|
GRAFT DERMIS DECELLULARIZED 3.5 X 3.5CM (12.25 SQ CM) AFLEX200
|
Facility
|
IP
|
$1,325.00
|
|
|
Service Code
|
HCPCS Q4125
|
| Hospital Charge Code |
5787662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.25 |
| Max. Negotiated Rate |
$1,219.00 |
| Rate for Payer: Aetna Commercial |
$1,192.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,139.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.25
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$1,219.00
|
| Rate for Payer: Health EOS Commercial |
$1,179.25
|
| Rate for Payer: HFN Commercial |
$1,219.00
|
| Rate for Payer: Multiplan Commercial |
$1,060.00
|
| Rate for Payer: NAPHCARE Commercial |
$795.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,219.00
|
| Rate for Payer: Quartz Beloit One Network |
$649.25
|
| Rate for Payer: Quartz Commercial |
$795.00
|
| Rate for Payer: WEA Trust Commercial |
$728.75
|
| Rate for Payer: WPS Commercial |
$981.43
|
|
|
GRAFT DERMIS DECELLULARIZED 3.5 X 3.5CM (12.25 SQ CM) AFLEX200
|
Facility
|
OP
|
$1,325.00
|
|
|
Service Code
|
HCPCS Q4125
|
| Hospital Charge Code |
5787662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$371.00 |
| Max. Negotiated Rate |
$5,300.00 |
| Rate for Payer: Aetna Commercial |
$1,192.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,139.50
|
| Rate for Payer: Aetna Managed Medicare |
$371.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$861.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$662.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$636.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.25
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$1,219.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$741.47
|
| Rate for Payer: Health EOS Commercial |
$1,179.25
|
| Rate for Payer: HFN Commercial |
$1,219.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$993.75
|
| Rate for Payer: Multiplan Commercial |
$1,060.00
|
| Rate for Payer: NAPHCARE Commercial |
$795.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,219.00
|
| Rate for Payer: Quartz Beloit One Network |
$649.25
|
| Rate for Payer: Quartz Commercial |
$861.25
|
| Rate for Payer: Quartz Medicare Advantage |
$795.00
|
| Rate for Payer: The Alliance Commercial |
$5,300.00
|
| Rate for Payer: WEA Trust Commercial |
$728.75
|
| Rate for Payer: WPS Commercial |
$981.43
|
|
|
GRAFT DERMIS DECELLULARIZED AFLEX100
|
Facility
|
OP
|
$13,840.00
|
|
| Hospital Charge Code |
3901338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,875.20 |
| Max. Negotiated Rate |
$55,360.00 |
| Rate for Payer: Aetna Commercial |
$12,456.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,902.40
|
| Rate for Payer: Aetna Managed Medicare |
$3,875.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,996.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,920.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,643.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,335.20
|
| Rate for Payer: Cash Price |
$4,152.00
|
| Rate for Payer: Cigna Commercial |
$12,732.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,744.86
|
| Rate for Payer: Health EOS Commercial |
$12,317.60
|
| Rate for Payer: HFN Commercial |
$12,732.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,380.00
|
| Rate for Payer: Multiplan Commercial |
$11,072.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,304.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,732.80
|
| Rate for Payer: Quartz Beloit One Network |
$6,781.60
|
| Rate for Payer: Quartz Commercial |
$8,996.00
|
| Rate for Payer: Quartz Medicare Advantage |
$8,304.00
|
| Rate for Payer: The Alliance Commercial |
$55,360.00
|
| Rate for Payer: WEA Trust Commercial |
$7,612.00
|
| Rate for Payer: WPS Commercial |
$10,251.29
|
|
|
GRAFT DERMIS DECELLULARIZED AFLEX100
|
Facility
|
IP
|
$13,840.00
|
|
| Hospital Charge Code |
3901338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,781.60 |
| Max. Negotiated Rate |
$12,732.80 |
| Rate for Payer: Aetna Commercial |
$12,456.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,902.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,335.20
|
| Rate for Payer: Cash Price |
$4,152.00
|
| Rate for Payer: Cigna Commercial |
$12,732.80
|
| Rate for Payer: Health EOS Commercial |
$12,317.60
|
| Rate for Payer: HFN Commercial |
$12,732.80
|
| Rate for Payer: Multiplan Commercial |
$11,072.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,304.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,732.80
|
| Rate for Payer: Quartz Beloit One Network |
$6,781.60
|
| Rate for Payer: Quartz Commercial |
$8,304.00
|
| Rate for Payer: WEA Trust Commercial |
$7,612.00
|
| Rate for Payer: WPS Commercial |
$10,251.29
|
|
|
GRAFT DERMIS DECELLULARIZED ARTHROFLEX 40 X 70 X 3.0 AFLEX301
|
Facility
|
OP
|
$20,187.00
|
|
|
Service Code
|
HCPCS Q4125
|
| Hospital Charge Code |
5611576
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,652.36 |
| Max. Negotiated Rate |
$80,748.00 |
| Rate for Payer: Aetna Commercial |
$18,168.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,360.82
|
| Rate for Payer: Aetna Managed Medicare |
$5,652.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,121.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,093.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,689.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,699.11
|
| Rate for Payer: Cash Price |
$6,056.10
|
| Rate for Payer: Cigna Commercial |
$18,572.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,296.65
|
| Rate for Payer: Health EOS Commercial |
$17,966.43
|
| Rate for Payer: HFN Commercial |
$18,572.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,140.25
|
| Rate for Payer: Multiplan Commercial |
$16,149.60
|
| Rate for Payer: NAPHCARE Commercial |
$12,112.20
|
| Rate for Payer: Preferred Network Access Commercial |
$18,572.04
|
| Rate for Payer: Quartz Beloit One Network |
$9,891.63
|
| Rate for Payer: Quartz Commercial |
$13,121.55
|
| Rate for Payer: Quartz Medicare Advantage |
$12,112.20
|
| Rate for Payer: The Alliance Commercial |
$80,748.00
|
| Rate for Payer: WEA Trust Commercial |
$11,102.85
|
| Rate for Payer: WPS Commercial |
$14,952.51
|
|
|
GRAFT DERMIS DECELLULARIZED ARTHROFLEX 40 X 70 X 3.0 AFLEX301
|
Facility
|
IP
|
$20,187.00
|
|
|
Service Code
|
HCPCS Q4125
|
| Hospital Charge Code |
5611576
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,891.63 |
| Max. Negotiated Rate |
$18,572.04 |
| Rate for Payer: Aetna Commercial |
$18,168.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,360.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,699.11
|
| Rate for Payer: Cash Price |
$6,056.10
|
| Rate for Payer: Cigna Commercial |
$18,572.04
|
| Rate for Payer: Health EOS Commercial |
$17,966.43
|
| Rate for Payer: HFN Commercial |
$18,572.04
|
| Rate for Payer: Multiplan Commercial |
$16,149.60
|
| Rate for Payer: NAPHCARE Commercial |
$12,112.20
|
| Rate for Payer: Preferred Network Access Commercial |
$18,572.04
|
| Rate for Payer: Quartz Beloit One Network |
$9,891.63
|
| Rate for Payer: Quartz Commercial |
$12,112.20
|
| Rate for Payer: WEA Trust Commercial |
$11,102.85
|
| Rate for Payer: WPS Commercial |
$14,952.51
|
|
|
GRAFT DISTAFLO 4MM X 10CM CVL4006C
|
Facility
|
OP
|
$8,503.00
|
|
| Hospital Charge Code |
2969345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,380.84 |
| Max. Negotiated Rate |
$34,012.00 |
| Rate for Payer: Aetna Commercial |
$7,652.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,312.58
|
| Rate for Payer: Aetna Managed Medicare |
$2,380.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,526.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,251.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,081.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,506.59
|
| Rate for Payer: Cash Price |
$2,550.90
|
| Rate for Payer: Cigna Commercial |
$7,822.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,758.28
|
| Rate for Payer: Health EOS Commercial |
$7,567.67
|
| Rate for Payer: HFN Commercial |
$7,822.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,377.25
|
| Rate for Payer: Multiplan Commercial |
$6,802.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,101.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,822.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,166.47
|
| Rate for Payer: Quartz Commercial |
$5,526.95
|
| Rate for Payer: Quartz Medicare Advantage |
$5,101.80
|
| Rate for Payer: The Alliance Commercial |
$34,012.00
|
| Rate for Payer: WEA Trust Commercial |
$4,676.65
|
| Rate for Payer: WPS Commercial |
$6,298.17
|
|
|
GRAFT DISTAFLO 4MM X 10CM CVL4006C
|
Facility
|
IP
|
$8,503.00
|
|
| Hospital Charge Code |
2969345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,166.47 |
| Max. Negotiated Rate |
$7,822.76 |
| Rate for Payer: Aetna Commercial |
$7,652.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,312.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,506.59
|
| Rate for Payer: Cash Price |
$2,550.90
|
| Rate for Payer: Cigna Commercial |
$7,822.76
|
| Rate for Payer: Health EOS Commercial |
$7,567.67
|
| Rate for Payer: HFN Commercial |
$7,822.76
|
| Rate for Payer: Multiplan Commercial |
$6,802.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,101.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,822.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,166.47
|
| Rate for Payer: Quartz Commercial |
$5,101.80
|
| Rate for Payer: WEA Trust Commercial |
$4,676.65
|
| Rate for Payer: WPS Commercial |
$6,298.17
|
|
|
GRAFT DISTAFLO 6MM X 70CM DF7006SC
|
Facility
|
OP
|
$12,119.00
|
|
| Hospital Charge Code |
5384692
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,393.32 |
| Max. Negotiated Rate |
$48,476.00 |
| Rate for Payer: Aetna Commercial |
$10,907.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,422.34
|
| Rate for Payer: Aetna Managed Medicare |
$3,393.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,877.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,059.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,817.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,423.07
|
| Rate for Payer: Cash Price |
$3,635.70
|
| Rate for Payer: Cigna Commercial |
$11,149.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,781.79
|
| Rate for Payer: Health EOS Commercial |
$10,785.91
|
| Rate for Payer: HFN Commercial |
$11,149.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,089.25
|
| Rate for Payer: Multiplan Commercial |
$9,695.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,271.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,149.48
|
| Rate for Payer: Quartz Beloit One Network |
$5,938.31
|
| Rate for Payer: Quartz Commercial |
$7,877.35
|
| Rate for Payer: Quartz Medicare Advantage |
$7,271.40
|
| Rate for Payer: The Alliance Commercial |
$48,476.00
|
| Rate for Payer: WEA Trust Commercial |
$6,665.45
|
| Rate for Payer: WPS Commercial |
$8,976.54
|
|
|
GRAFT DISTAFLO 6MM X 70CM DF7006SC
|
Facility
|
IP
|
$12,119.00
|
|
| Hospital Charge Code |
5384692
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,938.31 |
| Max. Negotiated Rate |
$11,149.48 |
| Rate for Payer: Aetna Commercial |
$10,907.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,422.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,423.07
|
| Rate for Payer: Cash Price |
$3,635.70
|
| Rate for Payer: Cigna Commercial |
$11,149.48
|
| Rate for Payer: Health EOS Commercial |
$10,785.91
|
| Rate for Payer: HFN Commercial |
$11,149.48
|
| Rate for Payer: Multiplan Commercial |
$9,695.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,271.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,149.48
|
| Rate for Payer: Quartz Beloit One Network |
$5,938.31
|
| Rate for Payer: Quartz Commercial |
$7,271.40
|
| Rate for Payer: WEA Trust Commercial |
$6,665.45
|
| Rate for Payer: WPS Commercial |
$8,976.54
|
|
|
GRAFT DISTAFLO 7MM X 70CM DF7007SC
|
Facility
|
OP
|
$12,586.00
|
|
| Hospital Charge Code |
5384693
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,524.08 |
| Max. Negotiated Rate |
$50,344.00 |
| Rate for Payer: Aetna Commercial |
$11,327.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,823.96
|
| Rate for Payer: Aetna Managed Medicare |
$3,524.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,180.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,293.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,041.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,670.58
|
| Rate for Payer: Cash Price |
$3,775.80
|
| Rate for Payer: Cigna Commercial |
$11,579.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,043.13
|
| Rate for Payer: Health EOS Commercial |
$11,201.54
|
| Rate for Payer: HFN Commercial |
$11,579.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,439.50
|
| Rate for Payer: Multiplan Commercial |
$10,068.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,551.60
|
| Rate for Payer: Preferred Network Access Commercial |
$11,579.12
|
| Rate for Payer: Quartz Beloit One Network |
$6,167.14
|
| Rate for Payer: Quartz Commercial |
$8,180.90
|
| Rate for Payer: Quartz Medicare Advantage |
$7,551.60
|
| Rate for Payer: The Alliance Commercial |
$50,344.00
|
| Rate for Payer: WEA Trust Commercial |
$6,922.30
|
| Rate for Payer: WPS Commercial |
$9,322.45
|
|
|
GRAFT DISTAFLO 7MM X 70CM DF7007SC
|
Facility
|
IP
|
$12,586.00
|
|
| Hospital Charge Code |
5384693
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,167.14 |
| Max. Negotiated Rate |
$11,579.12 |
| Rate for Payer: Aetna Commercial |
$11,327.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,823.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,670.58
|
| Rate for Payer: Cash Price |
$3,775.80
|
| Rate for Payer: Cigna Commercial |
$11,579.12
|
| Rate for Payer: Health EOS Commercial |
$11,201.54
|
| Rate for Payer: HFN Commercial |
$11,579.12
|
| Rate for Payer: Multiplan Commercial |
$10,068.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,551.60
|
| Rate for Payer: Preferred Network Access Commercial |
$11,579.12
|
| Rate for Payer: Quartz Beloit One Network |
$6,167.14
|
| Rate for Payer: Quartz Commercial |
$7,551.60
|
| Rate for Payer: WEA Trust Commercial |
$6,922.30
|
| Rate for Payer: WPS Commercial |
$9,322.45
|
|
|
GRAFT DISTAFLO 7MM X 80CM DF8007SC
|
Facility
|
OP
|
$12,492.00
|
|
| Hospital Charge Code |
2969346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,497.76 |
| Max. Negotiated Rate |
$49,968.00 |
| Rate for Payer: Aetna Commercial |
$11,242.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,743.12
|
| Rate for Payer: Aetna Managed Medicare |
$3,497.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,119.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,246.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,996.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,620.76
|
| Rate for Payer: Cash Price |
$3,747.60
|
| Rate for Payer: Cigna Commercial |
$11,492.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,990.52
|
| Rate for Payer: Health EOS Commercial |
$11,117.88
|
| Rate for Payer: HFN Commercial |
$11,492.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,369.00
|
| Rate for Payer: Multiplan Commercial |
$9,993.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,495.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,492.64
|
| Rate for Payer: Quartz Beloit One Network |
$6,121.08
|
| Rate for Payer: Quartz Commercial |
$8,119.80
|
| Rate for Payer: Quartz Medicare Advantage |
$7,495.20
|
| Rate for Payer: The Alliance Commercial |
$49,968.00
|
| Rate for Payer: WEA Trust Commercial |
$6,870.60
|
| Rate for Payer: WPS Commercial |
$9,252.82
|
|
|
GRAFT DISTAFLO 7MM X 80CM DF8007SC
|
Facility
|
IP
|
$12,492.00
|
|
| Hospital Charge Code |
2969346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,121.08 |
| Max. Negotiated Rate |
$11,492.64 |
| Rate for Payer: Aetna Commercial |
$11,242.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,743.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,620.76
|
| Rate for Payer: Cash Price |
$3,747.60
|
| Rate for Payer: Cigna Commercial |
$11,492.64
|
| Rate for Payer: Health EOS Commercial |
$11,117.88
|
| Rate for Payer: HFN Commercial |
$11,492.64
|
| Rate for Payer: Multiplan Commercial |
$9,993.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,495.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,492.64
|
| Rate for Payer: Quartz Beloit One Network |
$6,121.08
|
| Rate for Payer: Quartz Commercial |
$7,495.20
|
| Rate for Payer: WEA Trust Commercial |
$6,870.60
|
| Rate for Payer: WPS Commercial |
$9,252.82
|
|
|
GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)
|
Facility
|
OP
|
$23,153.12
|
|
|
Service Code
|
CPT 21235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,240.00 |
| Max. Negotiated Rate |
$23,153.12 |
| Rate for Payer: Aetna Managed Medicare |
$5,788.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,238.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,914.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,367.00
|
| Rate for Payer: Anthem Medicare Advantage |
$5,788.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,788.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,788.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,788.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,639.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,788.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,532.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,788.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,788.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,788.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,788.28
|
| Rate for Payer: NAPHCARE Commercial |
$8,682.42
|
| Rate for Payer: Quartz Medicare Advantage |
$5,788.28
|
| Rate for Payer: The Alliance Commercial |
$23,153.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,788.28
|
| Rate for Payer: United Healthcare PPO |
$4,240.00
|
| Rate for Payer: Wellcare Medicare |
$5,788.28
|
|
|
GRAFT HEPARIN STD WALL 6MM X 10CM H060010A
|
Facility
|
OP
|
$3,952.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.56 |
| Max. Negotiated Rate |
$15,808.00 |
| Rate for Payer: Aetna Commercial |
$3,556.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,398.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,106.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,568.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,976.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,896.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,094.56
|
| Rate for Payer: Cash Price |
$1,185.60
|
| Rate for Payer: Cigna Commercial |
$3,635.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,211.54
|
| Rate for Payer: Health EOS Commercial |
$3,517.28
|
| Rate for Payer: HFN Commercial |
$3,635.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,964.00
|
| Rate for Payer: Multiplan Commercial |
$3,161.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,371.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,635.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,936.48
|
| Rate for Payer: Quartz Commercial |
$2,568.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,371.20
|
| Rate for Payer: The Alliance Commercial |
$15,808.00
|
| Rate for Payer: WEA Trust Commercial |
$2,173.60
|
| Rate for Payer: WPS Commercial |
$2,927.25
|
|
|
GRAFT HEPARIN STD WALL 6MM X 10CM H060010A
|
Facility
|
IP
|
$3,952.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,936.48 |
| Max. Negotiated Rate |
$3,635.84 |
| Rate for Payer: Aetna Commercial |
$3,556.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,398.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,094.56
|
| Rate for Payer: Cash Price |
$1,185.60
|
| Rate for Payer: Cigna Commercial |
$3,635.84
|
| Rate for Payer: Health EOS Commercial |
$3,517.28
|
| Rate for Payer: HFN Commercial |
$3,635.84
|
| Rate for Payer: Multiplan Commercial |
$3,161.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,371.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,635.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,936.48
|
| Rate for Payer: Quartz Commercial |
$2,371.20
|
| Rate for Payer: WEA Trust Commercial |
$2,173.60
|
| Rate for Payer: WPS Commercial |
$2,927.25
|
|
|
GRAFT HEPARIN TAPER 4-7MM X 45CM H470045A
|
Facility
|
IP
|
$7,708.00
|
|
| Hospital Charge Code |
3525505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.92 |
| Max. Negotiated Rate |
$7,091.36 |
| Rate for Payer: Aetna Commercial |
$6,937.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,628.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,085.24
|
| Rate for Payer: Cash Price |
$2,312.40
|
| Rate for Payer: Cigna Commercial |
$7,091.36
|
| Rate for Payer: Health EOS Commercial |
$6,860.12
|
| Rate for Payer: HFN Commercial |
$7,091.36
|
| Rate for Payer: Multiplan Commercial |
$6,166.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,624.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,091.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,776.92
|
| Rate for Payer: Quartz Commercial |
$4,624.80
|
| Rate for Payer: WEA Trust Commercial |
$4,239.40
|
| Rate for Payer: WPS Commercial |
$5,709.32
|
|
|
GRAFT HEPARIN TAPER 4-7MM X 45CM H470045A
|
Facility
|
OP
|
$7,708.00
|
|
| Hospital Charge Code |
3525505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,158.24 |
| Max. Negotiated Rate |
$30,832.00 |
| Rate for Payer: Aetna Commercial |
$6,937.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,628.88
|
| Rate for Payer: Aetna Managed Medicare |
$2,158.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,010.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,699.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,085.24
|
| Rate for Payer: Cash Price |
$2,312.40
|
| Rate for Payer: Cigna Commercial |
$7,091.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,313.40
|
| Rate for Payer: Health EOS Commercial |
$6,860.12
|
| Rate for Payer: HFN Commercial |
$7,091.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,781.00
|
| Rate for Payer: Multiplan Commercial |
$6,166.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,624.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,091.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,776.92
|
| Rate for Payer: Quartz Commercial |
$5,010.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,624.80
|
| Rate for Payer: The Alliance Commercial |
$30,832.00
|
| Rate for Payer: WEA Trust Commercial |
$4,239.40
|
| Rate for Payer: WPS Commercial |
$5,709.32
|
|
|
GRAFT HEPARIN THIN WALL 8MM X 50CM 40CM RINGS HT084050A
|
Facility
|
IP
|
$11,085.00
|
|
| Hospital Charge Code |
3553530
|
|
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 HEPARIN THIN WALL 8MM X 50CM 40CM RINGS HT084050A
|
Facility
|
OP
|
$11,085.00
|
|
| Hospital Charge Code |
3553530
|
|
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 HYBRID 6MM X 50CM 0650HYB0605A
|
Facility
|
IP
|
$15,313.00
|
|
| Hospital Charge Code |
3495528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,503.37 |
| Max. Negotiated Rate |
$14,087.96 |
| Rate for Payer: Aetna Commercial |
$13,781.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,169.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,115.89
|
| Rate for Payer: Cash Price |
$4,593.90
|
| Rate for Payer: Cigna Commercial |
$14,087.96
|
| Rate for Payer: Health EOS Commercial |
$13,628.57
|
| Rate for Payer: HFN Commercial |
$14,087.96
|
| Rate for Payer: Multiplan Commercial |
$12,250.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,187.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,087.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,503.37
|
| Rate for Payer: Quartz Commercial |
$9,187.80
|
| Rate for Payer: WEA Trust Commercial |
$8,422.15
|
| Rate for Payer: WPS Commercial |
$11,342.34
|
|
|
GRAFT HYBRID 6MM X 50CM 0650HYB0605A
|
Facility
|
OP
|
$15,313.00
|
|
| Hospital Charge Code |
3495528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,287.64 |
| Max. Negotiated Rate |
$61,252.00 |
| Rate for Payer: Aetna Commercial |
$13,781.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,169.18
|
| Rate for Payer: Aetna Managed Medicare |
$4,287.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,953.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,656.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,350.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,115.89
|
| Rate for Payer: Cash Price |
$4,593.90
|
| Rate for Payer: Cigna Commercial |
$14,087.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,569.15
|
| Rate for Payer: Health EOS Commercial |
$13,628.57
|
| Rate for Payer: HFN Commercial |
$14,087.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,484.75
|
| Rate for Payer: Multiplan Commercial |
$12,250.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,187.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,087.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,503.37
|
| Rate for Payer: Quartz Commercial |
$9,953.45
|
| Rate for Payer: Quartz Medicare Advantage |
$9,187.80
|
| Rate for Payer: The Alliance Commercial |
$61,252.00
|
| Rate for Payer: WEA Trust Commercial |
$8,422.15
|
| Rate for Payer: WPS Commercial |
$11,342.34
|
|
|
GRAFT HYBRID 9MM X 50CM 0650HYB0905A
|
Facility
|
IP
|
$15,313.00
|
|
| Hospital Charge Code |
3525504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,503.37 |
| Max. Negotiated Rate |
$14,087.96 |
| Rate for Payer: Aetna Commercial |
$13,781.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,169.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,115.89
|
| Rate for Payer: Cash Price |
$4,593.90
|
| Rate for Payer: Cigna Commercial |
$14,087.96
|
| Rate for Payer: Health EOS Commercial |
$13,628.57
|
| Rate for Payer: HFN Commercial |
$14,087.96
|
| Rate for Payer: Multiplan Commercial |
$12,250.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,187.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,087.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,503.37
|
| Rate for Payer: Quartz Commercial |
$9,187.80
|
| Rate for Payer: WEA Trust Commercial |
$8,422.15
|
| Rate for Payer: WPS Commercial |
$11,342.34
|
|
|
GRAFT HYBRID 9MM X 50CM 0650HYB0905A
|
Facility
|
OP
|
$15,313.00
|
|
| Hospital Charge Code |
3525504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,287.64 |
| Max. Negotiated Rate |
$61,252.00 |
| Rate for Payer: Aetna Commercial |
$13,781.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,169.18
|
| Rate for Payer: Aetna Managed Medicare |
$4,287.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,953.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,656.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,350.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,115.89
|
| Rate for Payer: Cash Price |
$4,593.90
|
| Rate for Payer: Cigna Commercial |
$14,087.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,569.15
|
| Rate for Payer: Health EOS Commercial |
$13,628.57
|
| Rate for Payer: HFN Commercial |
$14,087.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,484.75
|
| Rate for Payer: Multiplan Commercial |
$12,250.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,187.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,087.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,503.37
|
| Rate for Payer: Quartz Commercial |
$9,953.45
|
| Rate for Payer: Quartz Medicare Advantage |
$9,187.80
|
| Rate for Payer: The Alliance Commercial |
$61,252.00
|
| Rate for Payer: WEA Trust Commercial |
$8,422.15
|
| Rate for Payer: WPS Commercial |
$11,342.34
|
|
