| Rate for Payer: Cigna Commercial |
$2,526.32
|
| Rate for Payer: Health EOS Commercial |
$2,443.94
|
| Rate for Payer: HFN Commercial |
$2,526.32
|
| Rate for Payer: Multiplan Commercial |
$2,196.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,647.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,526.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,345.54
|
| Rate for Payer: Quartz Commercial |
$1,647.60
|
| Rate for Payer: WEA Trust Commercial |
$1,510.30
|
| Rate for Payer: WPS Commercial |
$2,033.96
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 5X5 ENT-OTO-5X5 G44452
|
Facility
|
IP
|
$4,115.00
|
|
| Hospital Charge Code |
4858887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,016.35 |
| Max. Negotiated Rate |
$3,785.80 |
| Rate for Payer: Aetna Commercial |
$3,703.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,538.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,180.95
|
| Rate for Payer: Cash Price |
$1,234.50
|
| Rate for Payer: Cigna Commercial |
$3,785.80
|
| Rate for Payer: Health EOS Commercial |
$3,662.35
|
| Rate for Payer: HFN Commercial |
$3,785.80
|
| Rate for Payer: Multiplan Commercial |
$3,292.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,469.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,785.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,016.35
|
| Rate for Payer: Quartz Commercial |
$2,469.00
|
| Rate for Payer: WEA Trust Commercial |
$2,263.25
|
| Rate for Payer: WPS Commercial |
$3,047.98
|
|
|
GRAFT BIODESIGN OTOLOGIC REPAIR 5X5 ENT-OTO-5X5 G44452
|
Facility
|
OP
|
$4,115.00
|
|
| Hospital Charge Code |
4858887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,152.20 |
| Max. Negotiated Rate |
$16,460.00 |
| Rate for Payer: Aetna Commercial |
$3,703.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,538.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,152.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,674.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,057.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,975.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,180.95
|
| Rate for Payer: Cash Price |
$1,234.50
|
| Rate for Payer: Cigna Commercial |
$3,785.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,302.75
|
| Rate for Payer: Health EOS Commercial |
$3,662.35
|
| Rate for Payer: HFN Commercial |
$3,785.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,086.25
|
| Rate for Payer: Multiplan Commercial |
$3,292.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,469.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,785.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,016.35
|
| Rate for Payer: Quartz Commercial |
$2,674.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,469.00
|
| Rate for Payer: The Alliance Commercial |
$16,460.00
|
| Rate for Payer: WEA Trust Commercial |
$2,263.25
|
| Rate for Payer: WPS Commercial |
$3,047.98
|
|
|
GRAFT; COMPOSITE (EG, FULL THICKNESS OF EXTERNAL EAR OR NASAL ALA), INCLUDING PRIMARY CLOSURE, DONOR AREA
|
Facility
|
OP
|
$7,209.92
|
|
|
Service Code
|
CPT 15760
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.48 |
| Max. Negotiated Rate |
$7,209.92 |
| Rate for Payer: Aetna Managed Medicare |
$1,802.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,802.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,802.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,802.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,705.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,802.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,802.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,802.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,802.48
|
| Rate for Payer: NAPHCARE Commercial |
$2,703.72
|
| Rate for Payer: Quartz Medicare Advantage |
$1,802.48
|
| Rate for Payer: The Alliance Commercial |
$7,209.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,802.48
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,802.48
|
|
|
GRAFT COMPOSITE W/PRIMARY CLOSURE DONOR AREA 15760
|
Professional
|
Both
|
$3,461.00
|
|
|
Service Code
|
CPT 15760
|
| Hospital Charge Code |
6041658
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$659.43 |
| Max. Negotiated Rate |
$3,287.95 |
| Rate for Payer: Aetna Commercial |
$3,287.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,976.46
|
| Rate for Payer: Cash Price |
$1,038.30
|
| Rate for Payer: Cash Price |
$1,038.30
|
| Rate for Payer: Cash Price |
$1,038.30
|
| Rate for Payer: Cigna Commercial |
$3,287.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$659.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,076.60
|
| Rate for Payer: Health EOS Commercial |
$3,149.51
|
| Rate for Payer: HFN Commercial |
$3,287.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,328.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,328.49
|
| Rate for Payer: Multiplan Commercial |
$2,768.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,287.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,522.84
|
| Rate for Payer: Quartz Commercial |
$1,972.77
|
| Rate for Payer: The Alliance Commercial |
$1,730.50
|
| Rate for Payer: United Healthcare Medicaid |
$659.43
|
| Rate for Payer: WEA Trust Commercial |
$1,903.55
|
| Rate for Payer: WPS Commercial |
$2,563.56
|
|
