|
GRAFT JACKET MAX FORCE 5 X 5CM 86MX-5X05
|
Facility
|
IP
|
$18,946.00
|
|
| Hospital Charge Code |
2967397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,283.54 |
| Max. Negotiated Rate |
$17,430.32 |
| Rate for Payer: Aetna Commercial |
$17,051.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,293.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,041.38
|
| Rate for Payer: Cash Price |
$5,683.80
|
| Rate for Payer: Cigna Commercial |
$17,430.32
|
| Rate for Payer: Health EOS Commercial |
$16,861.94
|
| Rate for Payer: HFN Commercial |
$17,430.32
|
| Rate for Payer: Multiplan Commercial |
$15,156.80
|
| Rate for Payer: NAPHCARE Commercial |
$11,367.60
|
| Rate for Payer: Preferred Network Access Commercial |
$17,430.32
|
| Rate for Payer: Quartz Beloit One Network |
$9,283.54
|
| Rate for Payer: Quartz Commercial |
$11,367.60
|
| Rate for Payer: WEA Trust Commercial |
$10,420.30
|
| Rate for Payer: WPS Commercial |
$14,033.30
|
|
|
GRAFT JACKET MAX FORCE 5 X 5CM 86MX-5X05
|
Facility
|
OP
|
$18,946.00
|
|
| Hospital Charge Code |
2967397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,304.88 |
| Max. Negotiated Rate |
$75,784.00 |
| Rate for Payer: Aetna Commercial |
$17,051.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,293.56
|
| Rate for Payer: Aetna Managed Medicare |
$5,304.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,314.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,473.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,094.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,041.38
|
| Rate for Payer: Cash Price |
$5,683.80
|
| Rate for Payer: Cigna Commercial |
$17,430.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,602.18
|
| Rate for Payer: Health EOS Commercial |
$16,861.94
|
| Rate for Payer: HFN Commercial |
$17,430.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,209.50
|
| Rate for Payer: Multiplan Commercial |
$15,156.80
|
| Rate for Payer: NAPHCARE Commercial |
$11,367.60
|
| Rate for Payer: Preferred Network Access Commercial |
$17,430.32
|
| Rate for Payer: Quartz Beloit One Network |
$9,283.54
|
| Rate for Payer: Quartz Commercial |
$12,314.90
|
| Rate for Payer: Quartz Medicare Advantage |
$11,367.60
|
| Rate for Payer: The Alliance Commercial |
$75,784.00
|
| Rate for Payer: WEA Trust Commercial |
$10,420.30
|
| Rate for Payer: WPS Commercial |
$14,033.30
|
|
|
GRAFT KNIFE 10MM 232110
|
Facility
|
IP
|
$1,772.00
|
|
| Hospital Charge Code |
2965024
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$868.28 |
| Max. Negotiated Rate |
$1,630.24 |
| Rate for Payer: Aetna Commercial |
$1,594.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,523.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.16
|
| Rate for Payer: Cash Price |
$531.60
|
| Rate for Payer: Cigna Commercial |
$1,630.24
|
| Rate for Payer: Health EOS Commercial |
$1,577.08
|
| Rate for Payer: HFN Commercial |
$1,630.24
|
| Rate for Payer: Multiplan Commercial |
$1,417.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,063.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,630.24
|
| Rate for Payer: Quartz Beloit One Network |
$868.28
|
| Rate for Payer: Quartz Commercial |
$1,063.20
|
| Rate for Payer: WEA Trust Commercial |
$974.60
|
| Rate for Payer: WPS Commercial |
$1,312.52
|
|
|
GRAFT KNIFE 10MM 232110
|
Facility
|
OP
|
$1,772.00
|
|
| Hospital Charge Code |
2965024
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$496.16 |
| Max. Negotiated Rate |
$7,088.00 |
| Rate for Payer: Aetna Commercial |
$1,594.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,523.92
|
| Rate for Payer: Aetna Managed Medicare |
$496.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,151.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$886.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$850.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.16
|
| Rate for Payer: Cash Price |
$531.60
|
| Rate for Payer: Cigna Commercial |
$1,630.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$991.61
|
| Rate for Payer: Health EOS Commercial |
$1,577.08
|
| Rate for Payer: HFN Commercial |
$1,630.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,329.00
|
| Rate for Payer: Multiplan Commercial |
$1,417.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,063.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,630.24
|
| Rate for Payer: Quartz Beloit One Network |
$868.28
|
| Rate for Payer: Quartz Commercial |
$1,151.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,063.20
|
| Rate for Payer: The Alliance Commercial |
$7,088.00
|
| Rate for Payer: WEA Trust Commercial |
$974.60
|
| Rate for Payer: WPS Commercial |
$1,312.52
|
|
|
GRAFT KNIFE 11MM 232111
|
Facility
|
IP
|
$1,706.00
|
|
| Hospital Charge Code |
2965025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$835.94 |
| Max. Negotiated Rate |
$1,569.52 |
| Rate for Payer: Aetna Commercial |
$1,535.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,467.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$904.18
|
| Rate for Payer: Cash Price |
$511.80
|
| Rate for Payer: Cigna Commercial |
$1,569.52
|
| Rate for Payer: Health EOS Commercial |
$1,518.34
|
| Rate for Payer: HFN Commercial |
$1,569.52
|
| Rate for Payer: Multiplan Commercial |
$1,364.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,569.52
|
| Rate for Payer: Quartz Beloit One Network |
$835.94
|
| Rate for Payer: Quartz Commercial |
$1,023.60
|
| Rate for Payer: WEA Trust Commercial |
$938.30
|
| Rate for Payer: WPS Commercial |
$1,263.63
|
|
|
GRAFT KNIFE 11MM 232111
|
Facility
|
OP
|
$1,706.00
|
|
| Hospital Charge Code |
2965025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$477.68 |
| Max. Negotiated Rate |
$6,824.00 |
| Rate for Payer: Aetna Commercial |
$1,535.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,467.16
|
| Rate for Payer: Aetna Managed Medicare |
$477.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,108.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$853.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$818.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$904.18
|
| Rate for Payer: Cash Price |
$511.80
|
| Rate for Payer: Cigna Commercial |
$1,569.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$954.68
|
| Rate for Payer: Health EOS Commercial |
$1,518.34
|
| Rate for Payer: HFN Commercial |
$1,569.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,279.50
|
| Rate for Payer: Multiplan Commercial |
$1,364.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,569.52
|
| Rate for Payer: Quartz Beloit One Network |
$835.94
|
| Rate for Payer: Quartz Commercial |
$1,108.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,023.60
|
| Rate for Payer: The Alliance Commercial |
$6,824.00
|
| Rate for Payer: WEA Trust Commercial |
$938.30
|
| Rate for Payer: WPS Commercial |
$1,263.63
|
|
|
GRAFT KNIFE 9MM 232109
|
Facility
|
IP
|
$1,706.00
|
|
| Hospital Charge Code |
2965026
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$835.94 |
| Max. Negotiated Rate |
$1,569.52 |
| Rate for Payer: Aetna Commercial |
$1,535.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,467.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$904.18
|
| Rate for Payer: Cash Price |
$511.80
|
| Rate for Payer: Cigna Commercial |
$1,569.52
|
| Rate for Payer: Health EOS Commercial |
$1,518.34
|
| Rate for Payer: HFN Commercial |
$1,569.52
|
| Rate for Payer: Multiplan Commercial |
$1,364.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,569.52
|
| Rate for Payer: Quartz Beloit One Network |
$835.94
|
| Rate for Payer: Quartz Commercial |
$1,023.60
|
| Rate for Payer: WEA Trust Commercial |
$938.30
|
| Rate for Payer: WPS Commercial |
$1,263.63
|
|
|
GRAFT KNIFE 9MM 232109
|
Facility
|
OP
|
$1,706.00
|
|
| Hospital Charge Code |
2965026
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$477.68 |
| Max. Negotiated Rate |
$6,824.00 |
| Rate for Payer: Aetna Commercial |
$1,535.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,467.16
|
| Rate for Payer: Aetna Managed Medicare |
$477.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,108.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$853.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$818.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$904.18
|
| Rate for Payer: Cash Price |
$511.80
|
| Rate for Payer: Cigna Commercial |
$1,569.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$954.68
|
| Rate for Payer: Health EOS Commercial |
$1,518.34
|
| Rate for Payer: HFN Commercial |
$1,569.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,279.50
|
| Rate for Payer: Multiplan Commercial |
$1,364.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,569.52
|
| Rate for Payer: Quartz Beloit One Network |
$835.94
|
| Rate for Payer: Quartz Commercial |
$1,108.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,023.60
|
| Rate for Payer: The Alliance Commercial |
$6,824.00
|
| Rate for Payer: WEA Trust Commercial |
$938.30
|
| Rate for Payer: WPS Commercial |
$1,263.63
|
|
|
Graftmaster 3.0mm x 12mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162996
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,492.32 |
| Max. Negotiated Rate |
$64,176.00 |
| Rate for Payer: Aetna Commercial |
$14,439.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Aetna Managed Medicare |
$4,492.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,428.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,022.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,701.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,503.32
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$14,760.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,978.22
|
| Rate for Payer: Health EOS Commercial |
$14,279.16
|
| Rate for Payer: HFN Commercial |
$14,760.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,033.00
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,760.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,861.56
|
| Rate for Payer: Quartz Commercial |
$10,428.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,626.40
|
| Rate for Payer: The Alliance Commercial |
$64,176.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 3.0mm x 12mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162996
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,861.56 |
| Max. Negotiated Rate |
$14,760.48 |
| Rate for Payer: Aetna Commercial |
$14,439.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,503.32
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$14,760.48
|
| Rate for Payer: Health EOS Commercial |
$14,279.16
|
| Rate for Payer: HFN Commercial |
$14,760.48
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,760.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,861.56
|
| Rate for Payer: Quartz Commercial |
$9,626.40
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 3.0mm x 12mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162996
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,059.36 |
| Max. Negotiated Rate |
$15,241.80 |
| Rate for Payer: Aetna Commercial |
$15,241.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$15,241.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,022.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,626.40
|
| Rate for Payer: Health EOS Commercial |
$14,600.04
|
| Rate for Payer: HFN Commercial |
$15,241.80
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: Preferred Network Access Commercial |
$15,241.80
|
| Rate for Payer: Quartz Beloit One Network |
$7,059.36
|
| Rate for Payer: Quartz Commercial |
$9,145.08
|
| Rate for Payer: The Alliance Commercial |
$8,022.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 3.0mm x 16mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162998
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,492.32 |
| Max. Negotiated Rate |
$64,176.00 |
| Rate for Payer: Aetna Commercial |
$14,439.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Aetna Managed Medicare |
$4,492.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,428.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,022.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,701.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,503.32
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$14,760.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,978.22
|
| Rate for Payer: Health EOS Commercial |
$14,279.16
|
| Rate for Payer: HFN Commercial |
$14,760.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,033.00
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,760.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,861.56
|
| Rate for Payer: Quartz Commercial |
$10,428.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,626.40
|
| Rate for Payer: The Alliance Commercial |
$64,176.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 3.0mm x 16mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162998
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,861.56 |
| Max. Negotiated Rate |
$14,760.48 |
| Rate for Payer: Aetna Commercial |
$14,439.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,503.32
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$14,760.48
|
| Rate for Payer: Health EOS Commercial |
$14,279.16
|
| Rate for Payer: HFN Commercial |
$14,760.48
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,760.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,861.56
|
| Rate for Payer: Quartz Commercial |
$9,626.40
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 3.0mm x 16mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1162998
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,059.36 |
| Max. Negotiated Rate |
$15,241.80 |
| Rate for Payer: Aetna Commercial |
$15,241.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$15,241.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,022.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,626.40
|
| Rate for Payer: Health EOS Commercial |
$14,600.04
|
| Rate for Payer: HFN Commercial |
$15,241.80
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: Preferred Network Access Commercial |
$15,241.80
|
| Rate for Payer: Quartz Beloit One Network |
$7,059.36
|
| Rate for Payer: Quartz Commercial |
$9,145.08
|
| Rate for Payer: The Alliance Commercial |
$8,022.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 3.0mm x 19mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163000
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,492.32 |
| Max. Negotiated Rate |
$64,176.00 |
| Rate for Payer: Aetna Commercial |
$14,439.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Aetna Managed Medicare |
$4,492.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,428.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,022.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,701.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,503.32
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$14,760.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,978.22
|
| Rate for Payer: Health EOS Commercial |
$14,279.16
|
| Rate for Payer: HFN Commercial |
$14,760.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,033.00
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,760.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,861.56
|
| Rate for Payer: Quartz Commercial |
$10,428.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,626.40
|
| Rate for Payer: The Alliance Commercial |
$64,176.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 3.0mm x 19mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163000
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,059.36 |
| Max. Negotiated Rate |
$15,241.80 |
| Rate for Payer: Aetna Commercial |
$15,241.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$15,241.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,022.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,626.40
|
| Rate for Payer: Health EOS Commercial |
$14,600.04
|
| Rate for Payer: HFN Commercial |
$15,241.80
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: Preferred Network Access Commercial |
$15,241.80
|
| Rate for Payer: Quartz Beloit One Network |
$7,059.36
|
| Rate for Payer: Quartz Commercial |
$9,145.08
|
| Rate for Payer: The Alliance Commercial |
$8,022.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 3.0mm x 19mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163000
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,861.56 |
| Max. Negotiated Rate |
$14,760.48 |
| Rate for Payer: Aetna Commercial |
$14,439.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,503.32
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$14,760.48
|
| Rate for Payer: Health EOS Commercial |
$14,279.16
|
| Rate for Payer: HFN Commercial |
$14,760.48
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,760.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,861.56
|
| Rate for Payer: Quartz Commercial |
$9,626.40
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 4.0mm x 16mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163002
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,059.36 |
| Max. Negotiated Rate |
$15,241.80 |
| Rate for Payer: Aetna Commercial |
$15,241.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$15,241.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,022.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,626.40
|
| Rate for Payer: Health EOS Commercial |
$14,600.04
|
| Rate for Payer: HFN Commercial |
$15,241.80
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: Preferred Network Access Commercial |
$15,241.80
|
| Rate for Payer: Quartz Beloit One Network |
$7,059.36
|
| Rate for Payer: Quartz Commercial |
$9,145.08
|
| Rate for Payer: The Alliance Commercial |
$8,022.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 4.0mm x 16mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163002
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,492.32 |
| Max. Negotiated Rate |
$64,176.00 |
| Rate for Payer: Aetna Commercial |
$14,439.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Aetna Managed Medicare |
$4,492.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,428.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,022.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,701.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,503.32
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$14,760.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,978.22
|
| Rate for Payer: Health EOS Commercial |
$14,279.16
|
| Rate for Payer: HFN Commercial |
$14,760.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,033.00
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,760.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,861.56
|
| Rate for Payer: Quartz Commercial |
$10,428.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,626.40
|
| Rate for Payer: The Alliance Commercial |
$64,176.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 4.0mm x 16mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163002
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,861.56 |
| Max. Negotiated Rate |
$14,760.48 |
| Rate for Payer: Aetna Commercial |
$14,439.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,503.32
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$14,760.48
|
| Rate for Payer: Health EOS Commercial |
$14,279.16
|
| Rate for Payer: HFN Commercial |
$14,760.48
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,760.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,861.56
|
| Rate for Payer: Quartz Commercial |
$9,626.40
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 4.0mm x 19mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163004
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,861.56 |
| Max. Negotiated Rate |
$14,760.48 |
| Rate for Payer: Aetna Commercial |
$14,439.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,503.32
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$14,760.48
|
| Rate for Payer: Health EOS Commercial |
$14,279.16
|
| Rate for Payer: HFN Commercial |
$14,760.48
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,760.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,861.56
|
| Rate for Payer: Quartz Commercial |
$9,626.40
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 4.0mm x 19mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163004
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,059.36 |
| Max. Negotiated Rate |
$15,241.80 |
| Rate for Payer: Aetna Commercial |
$15,241.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$15,241.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,022.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,626.40
|
| Rate for Payer: Health EOS Commercial |
$14,600.04
|
| Rate for Payer: HFN Commercial |
$15,241.80
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: Preferred Network Access Commercial |
$15,241.80
|
| Rate for Payer: Quartz Beloit One Network |
$7,059.36
|
| Rate for Payer: Quartz Commercial |
$9,145.08
|
| Rate for Payer: The Alliance Commercial |
$8,022.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 4.0mm x 19mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163004
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,492.32 |
| Max. Negotiated Rate |
$64,176.00 |
| Rate for Payer: Aetna Commercial |
$14,439.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Aetna Managed Medicare |
$4,492.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,428.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,022.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,701.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,503.32
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$14,760.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,978.22
|
| Rate for Payer: Health EOS Commercial |
$14,279.16
|
| Rate for Payer: HFN Commercial |
$14,760.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,033.00
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,760.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,861.56
|
| Rate for Payer: Quartz Commercial |
$10,428.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,626.40
|
| Rate for Payer: The Alliance Commercial |
$64,176.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 5.0mm x 26mm
|
Professional
|
Both
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163006
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,059.36 |
| Max. Negotiated Rate |
$15,241.80 |
| Rate for Payer: Aetna Commercial |
$15,241.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$15,241.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,022.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,626.40
|
| Rate for Payer: Health EOS Commercial |
$14,600.04
|
| Rate for Payer: HFN Commercial |
$15,241.80
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: Preferred Network Access Commercial |
$15,241.80
|
| Rate for Payer: Quartz Beloit One Network |
$7,059.36
|
| Rate for Payer: Quartz Commercial |
$9,145.08
|
| Rate for Payer: The Alliance Commercial |
$8,022.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
|
Graftmaster 5.0mm x 26mm
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163006
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,492.32 |
| Max. Negotiated Rate |
$64,176.00 |
| Rate for Payer: Aetna Commercial |
$14,439.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,797.84
|
| Rate for Payer: Aetna Managed Medicare |
$4,492.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,428.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,022.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,701.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,503.32
|
| Rate for Payer: Cash Price |
$4,813.20
|
| Rate for Payer: Cigna Commercial |
$14,760.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,978.22
|
| Rate for Payer: Health EOS Commercial |
$14,279.16
|
| Rate for Payer: HFN Commercial |
$14,760.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,033.00
|
| Rate for Payer: Multiplan Commercial |
$12,835.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,760.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,861.56
|
| Rate for Payer: Quartz Commercial |
$10,428.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,626.40
|
| Rate for Payer: The Alliance Commercial |
$64,176.00
|
| Rate for Payer: WEA Trust Commercial |
$8,824.20
|
| Rate for Payer: WPS Commercial |
$11,883.79
|
|
