|
GranuFoam Bridge Dressing
|
Facility
|
IP
|
$905.00
|
|
| Hospital Charge Code |
3006909
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$461.19 |
| Max. Negotiated Rate |
$865.90 |
| Rate for Payer: Aetna Commercial |
$847.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$809.43
|
| 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: Health EOS Commercial |
$837.67
|
| Rate for Payer: HFN Commercial |
$865.90
|
| Rate for Payer: Multiplan Commercial |
$752.96
|
| Rate for Payer: Preferred Network Access Commercial |
$865.90
|
| Rate for Payer: Quartz Beloit One Network |
$461.19
|
| Rate for Payer: Quartz Commercial |
$564.72
|
| Rate for Payer: WEA Trust Commercial |
$517.66
|
| Rate for Payer: WPS Commercial |
$697.12
|
|
|
GranuFoam Silver/medium
|
Facility
|
IP
|
$1,127.00
|
|
| Hospital Charge Code |
3006922
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$574.32 |
| Max. Negotiated Rate |
$1,078.31 |
| Rate for Payer: Aetna Commercial |
$1,054.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,007.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$621.20
|
| Rate for Payer: Cash Price |
$338.10
|
| Rate for Payer: Cigna Commercial |
$1,078.31
|
| Rate for Payer: Health EOS Commercial |
$1,043.15
|
| Rate for Payer: HFN Commercial |
$1,078.31
|
| Rate for Payer: Multiplan Commercial |
$937.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,078.31
|
| Rate for Payer: Quartz Beloit One Network |
$574.32
|
| Rate for Payer: Quartz Commercial |
$703.25
|
| Rate for Payer: WEA Trust Commercial |
$644.64
|
| Rate for Payer: WPS Commercial |
$868.13
|
|
|
GranuFoam Silver/medium
|
Facility
|
OP
|
$1,127.00
|
|
| Hospital Charge Code |
3006922
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$328.18 |
| Max. Negotiated Rate |
$1,078.31 |
| Rate for Payer: Aetna Commercial |
$1,054.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,007.99
|
| Rate for Payer: Aetna Managed Medicare |
$328.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$761.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$586.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$562.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$621.20
|
| Rate for Payer: Cash Price |
$338.10
|
| Rate for Payer: Cigna Commercial |
$1,078.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$655.91
|
| Rate for Payer: Health EOS Commercial |
$1,043.15
|
| Rate for Payer: HFN Commercial |
$1,078.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$879.06
|
| Rate for Payer: Multiplan Commercial |
$937.66
|
| Rate for Payer: NAPHCARE Commercial |
$703.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,078.31
|
| Rate for Payer: Quartz Beloit One Network |
$574.32
|
| Rate for Payer: Quartz Commercial |
$761.85
|
| Rate for Payer: Quartz Medicare Advantage |
$703.25
|
| Rate for Payer: The Alliance Commercial |
$586.04
|
| Rate for Payer: WEA Trust Commercial |
$644.64
|
| Rate for Payer: WPS Commercial |
$868.13
|
|
|
GRANULES CHRONOS LARGE 10CC 710.026.975
|
Facility
|
IP
|
$6,765.00
|
|
| Hospital Charge Code |
2966235
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,447.44 |
| Max. Negotiated Rate |
$6,472.75 |
| Rate for Payer: Aetna Commercial |
$6,332.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,050.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,728.87
|
| Rate for Payer: Cash Price |
$2,029.50
|
| Rate for Payer: Cigna Commercial |
$6,472.75
|
| Rate for Payer: Health EOS Commercial |
$6,261.68
|
| Rate for Payer: HFN Commercial |
$6,472.75
|
| Rate for Payer: Multiplan Commercial |
$5,628.48
|
| Rate for Payer: Preferred Network Access Commercial |
$6,472.75
|
| Rate for Payer: Quartz Beloit One Network |
$3,447.44
|
| Rate for Payer: Quartz Commercial |
$4,221.36
|
| Rate for Payer: WEA Trust Commercial |
$3,869.58
|
| Rate for Payer: WPS Commercial |
$5,211.08
|
|
|
GRANULES CHRONOS LARGE 10CC 710.026.975
|
Facility
|
OP
|
$6,765.00
|
|
| Hospital Charge Code |
2966235
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,969.97 |
| Max. Negotiated Rate |
$6,472.75 |
| Rate for Payer: Aetna Commercial |
$6,332.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,050.62
|
| Rate for Payer: Aetna Managed Medicare |
$1,969.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,573.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,517.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,377.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,728.87
|
| Rate for Payer: Cash Price |
$2,029.50
|
| Rate for Payer: Cigna Commercial |
$6,472.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,937.23
|
| Rate for Payer: Health EOS Commercial |
$6,261.68
|
| Rate for Payer: HFN Commercial |
$6,472.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,276.70
|
| Rate for Payer: Multiplan Commercial |
$5,628.48
|
| Rate for Payer: NAPHCARE Commercial |
$4,221.36
|
| Rate for Payer: Preferred Network Access Commercial |
$6,472.75
|
| Rate for Payer: Quartz Beloit One Network |
$3,447.44
|
| Rate for Payer: Quartz Commercial |
$4,573.14
|
| Rate for Payer: Quartz Medicare Advantage |
$4,221.36
|
| Rate for Payer: The Alliance Commercial |
$3,517.80
|
| Rate for Payer: WEA Trust Commercial |
$3,869.58
|
| Rate for Payer: WPS Commercial |
$5,211.08
|
|
|
GRANULES CHRONOS-MEDIUM 5CC 710.014.97S
|
Facility
|
OP
|
$4,672.00
|
|
| Hospital Charge Code |
2966234
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.49 |
| Max. Negotiated Rate |
$4,470.17 |
| Rate for Payer: Aetna Commercial |
$4,372.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,178.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,158.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,429.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.21
|
| Rate for Payer: Cash Price |
$1,401.60
|
| Rate for Payer: Cigna Commercial |
$4,470.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.10
|
| Rate for Payer: Health EOS Commercial |
$4,324.40
|
| Rate for Payer: HFN Commercial |
$4,470.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,644.16
|
| Rate for Payer: Multiplan Commercial |
$3,887.10
|
| Rate for Payer: NAPHCARE Commercial |
$2,915.33
|
| Rate for Payer: Preferred Network Access Commercial |
$4,470.17
|
| Rate for Payer: Quartz Beloit One Network |
$2,380.85
|
| Rate for Payer: Quartz Commercial |
$3,158.27
|
| Rate for Payer: Quartz Medicare Advantage |
$2,915.33
|
| Rate for Payer: The Alliance Commercial |
$2,429.44
|
| Rate for Payer: WEA Trust Commercial |
$2,672.38
|
| Rate for Payer: WPS Commercial |
$3,598.84
|
|
|
GRANULES CHRONOS-MEDIUM 5CC 710.014.97S
|
Facility
|
IP
|
$4,672.00
|
|
| Hospital Charge Code |
2966234
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,380.85 |
| Max. Negotiated Rate |
$4,470.17 |
| Rate for Payer: Aetna Commercial |
$4,372.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,178.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.21
|
| Rate for Payer: Cash Price |
$1,401.60
|
| Rate for Payer: Cigna Commercial |
$4,470.17
|
| Rate for Payer: Health EOS Commercial |
$4,324.40
|
| Rate for Payer: HFN Commercial |
$4,470.17
|
| Rate for Payer: Multiplan Commercial |
$3,887.10
|
| Rate for Payer: Preferred Network Access Commercial |
$4,470.17
|
| Rate for Payer: Quartz Beloit One Network |
$2,380.85
|
| Rate for Payer: Quartz Commercial |
$2,915.33
|
| Rate for Payer: WEA Trust Commercial |
$2,672.38
|
| Rate for Payer: WPS Commercial |
$3,598.84
|
|
|
GRASPER 2.3 MINI-LAP ALLIGATOR
|
Facility
|
IP
|
$3,035.00
|
|
| Hospital Charge Code |
2962862
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,546.64 |
| Max. Negotiated Rate |
$2,903.89 |
| Rate for Payer: Aetna Commercial |
$2,840.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,714.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,672.89
|
| Rate for Payer: Cash Price |
$910.50
|
| Rate for Payer: Cigna Commercial |
$2,903.89
|
| Rate for Payer: Health EOS Commercial |
$2,809.20
|
| Rate for Payer: HFN Commercial |
$2,903.89
|
| Rate for Payer: Multiplan Commercial |
$2,525.12
|
| Rate for Payer: Preferred Network Access Commercial |
$2,903.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,546.64
|
| Rate for Payer: Quartz Commercial |
$1,893.84
|
| Rate for Payer: WEA Trust Commercial |
$1,736.02
|
| Rate for Payer: WPS Commercial |
$2,337.86
|
|
|
GRASPER 2.3 MINI-LAP ALLIGATOR
|
Facility
|
OP
|
$3,035.00
|
|
| Hospital Charge Code |
2962862
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$883.79 |
| Max. Negotiated Rate |
$2,903.89 |
| Rate for Payer: Aetna Commercial |
$2,840.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,714.50
|
| Rate for Payer: Aetna Managed Medicare |
$883.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,051.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,578.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,515.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,672.89
|
| Rate for Payer: Cash Price |
$910.50
|
| Rate for Payer: Cigna Commercial |
$2,903.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,766.37
|
| Rate for Payer: Health EOS Commercial |
$2,809.20
|
| Rate for Payer: HFN Commercial |
$2,903.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,367.30
|
| Rate for Payer: Multiplan Commercial |
$2,525.12
|
| Rate for Payer: NAPHCARE Commercial |
$1,893.84
|
| Rate for Payer: Preferred Network Access Commercial |
$2,903.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,546.64
|
| Rate for Payer: Quartz Commercial |
$2,051.66
|
| Rate for Payer: Quartz Medicare Advantage |
$1,893.84
|
| Rate for Payer: The Alliance Commercial |
$1,578.20
|
| Rate for Payer: WEA Trust Commercial |
$1,736.02
|
| Rate for Payer: WPS Commercial |
$2,337.86
|
|
|
GRASPER FORCEP 3FR RAT TOOTH 210310 G14921
|
Facility
|
OP
|
$2,695.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2964982
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$784.78 |
| Max. Negotiated Rate |
$2,578.58 |
| Rate for Payer: Aetna Commercial |
$2,522.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,410.41
|
| Rate for Payer: Aetna Managed Medicare |
$784.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,821.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,401.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,345.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,485.48
|
| Rate for Payer: Cash Price |
$808.50
|
| Rate for Payer: Cigna Commercial |
$2,578.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,568.49
|
| Rate for Payer: Health EOS Commercial |
$2,494.49
|
| Rate for Payer: HFN Commercial |
$2,578.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,102.10
|
| Rate for Payer: Multiplan Commercial |
$2,242.24
|
| Rate for Payer: NAPHCARE Commercial |
$1,681.68
|
| Rate for Payer: Preferred Network Access Commercial |
$2,578.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,373.37
|
| Rate for Payer: Quartz Commercial |
$1,821.82
|
| Rate for Payer: Quartz Medicare Advantage |
$1,681.68
|
| Rate for Payer: The Alliance Commercial |
$1,401.40
|
| Rate for Payer: WEA Trust Commercial |
$1,541.54
|
| Rate for Payer: WPS Commercial |
$2,075.96
|
|
|
GRASPER FORCEP 3FR RAT TOOTH 210310 G14921
|
Facility
|
IP
|
$2,695.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2964982
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,373.37 |
| Max. Negotiated Rate |
$2,578.58 |
| Rate for Payer: Aetna Commercial |
$2,522.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,410.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,485.48
|
| Rate for Payer: Cash Price |
$808.50
|
| Rate for Payer: Cigna Commercial |
$2,578.58
|
| Rate for Payer: Health EOS Commercial |
$2,494.49
|
| Rate for Payer: HFN Commercial |
$2,578.58
|
| Rate for Payer: Multiplan Commercial |
$2,242.24
|
| Rate for Payer: Preferred Network Access Commercial |
$2,578.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,373.37
|
| Rate for Payer: Quartz Commercial |
$1,681.68
|
| Rate for Payer: WEA Trust Commercial |
$1,541.54
|
| Rate for Payer: WPS Commercial |
$2,075.96
|
|
|
Gravity tubing changed - Peripheral IV Care:
|
Facility
|
IP
|
$76.00
|
|
| Hospital Charge Code |
3000018
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$47.42
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$58.54
|
|
|
Gravity tubing changed - Peripheral IV Care:
|
Facility
|
OP
|
$76.00
|
|
| Hospital Charge Code |
3000018
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.13 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Aetna Managed Medicare |
$22.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.23
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.28
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: NAPHCARE Commercial |
$47.42
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$51.38
|
| Rate for Payer: Quartz Medicare Advantage |
$47.42
|
| Rate for Payer: The Alliance Commercial |
$39.52
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$58.54
|
|
|
Gravity tubing - Peripheral IV Equipment:
|
Facility
|
OP
|
$76.00
|
|
| Hospital Charge Code |
3003557
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.13 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Aetna Managed Medicare |
$22.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.23
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.28
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: NAPHCARE Commercial |
$47.42
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$51.38
|
| Rate for Payer: Quartz Medicare Advantage |
$47.42
|
| Rate for Payer: The Alliance Commercial |
$39.52
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$58.54
|
|
|
Gravity tubing - Peripheral IV Equipment:
|
Facility
|
IP
|
$76.00
|
|
| Hospital Charge Code |
3003557
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$47.42
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$58.54
|
|
|
GREAT VESSEL INJURY REPAIR, TRAUMA
|
Facility
|
IP
|
$15,548.00
|
|
| Hospital Charge Code |
2960503
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,923.26 |
| Max. Negotiated Rate |
$14,876.33 |
| Rate for Payer: Aetna Commercial |
$14,552.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,906.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,570.06
|
| Rate for Payer: Cash Price |
$4,664.40
|
| Rate for Payer: Cigna Commercial |
$14,876.33
|
| Rate for Payer: Health EOS Commercial |
$14,391.23
|
| Rate for Payer: HFN Commercial |
$14,876.33
|
| Rate for Payer: Multiplan Commercial |
$12,935.94
|
| Rate for Payer: Preferred Network Access Commercial |
$14,876.33
|
| Rate for Payer: Quartz Beloit One Network |
$7,923.26
|
| Rate for Payer: Quartz Commercial |
$9,701.95
|
| Rate for Payer: WEA Trust Commercial |
$8,893.46
|
| Rate for Payer: WPS Commercial |
$11,976.62
|
|
|
GREAT VESSEL INJURY REPAIR, TRAUMA
|
Facility
|
OP
|
$15,548.00
|
|
| Hospital Charge Code |
2960503
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,527.58 |
| Max. Negotiated Rate |
$14,876.33 |
| Rate for Payer: Aetna Commercial |
$14,552.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,906.13
|
| Rate for Payer: Aetna Managed Medicare |
$4,527.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,510.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,084.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,761.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,570.06
|
| Rate for Payer: Cash Price |
$4,664.40
|
| Rate for Payer: Cigna Commercial |
$14,876.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,048.94
|
| Rate for Payer: Health EOS Commercial |
$14,391.23
|
| Rate for Payer: HFN Commercial |
$14,876.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,127.44
|
| Rate for Payer: Multiplan Commercial |
$12,935.94
|
| Rate for Payer: NAPHCARE Commercial |
$9,701.95
|
| Rate for Payer: Preferred Network Access Commercial |
$14,876.33
|
| Rate for Payer: Quartz Beloit One Network |
$7,923.26
|
| Rate for Payer: Quartz Commercial |
$10,510.45
|
| Rate for Payer: Quartz Medicare Advantage |
$9,701.95
|
| Rate for Payer: The Alliance Commercial |
$8,084.96
|
| Rate for Payer: WEA Trust Commercial |
$8,893.46
|
| Rate for Payer: WPS Commercial |
$11,976.62
|
|
|
Green (prong O.D.: 3.0mm) - RAM Cannula
|
Facility
|
IP
|
$223.00
|
|
| Hospital Charge Code |
5983677
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.64 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$139.15
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
Green (prong O.D.: 3.0mm) - RAM Cannula
|
Facility
|
OP
|
$223.00
|
|
| Hospital Charge Code |
5983677
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$64.94 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$64.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.79
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$173.94
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$139.15
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$150.75
|
| Rate for Payer: Quartz Medicare Advantage |
$139.15
|
| Rate for Payer: The Alliance Commercial |
$115.96
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
GRIP 1.6MM HOLE SM 6704-5-016
|
Facility
|
OP
|
$5,030.00
|
|
| Hospital Charge Code |
2966079
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,464.74 |
| Max. Negotiated Rate |
$4,812.70 |
| Rate for Payer: Aetna Commercial |
$4,708.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,498.83
|
| Rate for Payer: Aetna Managed Medicare |
$1,464.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,400.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,615.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,510.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,772.54
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,812.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,927.46
|
| Rate for Payer: Health EOS Commercial |
$4,655.77
|
| Rate for Payer: HFN Commercial |
$4,812.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,923.40
|
| Rate for Payer: Multiplan Commercial |
$4,184.96
|
| Rate for Payer: NAPHCARE Commercial |
$3,138.72
|
| Rate for Payer: Preferred Network Access Commercial |
$4,812.70
|
| Rate for Payer: Quartz Beloit One Network |
$2,563.29
|
| Rate for Payer: Quartz Commercial |
$3,400.28
|
| Rate for Payer: Quartz Medicare Advantage |
$3,138.72
|
| Rate for Payer: The Alliance Commercial |
$2,615.60
|
| Rate for Payer: WEA Trust Commercial |
$2,877.16
|
| Rate for Payer: WPS Commercial |
$3,874.61
|
|
|
GRIP 1.6MM HOLE SM 6704-5-016
|
Facility
|
IP
|
$5,030.00
|
|
| Hospital Charge Code |
2966079
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,563.29 |
| Max. Negotiated Rate |
$4,812.70 |
| Rate for Payer: Aetna Commercial |
$4,708.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,498.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,772.54
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,812.70
|
| Rate for Payer: Health EOS Commercial |
$4,655.77
|
| Rate for Payer: HFN Commercial |
$4,812.70
|
| Rate for Payer: Multiplan Commercial |
$4,184.96
|
| Rate for Payer: Preferred Network Access Commercial |
$4,812.70
|
| Rate for Payer: Quartz Beloit One Network |
$2,563.29
|
| Rate for Payer: Quartz Commercial |
$3,138.72
|
| Rate for Payer: WEA Trust Commercial |
$2,877.16
|
| Rate for Payer: WPS Commercial |
$3,874.61
|
|
|
GRIP 2.0MM HOLE LG 6704-7-020
|
Facility
|
IP
|
$5,030.00
|
|
| Hospital Charge Code |
2966080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,563.29 |
| Max. Negotiated Rate |
$4,812.70 |
| Rate for Payer: Aetna Commercial |
$4,708.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,498.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,772.54
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,812.70
|
| Rate for Payer: Health EOS Commercial |
$4,655.77
|
| Rate for Payer: HFN Commercial |
$4,812.70
|
| Rate for Payer: Multiplan Commercial |
$4,184.96
|
| Rate for Payer: Preferred Network Access Commercial |
$4,812.70
|
| Rate for Payer: Quartz Beloit One Network |
$2,563.29
|
| Rate for Payer: Quartz Commercial |
$3,138.72
|
| Rate for Payer: WEA Trust Commercial |
$2,877.16
|
| Rate for Payer: WPS Commercial |
$3,874.61
|
|
|
GRIP 2.0MM HOLE LG 6704-7-020
|
Facility
|
OP
|
$5,030.00
|
|
| Hospital Charge Code |
2966080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,464.74 |
| Max. Negotiated Rate |
$4,812.70 |
| Rate for Payer: Aetna Commercial |
$4,708.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,498.83
|
| Rate for Payer: Aetna Managed Medicare |
$1,464.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,400.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,615.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,510.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,772.54
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,812.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,927.46
|
| Rate for Payer: Health EOS Commercial |
$4,655.77
|
| Rate for Payer: HFN Commercial |
$4,812.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,923.40
|
| Rate for Payer: Multiplan Commercial |
$4,184.96
|
| Rate for Payer: NAPHCARE Commercial |
$3,138.72
|
| Rate for Payer: Preferred Network Access Commercial |
$4,812.70
|
| Rate for Payer: Quartz Beloit One Network |
$2,563.29
|
| Rate for Payer: Quartz Commercial |
$3,400.28
|
| Rate for Payer: Quartz Medicare Advantage |
$3,138.72
|
| Rate for Payer: The Alliance Commercial |
$2,615.60
|
| Rate for Payer: WEA Trust Commercial |
$2,877.16
|
| Rate for Payer: WPS Commercial |
$3,874.61
|
|
|
GRIP 2.0MM HOLE MED 6704-6-020
|
Facility
|
OP
|
$5,030.00
|
|
| Hospital Charge Code |
2966081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,464.74 |
| Max. Negotiated Rate |
$4,812.70 |
| Rate for Payer: Aetna Commercial |
$4,708.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,498.83
|
| Rate for Payer: Aetna Managed Medicare |
$1,464.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,400.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,615.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,510.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,772.54
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,812.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,927.46
|
| Rate for Payer: Health EOS Commercial |
$4,655.77
|
| Rate for Payer: HFN Commercial |
$4,812.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,923.40
|
| Rate for Payer: Multiplan Commercial |
$4,184.96
|
| Rate for Payer: NAPHCARE Commercial |
$3,138.72
|
| Rate for Payer: Preferred Network Access Commercial |
$4,812.70
|
| Rate for Payer: Quartz Beloit One Network |
$2,563.29
|
| Rate for Payer: Quartz Commercial |
$3,400.28
|
| Rate for Payer: Quartz Medicare Advantage |
$3,138.72
|
| Rate for Payer: The Alliance Commercial |
$2,615.60
|
| Rate for Payer: WEA Trust Commercial |
$2,877.16
|
| Rate for Payer: WPS Commercial |
$3,874.61
|
|
|
GRIP 2.0MM HOLE MED 6704-6-020
|
Facility
|
IP
|
$5,030.00
|
|
| Hospital Charge Code |
2966081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,563.29 |
| Max. Negotiated Rate |
$4,812.70 |
| Rate for Payer: Aetna Commercial |
$4,708.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,498.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,772.54
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,812.70
|
| Rate for Payer: Health EOS Commercial |
$4,655.77
|
| Rate for Payer: HFN Commercial |
$4,812.70
|
| Rate for Payer: Multiplan Commercial |
$4,184.96
|
| Rate for Payer: Preferred Network Access Commercial |
$4,812.70
|
| Rate for Payer: Quartz Beloit One Network |
$2,563.29
|
| Rate for Payer: Quartz Commercial |
$3,138.72
|
| Rate for Payer: WEA Trust Commercial |
$2,877.16
|
| Rate for Payer: WPS Commercial |
$3,874.61
|
|
