|
GRAFT STRAVIX MESHED 3CM X 6CM (18 SQ CM) FROZEN PS60036
|
Facility
|
OP
|
$15,841.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5885642
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| 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: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,708.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,237.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,907.83
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,731.56
|
| 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 |
$4,752.30
|
| Rate for Payer: Cash Price |
$4,752.30
|
| Rate for Payer: Cigna Commercial |
$15,156.67
|
| 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 |
$14,662.43
|
| Rate for Payer: HFN Commercial |
$15,156.67
|
| 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 |
$13,179.71
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| 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 |
$10,708.52
|
| 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 |
$9,061.05
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$372.39
|
|
|
GRAFT STRAVIX PL 2CM X 4CM (8 SQ CM) SHELF STABLE PS61024
|
Facility
|
IP
|
$8,086.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5881629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,120.63 |
| Max. Negotiated Rate |
$7,736.68 |
| Rate for Payer: Aetna Commercial |
$7,568.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,232.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,457.00
|
| Rate for Payer: Cash Price |
$2,425.80
|
| Rate for Payer: Cigna Commercial |
$7,736.68
|
| Rate for Payer: Health EOS Commercial |
$7,484.40
|
| Rate for Payer: HFN Commercial |
$7,736.68
|
| Rate for Payer: Multiplan Commercial |
$6,727.55
|
| Rate for Payer: Preferred Network Access Commercial |
$7,736.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,120.63
|
| Rate for Payer: Quartz Commercial |
$5,045.66
|
| Rate for Payer: WEA Trust Commercial |
$4,625.19
|
| Rate for Payer: WPS Commercial |
$6,228.65
|
|
|
GRAFT STRAVIX PL 2CM X 4CM (8 SQ CM) SHELF STABLE PS61024
|
Facility
|
OP
|
$8,086.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5881629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$7,736.68 |
| Rate for Payer: Aetna Commercial |
$7,568.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,232.12
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,466.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,204.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,036.53
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,457.00
|
| 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 |
$2,425.80
|
| Rate for Payer: Cash Price |
$2,425.80
|
| Rate for Payer: Cigna Commercial |
$7,736.68
|
| 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 |
$7,484.40
|
| Rate for Payer: HFN Commercial |
$7,736.68
|
| 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 |
$6,727.55
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$7,736.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,120.63
|
| Rate for Payer: Quartz Commercial |
$5,466.14
|
| 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 |
$4,625.19
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$372.39
|
|
|
GRAFT STRAVIX PL 3CM X 6CM (18 SQ CM) SHELF STABLE PS61036
|
Facility
|
OP
|
$14,044.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5881628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$13,437.30 |
| Rate for Payer: Aetna Commercial |
$13,145.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,560.95
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,493.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,302.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,010.76
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,741.05
|
| 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 |
$4,213.20
|
| Rate for Payer: Cash Price |
$4,213.20
|
| Rate for Payer: Cigna Commercial |
$13,437.30
|
| 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 |
$12,999.13
|
| Rate for Payer: HFN Commercial |
$13,437.30
|
| 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 |
$11,684.61
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$13,437.30
|
| Rate for Payer: Quartz Beloit One Network |
$7,156.82
|
| Rate for Payer: Quartz Commercial |
$9,493.74
|
| 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 |
$8,033.17
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$372.39
|
|
|
GRAFT STRAVIX PL 3CM X 6CM (18 SQ CM) SHELF STABLE PS61036
|
Facility
|
IP
|
$14,044.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5881628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,156.82 |
| Max. Negotiated Rate |
$13,437.30 |
| Rate for Payer: Aetna Commercial |
$13,145.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,560.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,741.05
|
| Rate for Payer: Cash Price |
$4,213.20
|
| Rate for Payer: Cigna Commercial |
$13,437.30
|
| Rate for Payer: Health EOS Commercial |
$12,999.13
|
| Rate for Payer: HFN Commercial |
$13,437.30
|
| Rate for Payer: Multiplan Commercial |
$11,684.61
|
| Rate for Payer: Preferred Network Access Commercial |
$13,437.30
|
| Rate for Payer: Quartz Beloit One Network |
$7,156.82
|
| Rate for Payer: Quartz Commercial |
$8,763.46
|
| Rate for Payer: WEA Trust Commercial |
$8,033.17
|
| Rate for Payer: WPS Commercial |
$10,818.09
|
|
|
GRAFT STRETCH 4 - 6MM X 45CM PROPATEN IRH463845
|
Facility
|
OP
|
$7,499.00
|
|
| Hospital Charge Code |
3525506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,183.71 |
| Max. Negotiated Rate |
$7,175.04 |
| Rate for Payer: Aetna Commercial |
$7,019.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,707.11
|
| Rate for Payer: Aetna Managed Medicare |
$2,183.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,069.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,899.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,743.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,133.45
|
| Rate for Payer: Cash Price |
$2,249.70
|
| Rate for Payer: Cigna Commercial |
$7,175.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,364.42
|
| Rate for Payer: Health EOS Commercial |
$6,941.07
|
| Rate for Payer: HFN Commercial |
$7,175.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,849.22
|
| Rate for Payer: Multiplan Commercial |
$6,239.17
|
| Rate for Payer: NAPHCARE Commercial |
$4,679.38
|
| Rate for Payer: Preferred Network Access Commercial |
$7,175.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,821.49
|
| Rate for Payer: Quartz Commercial |
$5,069.32
|
| Rate for Payer: Quartz Medicare Advantage |
$4,679.38
|
| Rate for Payer: The Alliance Commercial |
$3,899.48
|
| Rate for Payer: WEA Trust Commercial |
$4,289.43
|
| Rate for Payer: WPS Commercial |
$5,776.48
|
|
|
GRAFT STRETCH 4 - 6MM X 45CM PROPATEN IRH463845
|
Facility
|
IP
|
$7,499.00
|
|
| Hospital Charge Code |
3525506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,821.49 |
| Max. Negotiated Rate |
$7,175.04 |
| Rate for Payer: Aetna Commercial |
$7,019.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,707.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,133.45
|
| Rate for Payer: Cash Price |
$2,249.70
|
| Rate for Payer: Cigna Commercial |
$7,175.04
|
| Rate for Payer: Health EOS Commercial |
$6,941.07
|
| Rate for Payer: HFN Commercial |
$7,175.04
|
| Rate for Payer: Multiplan Commercial |
$6,239.17
|
| Rate for Payer: Preferred Network Access Commercial |
$7,175.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,821.49
|
| Rate for Payer: Quartz Commercial |
$4,679.38
|
| Rate for Payer: WEA Trust Commercial |
$4,289.43
|
| Rate for Payer: WPS Commercial |
$5,776.48
|
|
|
GRAFT STRETCH HEPARIN TAPER 4-6MM X 45CM 38CM IRH463845
|
Facility
|
IP
|
$7,994.00
|
|
| Hospital Charge Code |
3553535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,073.74 |
| Max. Negotiated Rate |
$7,648.66 |
| Rate for Payer: Aetna Commercial |
$7,482.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,149.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,406.29
|
| Rate for Payer: Cash Price |
$2,398.20
|
| Rate for Payer: Cigna Commercial |
$7,648.66
|
| Rate for Payer: Health EOS Commercial |
$7,399.25
|
| Rate for Payer: HFN Commercial |
$7,648.66
|
| Rate for Payer: Multiplan Commercial |
$6,651.01
|
| Rate for Payer: Preferred Network Access Commercial |
$7,648.66
|
| Rate for Payer: Quartz Beloit One Network |
$4,073.74
|
| Rate for Payer: Quartz Commercial |
$4,988.26
|
| Rate for Payer: WEA Trust Commercial |
$4,572.57
|
| Rate for Payer: WPS Commercial |
$6,157.78
|
|
|
GRAFT STRETCH HEPARIN TAPER 4-6MM X 45CM 38CM IRH463845
|
Facility
|
OP
|
$7,994.00
|
|
| Hospital Charge Code |
3553535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,327.85 |
| Max. Negotiated Rate |
$7,648.66 |
| Rate for Payer: Aetna Commercial |
$7,482.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,149.83
|
| Rate for Payer: Aetna Managed Medicare |
$2,327.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,403.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,156.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,990.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,406.29
|
| Rate for Payer: Cash Price |
$2,398.20
|
| Rate for Payer: Cigna Commercial |
$7,648.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,652.51
|
| Rate for Payer: Health EOS Commercial |
$7,399.25
|
| Rate for Payer: HFN Commercial |
$7,648.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,235.32
|
| Rate for Payer: Multiplan Commercial |
$6,651.01
|
| Rate for Payer: NAPHCARE Commercial |
$4,988.26
|
| Rate for Payer: Preferred Network Access Commercial |
$7,648.66
|
| Rate for Payer: Quartz Beloit One Network |
$4,073.74
|
| Rate for Payer: Quartz Commercial |
$5,403.94
|
| Rate for Payer: Quartz Medicare Advantage |
$4,988.26
|
| Rate for Payer: The Alliance Commercial |
$4,156.88
|
| Rate for Payer: WEA Trust Commercial |
$4,572.57
|
| Rate for Payer: WPS Commercial |
$6,157.78
|
|
|
GRAFT STRETCH STD WALL 8MM X 10CM S0801
|
Facility
|
OP
|
$2,634.00
|
|
| Hospital Charge Code |
3553527
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$767.02 |
| Max. Negotiated Rate |
$2,520.21 |
| Rate for Payer: Aetna Commercial |
$2,465.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,355.85
|
| Rate for Payer: Aetna Managed Medicare |
$767.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,780.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,369.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,314.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,451.86
|
| Rate for Payer: Cash Price |
$790.20
|
| Rate for Payer: Cigna Commercial |
$2,520.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,532.99
|
| Rate for Payer: Health EOS Commercial |
$2,438.03
|
| Rate for Payer: HFN Commercial |
$2,520.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,054.52
|
| Rate for Payer: Multiplan Commercial |
$2,191.49
|
| Rate for Payer: NAPHCARE Commercial |
$1,643.62
|
| Rate for Payer: Preferred Network Access Commercial |
$2,520.21
|
| Rate for Payer: Quartz Beloit One Network |
$1,342.29
|
| Rate for Payer: Quartz Commercial |
$1,780.58
|
| Rate for Payer: Quartz Medicare Advantage |
$1,643.62
|
| Rate for Payer: The Alliance Commercial |
$1,369.68
|
| Rate for Payer: WEA Trust Commercial |
$1,506.65
|
| Rate for Payer: WPS Commercial |
$2,028.97
|
|
|
GRAFT STRETCH STD WALL 8MM X 10CM S0801
|
Facility
|
IP
|
$2,634.00
|
|
| Hospital Charge Code |
3553527
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,342.29 |
| Max. Negotiated Rate |
$2,520.21 |
| Rate for Payer: Aetna Commercial |
$2,465.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,355.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,451.86
|
| Rate for Payer: Cash Price |
$790.20
|
| Rate for Payer: Cigna Commercial |
$2,520.21
|
| Rate for Payer: Health EOS Commercial |
$2,438.03
|
| Rate for Payer: HFN Commercial |
$2,520.21
|
| Rate for Payer: Multiplan Commercial |
$2,191.49
|
| Rate for Payer: Preferred Network Access Commercial |
$2,520.21
|
| Rate for Payer: Quartz Beloit One Network |
$1,342.29
|
| Rate for Payer: Quartz Commercial |
$1,643.62
|
| Rate for Payer: WEA Trust Commercial |
$1,506.65
|
| Rate for Payer: WPS Commercial |
$2,028.97
|
|
|
GRAFT STRETCH THIN WALL 10MM X 40CM ST1004
|
Facility
|
IP
|
$6,979.00
|
|
| Hospital Charge Code |
3553532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,556.50 |
| Max. Negotiated Rate |
$6,677.51 |
| Rate for Payer: Aetna Commercial |
$6,532.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,242.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,846.82
|
| Rate for Payer: Cash Price |
$2,093.70
|
| Rate for Payer: Cigna Commercial |
$6,677.51
|
| Rate for Payer: Health EOS Commercial |
$6,459.76
|
| Rate for Payer: HFN Commercial |
$6,677.51
|
| Rate for Payer: Multiplan Commercial |
$5,806.53
|
| Rate for Payer: Preferred Network Access Commercial |
$6,677.51
|
| Rate for Payer: Quartz Beloit One Network |
$3,556.50
|
| Rate for Payer: Quartz Commercial |
$4,354.90
|
| Rate for Payer: WEA Trust Commercial |
$3,991.99
|
| Rate for Payer: WPS Commercial |
$5,375.92
|
|
|
GRAFT STRETCH THIN WALL 10MM X 40CM ST1004
|
Facility
|
OP
|
$6,979.00
|
|
| Hospital Charge Code |
3553532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,032.28 |
| Max. Negotiated Rate |
$6,677.51 |
| Rate for Payer: Aetna Commercial |
$6,532.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,242.02
|
| Rate for Payer: Aetna Managed Medicare |
$2,032.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,717.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,629.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,483.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,846.82
|
| Rate for Payer: Cash Price |
$2,093.70
|
| Rate for Payer: Cigna Commercial |
$6,677.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,061.78
|
| Rate for Payer: Health EOS Commercial |
$6,459.76
|
| Rate for Payer: HFN Commercial |
$6,677.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,443.62
|
| Rate for Payer: Multiplan Commercial |
$5,806.53
|
| Rate for Payer: NAPHCARE Commercial |
$4,354.90
|
| Rate for Payer: Preferred Network Access Commercial |
$6,677.51
|
| Rate for Payer: Quartz Beloit One Network |
$3,556.50
|
| Rate for Payer: Quartz Commercial |
$4,717.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,354.90
|
| Rate for Payer: The Alliance Commercial |
$3,629.08
|
| Rate for Payer: WEA Trust Commercial |
$3,991.99
|
| Rate for Payer: WPS Commercial |
$5,375.92
|
|
|
GRAFT STRETCH THIN WALL 10MM X 80CM ST1008
|
Facility
|
IP
|
$8,513.00
|
|
| Hospital Charge Code |
3553534
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,338.22 |
| Max. Negotiated Rate |
$8,145.24 |
| Rate for Payer: Aetna Commercial |
$7,968.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,614.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,692.37
|
| Rate for Payer: Cash Price |
$2,553.90
|
| Rate for Payer: Cigna Commercial |
$8,145.24
|
| Rate for Payer: Health EOS Commercial |
$7,879.63
|
| Rate for Payer: HFN Commercial |
$8,145.24
|
| Rate for Payer: Multiplan Commercial |
$7,082.82
|
| Rate for Payer: Preferred Network Access Commercial |
$8,145.24
|
| Rate for Payer: Quartz Beloit One Network |
$4,338.22
|
| Rate for Payer: Quartz Commercial |
$5,312.11
|
| Rate for Payer: WEA Trust Commercial |
$4,869.44
|
| Rate for Payer: WPS Commercial |
$6,557.56
|
|
|
GRAFT STRETCH THIN WALL 10MM X 80CM ST1008
|
Facility
|
OP
|
$8,513.00
|
|
| Hospital Charge Code |
3553534
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,478.99 |
| Max. Negotiated Rate |
$8,145.24 |
| Rate for Payer: Aetna Commercial |
$7,968.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,614.03
|
| Rate for Payer: Aetna Managed Medicare |
$2,478.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,754.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,426.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,249.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,692.37
|
| Rate for Payer: Cash Price |
$2,553.90
|
| Rate for Payer: Cigna Commercial |
$8,145.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,954.57
|
| Rate for Payer: Health EOS Commercial |
$7,879.63
|
| Rate for Payer: HFN Commercial |
$8,145.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,640.14
|
| Rate for Payer: Multiplan Commercial |
$7,082.82
|
| Rate for Payer: NAPHCARE Commercial |
$5,312.11
|
| Rate for Payer: Preferred Network Access Commercial |
$8,145.24
|
| Rate for Payer: Quartz Beloit One Network |
$4,338.22
|
| Rate for Payer: Quartz Commercial |
$5,754.79
|
| Rate for Payer: Quartz Medicare Advantage |
$5,312.11
|
| Rate for Payer: The Alliance Commercial |
$4,426.76
|
| Rate for Payer: WEA Trust Commercial |
$4,869.44
|
| Rate for Payer: WPS Commercial |
$6,557.56
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-001-006
|
Facility
|
OP
|
$18,299.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299214
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,328.67 |
| Max. Negotiated Rate |
$17,508.48 |
| Rate for Payer: Aetna Commercial |
$17,127.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,366.63
|
| Rate for Payer: Aetna Managed Medicare |
$5,328.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,370.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,515.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,134.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,086.41
|
| Rate for Payer: Cash Price |
$5,489.70
|
| Rate for Payer: Cigna Commercial |
$17,508.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,650.02
|
| Rate for Payer: Health EOS Commercial |
$16,937.55
|
| Rate for Payer: HFN Commercial |
$17,508.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,273.22
|
| Rate for Payer: Multiplan Commercial |
$15,224.77
|
| Rate for Payer: NAPHCARE Commercial |
$11,418.58
|
| Rate for Payer: Preferred Network Access Commercial |
$17,508.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,325.17
|
| Rate for Payer: Quartz Commercial |
$12,370.12
|
| Rate for Payer: Quartz Medicare Advantage |
$11,418.58
|
| Rate for Payer: The Alliance Commercial |
$9,515.48
|
| Rate for Payer: WEA Trust Commercial |
$10,467.03
|
| Rate for Payer: WPS Commercial |
$14,095.72
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-001-006
|
Facility
|
IP
|
$18,299.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299214
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,325.17 |
| Max. Negotiated Rate |
$17,508.48 |
| Rate for Payer: Aetna Commercial |
$17,127.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,366.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,086.41
|
| Rate for Payer: Cash Price |
$5,489.70
|
| Rate for Payer: Cigna Commercial |
$17,508.48
|
| Rate for Payer: Health EOS Commercial |
$16,937.55
|
| Rate for Payer: HFN Commercial |
$17,508.48
|
| Rate for Payer: Multiplan Commercial |
$15,224.77
|
| Rate for Payer: Preferred Network Access Commercial |
$17,508.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,325.17
|
| Rate for Payer: Quartz Commercial |
$11,418.58
|
| Rate for Payer: WEA Trust Commercial |
$10,467.03
|
| Rate for Payer: WPS Commercial |
$14,095.72
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-004-100
|
Facility
|
OP
|
$20,134.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
2967343
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,863.02 |
| Max. Negotiated Rate |
$19,264.21 |
| Rate for Payer: Aetna Commercial |
$18,845.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,007.85
|
| Rate for Payer: Aetna Managed Medicare |
$5,863.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,610.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,469.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,050.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,097.86
|
| Rate for Payer: Cash Price |
$6,040.20
|
| Rate for Payer: Cigna Commercial |
$19,264.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,717.99
|
| Rate for Payer: Health EOS Commercial |
$18,636.03
|
| Rate for Payer: HFN Commercial |
$19,264.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,704.52
|
| Rate for Payer: Multiplan Commercial |
$16,751.49
|
| Rate for Payer: NAPHCARE Commercial |
$12,563.62
|
| Rate for Payer: Preferred Network Access Commercial |
$19,264.21
|
| Rate for Payer: Quartz Beloit One Network |
$10,260.29
|
| Rate for Payer: Quartz Commercial |
$13,610.58
|
| Rate for Payer: Quartz Medicare Advantage |
$12,563.62
|
| Rate for Payer: The Alliance Commercial |
$10,469.68
|
| Rate for Payer: WEA Trust Commercial |
$11,516.65
|
| Rate for Payer: WPS Commercial |
$15,509.22
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-004-100
|
Facility
|
IP
|
$20,134.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
2967343
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,260.29 |
| Max. Negotiated Rate |
$19,264.21 |
| Rate for Payer: Aetna Commercial |
$18,845.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,007.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,097.86
|
| Rate for Payer: Cash Price |
$6,040.20
|
| Rate for Payer: Cigna Commercial |
$19,264.21
|
| Rate for Payer: Health EOS Commercial |
$18,636.03
|
| Rate for Payer: HFN Commercial |
$19,264.21
|
| Rate for Payer: Multiplan Commercial |
$16,751.49
|
| Rate for Payer: Preferred Network Access Commercial |
$19,264.21
|
| Rate for Payer: Quartz Beloit One Network |
$10,260.29
|
| Rate for Payer: Quartz Commercial |
$12,563.62
|
| Rate for Payer: WEA Trust Commercial |
$11,516.65
|
| Rate for Payer: WPS Commercial |
$15,509.22
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-200-006
|
Facility
|
OP
|
$20,134.00
|
|
| Hospital Charge Code |
2967341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,863.02 |
| Max. Negotiated Rate |
$19,264.21 |
| Rate for Payer: Aetna Commercial |
$18,845.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,007.85
|
| Rate for Payer: Aetna Managed Medicare |
$5,863.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,610.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,469.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,050.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,097.86
|
| Rate for Payer: Cash Price |
$6,040.20
|
| Rate for Payer: Cigna Commercial |
$19,264.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,717.99
|
| Rate for Payer: Health EOS Commercial |
$18,636.03
|
| Rate for Payer: HFN Commercial |
$19,264.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,704.52
|
| Rate for Payer: Multiplan Commercial |
$16,751.49
|
| Rate for Payer: NAPHCARE Commercial |
$12,563.62
|
| Rate for Payer: Preferred Network Access Commercial |
$19,264.21
|
| Rate for Payer: Quartz Beloit One Network |
$10,260.29
|
| Rate for Payer: Quartz Commercial |
$13,610.58
|
| Rate for Payer: Quartz Medicare Advantage |
$12,563.62
|
| Rate for Payer: The Alliance Commercial |
$10,469.68
|
| Rate for Payer: WEA Trust Commercial |
$11,516.65
|
| Rate for Payer: WPS Commercial |
$15,509.22
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-200-006
|
Facility
|
IP
|
$20,134.00
|
|
| Hospital Charge Code |
2967341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,260.29 |
| Max. Negotiated Rate |
$19,264.21 |
| Rate for Payer: Aetna Commercial |
$18,845.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,007.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,097.86
|
| Rate for Payer: Cash Price |
$6,040.20
|
| Rate for Payer: Cigna Commercial |
$19,264.21
|
| Rate for Payer: Health EOS Commercial |
$18,636.03
|
| Rate for Payer: HFN Commercial |
$19,264.21
|
| Rate for Payer: Multiplan Commercial |
$16,751.49
|
| Rate for Payer: Preferred Network Access Commercial |
$19,264.21
|
| Rate for Payer: Quartz Beloit One Network |
$10,260.29
|
| Rate for Payer: Quartz Commercial |
$12,563.62
|
| Rate for Payer: WEA Trust Commercial |
$11,516.65
|
| Rate for Payer: WPS Commercial |
$15,509.22
|
|
|
GRAFT SURGIMEND 16 X 20CM 606-001-008
|
Facility
|
OP
|
$39,035.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299217
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,366.99 |
| Max. Negotiated Rate |
$37,348.69 |
| Rate for Payer: Aetna Commercial |
$36,536.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34,912.90
|
| Rate for Payer: Aetna Managed Medicare |
$11,366.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26,387.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,298.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19,486.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21,516.09
|
| Rate for Payer: Cash Price |
$11,710.50
|
| Rate for Payer: Cigna Commercial |
$37,348.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,718.37
|
| Rate for Payer: Health EOS Commercial |
$36,130.80
|
| Rate for Payer: HFN Commercial |
$37,348.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30,447.30
|
| Rate for Payer: Multiplan Commercial |
$32,477.12
|
| Rate for Payer: NAPHCARE Commercial |
$24,357.84
|
| Rate for Payer: Preferred Network Access Commercial |
$37,348.69
|
| Rate for Payer: Quartz Beloit One Network |
$19,892.24
|
| Rate for Payer: Quartz Commercial |
$26,387.66
|
| Rate for Payer: Quartz Medicare Advantage |
$24,357.84
|
| Rate for Payer: The Alliance Commercial |
$20,298.20
|
| Rate for Payer: WEA Trust Commercial |
$22,328.02
|
| Rate for Payer: WPS Commercial |
$30,068.66
|
|
|
GRAFT SURGIMEND 16 X 20CM 606-001-008
|
Facility
|
IP
|
$39,035.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299217
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19,892.24 |
| Max. Negotiated Rate |
$37,348.69 |
| Rate for Payer: Aetna Commercial |
$36,536.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34,912.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21,516.09
|
| Rate for Payer: Cash Price |
$11,710.50
|
| Rate for Payer: Cigna Commercial |
$37,348.69
|
| Rate for Payer: Health EOS Commercial |
$36,130.80
|
| Rate for Payer: HFN Commercial |
$37,348.69
|
| Rate for Payer: Multiplan Commercial |
$32,477.12
|
| Rate for Payer: Preferred Network Access Commercial |
$37,348.69
|
| Rate for Payer: Quartz Beloit One Network |
$19,892.24
|
| Rate for Payer: Quartz Commercial |
$24,357.84
|
| Rate for Payer: WEA Trust Commercial |
$22,328.02
|
| Rate for Payer: WPS Commercial |
$30,068.66
|
|
|
GRAFT SURGIMEND 25 X 40CM 606-001-016
|
Facility
|
OP
|
$134,184.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299215
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39,074.38 |
| Max. Negotiated Rate |
$128,387.25 |
| Rate for Payer: Aetna Commercial |
$125,596.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120,014.17
|
| Rate for Payer: Aetna Managed Medicare |
$39,074.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$90,708.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69,775.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66,984.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73,962.22
|
| Rate for Payer: Cash Price |
$40,255.20
|
| Rate for Payer: Cigna Commercial |
$128,387.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78,095.09
|
| Rate for Payer: Health EOS Commercial |
$124,200.71
|
| Rate for Payer: HFN Commercial |
$128,387.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$104,663.52
|
| Rate for Payer: Multiplan Commercial |
$111,641.09
|
| Rate for Payer: NAPHCARE Commercial |
$83,730.82
|
| Rate for Payer: Preferred Network Access Commercial |
$128,387.25
|
| Rate for Payer: Quartz Beloit One Network |
$68,380.17
|
| Rate for Payer: Quartz Commercial |
$90,708.38
|
| Rate for Payer: Quartz Medicare Advantage |
$83,730.82
|
| Rate for Payer: The Alliance Commercial |
$69,775.68
|
| Rate for Payer: WEA Trust Commercial |
$76,753.25
|
| Rate for Payer: WPS Commercial |
$103,361.94
|
|
|
GRAFT SURGIMEND 25 X 40CM 606-001-016
|
Facility
|
IP
|
$134,184.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299215
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$68,380.17 |
| Max. Negotiated Rate |
$128,387.25 |
| Rate for Payer: Aetna Commercial |
$125,596.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120,014.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73,962.22
|
| Rate for Payer: Cash Price |
$40,255.20
|
| Rate for Payer: Cigna Commercial |
$128,387.25
|
| Rate for Payer: Health EOS Commercial |
$124,200.71
|
| Rate for Payer: HFN Commercial |
$128,387.25
|
| Rate for Payer: Multiplan Commercial |
$111,641.09
|
| Rate for Payer: Preferred Network Access Commercial |
$128,387.25
|
| Rate for Payer: Quartz Beloit One Network |
$68,380.17
|
| Rate for Payer: Quartz Commercial |
$83,730.82
|
| Rate for Payer: WEA Trust Commercial |
$76,753.25
|
| Rate for Payer: WPS Commercial |
$103,361.94
|
|
