|
GRAFT SURGIMEND 8 X 16CM 606-004-103
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
GRAFT SURGIMEND 8 X 16CM 606-004-103
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
Graft Theraskin per sq cm Q4121
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
HCPCS Q4121
|
| Hospital Charge Code |
4506680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.65 |
| Max. Negotiated Rate |
$164.57 |
| Rate for Payer: Aetna Commercial |
$160.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.81
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$164.57
|
| Rate for Payer: Health EOS Commercial |
$159.20
|
| Rate for Payer: HFN Commercial |
$164.57
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: Preferred Network Access Commercial |
$164.57
|
| Rate for Payer: Quartz Beloit One Network |
$87.65
|
| Rate for Payer: Quartz Commercial |
$107.33
|
| Rate for Payer: WEA Trust Commercial |
$98.38
|
| Rate for Payer: WPS Commercial |
$132.49
|
|
|
Graft Theraskin per sq cm Q4121
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS Q4121
|
| Hospital Charge Code |
4506680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.48 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$160.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.84
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$116.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$89.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$85.86
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.81
|
| 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 |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$164.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.48
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$159.20
|
| Rate for Payer: HFN Commercial |
$164.57
|
| 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 |
$143.10
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$164.57
|
| Rate for Payer: Quartz Beloit One Network |
$87.65
|
| Rate for Payer: Quartz Commercial |
$116.27
|
| 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 |
$98.38
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$119.95
|
|
|
Graft Theraskin per sq cm Q4121
|
Professional
|
Both
|
$172.00
|
|
|
Service Code
|
HCPCS Q4121
|
| Hospital Charge Code |
4506680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.98 |
| Max. Negotiated Rate |
$348.66 |
| Rate for Payer: Aetna Commercial |
$169.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.84
|
| Rate for Payer: Aetna Managed Medicare |
$126.79
|
| Rate for Payer: Anthem Medicare Advantage |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.79
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$169.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.98
|
| Rate for Payer: Health EOS Commercial |
$162.78
|
| Rate for Payer: HFN Commercial |
$169.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$160.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$160.79
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: NAPHCARE Commercial |
$190.18
|
| Rate for Payer: Preferred Network Access Commercial |
$169.94
|
| Rate for Payer: Quartz Beloit One Network |
$78.71
|
| Rate for Payer: Quartz Commercial |
$101.96
|
| Rate for Payer: Quartz Medicare Advantage |
$126.79
|
| Rate for Payer: The Alliance Commercial |
$348.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.79
|
| Rate for Payer: WEA Trust Commercial |
$98.38
|
| Rate for Payer: WPS Commercial |
$119.95
|
|
|
GRAFT TUTOPLAST PERICARDIUM 1.5 X 15.CM 68250
|
Facility
|
OP
|
$2,990.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6172005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$870.69 |
| Max. Negotiated Rate |
$2,860.83 |
| Rate for Payer: Aetna Commercial |
$2,798.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,674.26
|
| Rate for Payer: Aetna Managed Medicare |
$870.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,021.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,554.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,492.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,648.09
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,860.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,740.18
|
| Rate for Payer: Health EOS Commercial |
$2,767.54
|
| Rate for Payer: HFN Commercial |
$2,860.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,332.20
|
| Rate for Payer: Multiplan Commercial |
$2,487.68
|
| Rate for Payer: NAPHCARE Commercial |
$1,865.76
|
| Rate for Payer: Preferred Network Access Commercial |
$2,860.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.70
|
| Rate for Payer: Quartz Commercial |
$2,021.24
|
| Rate for Payer: Quartz Medicare Advantage |
$1,865.76
|
| Rate for Payer: The Alliance Commercial |
$1,554.80
|
| Rate for Payer: WEA Trust Commercial |
$1,710.28
|
| Rate for Payer: WPS Commercial |
$2,303.20
|
|
|
GRAFT TUTOPLAST PERICARDIUM 1.5 X 15.CM 68250
|
Facility
|
IP
|
$2,990.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6172005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,523.70 |
| Max. Negotiated Rate |
$2,860.83 |
| Rate for Payer: Aetna Commercial |
$2,798.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,674.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,648.09
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,860.83
|
| Rate for Payer: Health EOS Commercial |
$2,767.54
|
| Rate for Payer: HFN Commercial |
$2,860.83
|
| Rate for Payer: Multiplan Commercial |
$2,487.68
|
| Rate for Payer: Preferred Network Access Commercial |
$2,860.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.70
|
| Rate for Payer: Quartz Commercial |
$1,865.76
|
| Rate for Payer: WEA Trust Commercial |
$1,710.28
|
| Rate for Payer: WPS Commercial |
$2,303.20
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN 6MM X 80CM 60CM RINGS HT066080A
|
Facility
|
IP
|
$16,630.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,474.65 |
| Max. Negotiated Rate |
$15,911.58 |
| Rate for Payer: Aetna Commercial |
$15,565.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,873.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,166.46
|
| Rate for Payer: Cash Price |
$4,989.00
|
| Rate for Payer: Cigna Commercial |
$15,911.58
|
| Rate for Payer: Health EOS Commercial |
$15,392.73
|
| Rate for Payer: HFN Commercial |
$15,911.58
|
| Rate for Payer: Multiplan Commercial |
$13,836.16
|
| Rate for Payer: Preferred Network Access Commercial |
$15,911.58
|
| Rate for Payer: Quartz Beloit One Network |
$8,474.65
|
| Rate for Payer: Quartz Commercial |
$10,377.12
|
| Rate for Payer: WEA Trust Commercial |
$9,512.36
|
| Rate for Payer: WPS Commercial |
$12,810.09
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN 6MM X 80CM 60CM RINGS HT066080A
|
Facility
|
OP
|
$16,630.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,842.66 |
| Max. Negotiated Rate |
$15,911.58 |
| Rate for Payer: Aetna Commercial |
$15,565.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,873.87
|
| Rate for Payer: Aetna Managed Medicare |
$4,842.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,241.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,647.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,301.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,166.46
|
| Rate for Payer: Cash Price |
$4,989.00
|
| Rate for Payer: Cigna Commercial |
$15,911.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,678.66
|
| Rate for Payer: Health EOS Commercial |
$15,392.73
|
| Rate for Payer: HFN Commercial |
$15,911.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,971.40
|
| Rate for Payer: Multiplan Commercial |
$13,836.16
|
| Rate for Payer: NAPHCARE Commercial |
$10,377.12
|
| Rate for Payer: Preferred Network Access Commercial |
$15,911.58
|
| Rate for Payer: Quartz Beloit One Network |
$8,474.65
|
| Rate for Payer: Quartz Commercial |
$11,241.88
|
| Rate for Payer: Quartz Medicare Advantage |
$10,377.12
|
| Rate for Payer: The Alliance Commercial |
$8,647.60
|
| Rate for Payer: WEA Trust Commercial |
$9,512.36
|
| Rate for Payer: WPS Commercial |
$12,810.09
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN 7MM X 80CM 60CM RINGS HT076080A
|
Facility
|
IP
|
$15,991.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5286609
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,149.01 |
| Max. Negotiated Rate |
$15,300.19 |
| Rate for Payer: Aetna Commercial |
$14,967.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,302.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,814.24
|
| Rate for Payer: Cash Price |
$4,797.30
|
| Rate for Payer: Cigna Commercial |
$15,300.19
|
| Rate for Payer: Health EOS Commercial |
$14,801.27
|
| Rate for Payer: HFN Commercial |
$15,300.19
|
| Rate for Payer: Multiplan Commercial |
$13,304.51
|
| Rate for Payer: Preferred Network Access Commercial |
$15,300.19
|
| Rate for Payer: Quartz Beloit One Network |
$8,149.01
|
| Rate for Payer: Quartz Commercial |
$9,978.38
|
| Rate for Payer: WEA Trust Commercial |
$9,146.85
|
| Rate for Payer: WPS Commercial |
$12,317.87
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN 7MM X 80CM 60CM RINGS HT076080A
|
Facility
|
OP
|
$15,991.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5286609
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,656.58 |
| Max. Negotiated Rate |
$15,300.19 |
| Rate for Payer: Aetna Commercial |
$14,967.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,302.35
|
| Rate for Payer: Aetna Managed Medicare |
$4,656.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,809.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,315.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,982.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,814.24
|
| Rate for Payer: Cash Price |
$4,797.30
|
| Rate for Payer: Cigna Commercial |
$15,300.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,306.76
|
| Rate for Payer: Health EOS Commercial |
$14,801.27
|
| Rate for Payer: HFN Commercial |
$15,300.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,472.98
|
| Rate for Payer: Multiplan Commercial |
$13,304.51
|
| Rate for Payer: NAPHCARE Commercial |
$9,978.38
|
| Rate for Payer: Preferred Network Access Commercial |
$15,300.19
|
| Rate for Payer: Quartz Beloit One Network |
$8,149.01
|
| Rate for Payer: Quartz Commercial |
$10,809.92
|
| Rate for Payer: Quartz Medicare Advantage |
$9,978.38
|
| Rate for Payer: The Alliance Commercial |
$8,315.32
|
| Rate for Payer: WEA Trust Commercial |
$9,146.85
|
| Rate for Payer: WPS Commercial |
$12,317.87
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN THIN WALL 6MM X 50CM 40CM RINGS HT064050A
|
Facility
|
OP
|
$11,512.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553529
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,352.29 |
| Max. Negotiated Rate |
$11,014.68 |
| Rate for Payer: Aetna Commercial |
$10,775.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,296.33
|
| Rate for Payer: Aetna Managed Medicare |
$3,352.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,782.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,986.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,746.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,345.41
|
| Rate for Payer: Cash Price |
$3,453.60
|
| Rate for Payer: Cigna Commercial |
$11,014.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,699.98
|
| Rate for Payer: Health EOS Commercial |
$10,655.51
|
| Rate for Payer: HFN Commercial |
$11,014.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,979.36
|
| Rate for Payer: Multiplan Commercial |
$9,577.98
|
| Rate for Payer: NAPHCARE Commercial |
$7,183.49
|
| Rate for Payer: Preferred Network Access Commercial |
$11,014.68
|
| Rate for Payer: Quartz Beloit One Network |
$5,866.52
|
| Rate for Payer: Quartz Commercial |
$7,782.11
|
| Rate for Payer: Quartz Medicare Advantage |
$7,183.49
|
| Rate for Payer: The Alliance Commercial |
$5,986.24
|
| Rate for Payer: WEA Trust Commercial |
$6,584.86
|
| Rate for Payer: WPS Commercial |
$8,867.69
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN THIN WALL 6MM X 50CM 40CM RINGS HT064050A
|
Facility
|
IP
|
$11,512.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553529
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,866.52 |
| Max. Negotiated Rate |
$11,014.68 |
| Rate for Payer: Aetna Commercial |
$10,775.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,296.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,345.41
|
| Rate for Payer: Cash Price |
$3,453.60
|
| Rate for Payer: Cigna Commercial |
$11,014.68
|
| Rate for Payer: Health EOS Commercial |
$10,655.51
|
| Rate for Payer: HFN Commercial |
$11,014.68
|
| Rate for Payer: Multiplan Commercial |
$9,577.98
|
| Rate for Payer: Preferred Network Access Commercial |
$11,014.68
|
| Rate for Payer: Quartz Beloit One Network |
$5,866.52
|
| Rate for Payer: Quartz Commercial |
$7,183.49
|
| Rate for Payer: WEA Trust Commercial |
$6,584.86
|
| Rate for Payer: WPS Commercial |
$8,867.69
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN THIN WALL 7MM X 50CM 40CM RINGS HT074050A
|
Facility
|
IP
|
$9,686.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5563708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,935.99 |
| Max. Negotiated Rate |
$9,267.56 |
| Rate for Payer: Aetna Commercial |
$9,066.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,663.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,338.92
|
| Rate for Payer: Cash Price |
$2,905.80
|
| Rate for Payer: Cigna Commercial |
$9,267.56
|
| Rate for Payer: Health EOS Commercial |
$8,965.36
|
| Rate for Payer: HFN Commercial |
$9,267.56
|
| Rate for Payer: Multiplan Commercial |
$8,058.75
|
| Rate for Payer: Preferred Network Access Commercial |
$9,267.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,935.99
|
| Rate for Payer: Quartz Commercial |
$6,044.06
|
| Rate for Payer: WEA Trust Commercial |
$5,540.39
|
| Rate for Payer: WPS Commercial |
$7,461.13
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN THIN WALL 7MM X 50CM 40CM RINGS HT074050A
|
Facility
|
OP
|
$9,686.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5563708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,820.56 |
| Max. Negotiated Rate |
$9,267.56 |
| Rate for Payer: Aetna Commercial |
$9,066.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,663.16
|
| Rate for Payer: Aetna Managed Medicare |
$2,820.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,547.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,036.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,835.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,338.92
|
| Rate for Payer: Cash Price |
$2,905.80
|
| Rate for Payer: Cigna Commercial |
$9,267.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,637.25
|
| Rate for Payer: Health EOS Commercial |
$8,965.36
|
| Rate for Payer: HFN Commercial |
$9,267.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,555.08
|
| Rate for Payer: Multiplan Commercial |
$8,058.75
|
| Rate for Payer: NAPHCARE Commercial |
$6,044.06
|
| Rate for Payer: Preferred Network Access Commercial |
$9,267.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,935.99
|
| Rate for Payer: Quartz Commercial |
$6,547.74
|
| Rate for Payer: Quartz Medicare Advantage |
$6,044.06
|
| Rate for Payer: The Alliance Commercial |
$5,036.72
|
| Rate for Payer: WEA Trust Commercial |
$5,540.39
|
| Rate for Payer: WPS Commercial |
$7,461.13
|
|
|
GRAFT XENMATRIX AB 10CM X 15CM 1151015
|
Facility
|
OP
|
$161.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$154.04 |
| Rate for Payer: Aetna Commercial |
$150.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.00
|
| Rate for Payer: Aetna Managed Medicare |
$46.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$108.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$83.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$80.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.74
|
| Rate for Payer: Cash Price |
$48.30
|
| Rate for Payer: Cigna Commercial |
$154.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.70
|
| Rate for Payer: Health EOS Commercial |
$149.02
|
| Rate for Payer: HFN Commercial |
$154.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$125.58
|
| Rate for Payer: Multiplan Commercial |
$133.95
|
| Rate for Payer: NAPHCARE Commercial |
$100.46
|
| Rate for Payer: Preferred Network Access Commercial |
$154.04
|
| Rate for Payer: Quartz Beloit One Network |
$82.05
|
| Rate for Payer: Quartz Commercial |
$108.84
|
| Rate for Payer: Quartz Medicare Advantage |
$100.46
|
| Rate for Payer: The Alliance Commercial |
$83.72
|
| Rate for Payer: WEA Trust Commercial |
$92.09
|
| Rate for Payer: WPS Commercial |
$124.02
|
|
|
GRAFT XENMATRIX AB 10CM X 15CM 1151015
|
Facility
|
IP
|
$161.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$82.05 |
| Max. Negotiated Rate |
$154.04 |
| Rate for Payer: Aetna Commercial |
$150.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.74
|
| Rate for Payer: Cash Price |
$48.30
|
| Rate for Payer: Cigna Commercial |
$154.04
|
| Rate for Payer: Health EOS Commercial |
$149.02
|
| Rate for Payer: HFN Commercial |
$154.04
|
| Rate for Payer: Multiplan Commercial |
$133.95
|
| Rate for Payer: Preferred Network Access Commercial |
$154.04
|
| Rate for Payer: Quartz Beloit One Network |
$82.05
|
| Rate for Payer: Quartz Commercial |
$100.46
|
| Rate for Payer: WEA Trust Commercial |
$92.09
|
| Rate for Payer: WPS Commercial |
$124.02
|
|
|
GRAFT XENMATRIX AB 15CM X 20CM 1151520
|
Facility
|
OP
|
$38,946.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4595246
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,341.08 |
| Max. Negotiated Rate |
$37,263.53 |
| Rate for Payer: Aetna Commercial |
$36,453.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34,833.30
|
| Rate for Payer: Aetna Managed Medicare |
$11,341.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26,327.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,251.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19,441.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21,467.04
|
| Rate for Payer: Cash Price |
$11,683.80
|
| Rate for Payer: Cigna Commercial |
$37,263.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,666.57
|
| Rate for Payer: Health EOS Commercial |
$36,048.42
|
| Rate for Payer: HFN Commercial |
$37,263.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30,377.88
|
| Rate for Payer: Multiplan Commercial |
$32,403.07
|
| Rate for Payer: NAPHCARE Commercial |
$24,302.30
|
| Rate for Payer: Preferred Network Access Commercial |
$37,263.53
|
| Rate for Payer: Quartz Beloit One Network |
$19,846.88
|
| Rate for Payer: Quartz Commercial |
$26,327.50
|
| Rate for Payer: Quartz Medicare Advantage |
$24,302.30
|
| Rate for Payer: The Alliance Commercial |
$20,251.92
|
| Rate for Payer: WEA Trust Commercial |
$22,277.11
|
| Rate for Payer: WPS Commercial |
$30,000.10
|
|
|
GRAFT XENMATRIX AB 15CM X 20CM 1151520
|
Facility
|
IP
|
$38,946.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4595246
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19,846.88 |
| Max. Negotiated Rate |
$37,263.53 |
| Rate for Payer: Aetna Commercial |
$36,453.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34,833.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21,467.04
|
| Rate for Payer: Cash Price |
$11,683.80
|
| Rate for Payer: Cigna Commercial |
$37,263.53
|
| Rate for Payer: Health EOS Commercial |
$36,048.42
|
| Rate for Payer: HFN Commercial |
$37,263.53
|
| Rate for Payer: Multiplan Commercial |
$32,403.07
|
| Rate for Payer: Preferred Network Access Commercial |
$37,263.53
|
| Rate for Payer: Quartz Beloit One Network |
$19,846.88
|
| Rate for Payer: Quartz Commercial |
$24,302.30
|
| Rate for Payer: WEA Trust Commercial |
$22,277.11
|
| Rate for Payer: WPS Commercial |
$30,000.10
|
|
|
GRAFT XENMATRIX AB 20CM X 25CM 1152025
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998775
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.03 |
| Max. Negotiated Rate |
$152.13 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$99.22
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
GRAFT XENMATRIX AB 20CM X 25CM 1152025
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998775
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$46.30 |
| Max. Negotiated Rate |
$152.13 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Aetna Managed Medicare |
$46.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$107.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.54
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$124.02
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: NAPHCARE Commercial |
$99.22
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$107.48
|
| Rate for Payer: Quartz Medicare Advantage |
$99.22
|
| Rate for Payer: The Alliance Commercial |
$82.68
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
Gram Stain Report
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 87205
|
| Hospital Charge Code |
634217
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$4.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7.77
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7.37
|
| Rate for Payer: Anthem Medicare Advantage |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.44
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.44
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.44
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$4.44
|
| Rate for Payer: The Alliance Commercial |
$17.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.44
|
| Rate for Payer: United Healthcare PPO |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: Wellcare Medicare |
$4.44
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
Gram Stain Report
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 87205
|
| Hospital Charge Code |
634217
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
Gram Stain Report
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
CPT 87205
|
| Hospital Charge Code |
634217
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$98.80 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$4.44
|
| Rate for Payer: Anthem Medicare Advantage |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.44
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.44
|
| Rate for Payer: Health EOS Commercial |
$94.64
|
| Rate for Payer: HFN Commercial |
$98.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.44
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$98.80
|
| Rate for Payer: Quartz Beloit One Network |
$45.76
|
| Rate for Payer: Quartz Commercial |
$59.28
|
| Rate for Payer: Quartz Medicare Advantage |
$4.44
|
| Rate for Payer: The Alliance Commercial |
$17.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.44
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$19.54
|
|
|
GranuFoam Bridge Dressing
|
Facility
|
OP
|
$905.00
|
|
| Hospital Charge Code |
3006909
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$263.54 |
| Max. Negotiated Rate |
$865.90 |
| Rate for Payer: Aetna Commercial |
$847.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$809.43
|
| Rate for Payer: Aetna Managed Medicare |
$263.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.84
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$865.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.71
|
| Rate for Payer: Health EOS Commercial |
$837.67
|
| Rate for Payer: HFN Commercial |
$865.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.90
|
| Rate for Payer: Multiplan Commercial |
$752.96
|
| Rate for Payer: NAPHCARE Commercial |
$564.72
|
| Rate for Payer: Preferred Network Access Commercial |
$865.90
|
| Rate for Payer: Quartz Beloit One Network |
$461.19
|
| Rate for Payer: Quartz Commercial |
$611.78
|
| Rate for Payer: Quartz Medicare Advantage |
$564.72
|
| Rate for Payer: The Alliance Commercial |
$470.60
|
| Rate for Payer: WEA Trust Commercial |
$517.66
|
| Rate for Payer: WPS Commercial |
$697.12
|
|
