|
Graftmaster 5.0mm x 26mm
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
1163006
|
|
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
|
|
|
GRAFT OPTIGRAFT HALF-MOON SPLIT THICKNESS V0129/V0137
|
Facility
|
IP
|
$3,197.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6171648
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,566.53 |
| Max. Negotiated Rate |
$2,941.24 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$1,918.20
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
GRAFT OPTIGRAFT HALF-MOON SPLIT THICKNESS V0129/V0137
|
Facility
|
OP
|
$3,197.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6171648
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$895.16 |
| Max. Negotiated Rate |
$12,788.00 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Aetna Managed Medicare |
$895.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,078.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,598.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,534.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,789.04
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,397.75
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$2,078.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,918.20
|
| Rate for Payer: The Alliance Commercial |
$12,788.00
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
GRAFT PATCH VASCULAR 2X9CMX.4MM
|
Facility
|
IP
|
$2,893.00
|
|
| Hospital Charge Code |
2967379
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,417.57 |
| Max. Negotiated Rate |
$2,661.56 |
| Rate for Payer: Aetna Commercial |
$2,603.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,487.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,533.29
|
| Rate for Payer: Cash Price |
$867.90
|
| Rate for Payer: Cigna Commercial |
$2,661.56
|
| Rate for Payer: Health EOS Commercial |
$2,574.77
|
| Rate for Payer: HFN Commercial |
$2,661.56
|
| Rate for Payer: Multiplan Commercial |
$2,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,735.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,661.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,417.57
|
| Rate for Payer: Quartz Commercial |
$1,735.80
|
| Rate for Payer: WEA Trust Commercial |
$1,591.15
|
| Rate for Payer: WPS Commercial |
$2,142.85
|
|
|
GRAFT PATCH VASCULAR 2X9CMX.4MM
|
Facility
|
OP
|
$2,893.00
|
|
| Hospital Charge Code |
2967379
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$810.04 |
| Max. Negotiated Rate |
$11,572.00 |
| Rate for Payer: Aetna Commercial |
$2,603.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,487.98
|
| Rate for Payer: Aetna Managed Medicare |
$810.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,880.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,446.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,388.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,533.29
|
| Rate for Payer: Cash Price |
$867.90
|
| Rate for Payer: Cigna Commercial |
$2,661.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,618.92
|
| Rate for Payer: Health EOS Commercial |
$2,574.77
|
| Rate for Payer: HFN Commercial |
$2,661.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,169.75
|
| Rate for Payer: Multiplan Commercial |
$2,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,735.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,661.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,417.57
|
| Rate for Payer: Quartz Commercial |
$1,880.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,735.80
|
| Rate for Payer: The Alliance Commercial |
$11,572.00
|
| Rate for Payer: WEA Trust Commercial |
$1,591.15
|
| Rate for Payer: WPS Commercial |
$2,142.85
|
|
|
GRAFT PRIMATRIX 6X6 MESH 607-005-660
|
Facility
|
IP
|
$4,302.00
|
|
| Hospital Charge Code |
3075851
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,107.98 |
| Max. Negotiated Rate |
$3,957.84 |
| Rate for Payer: Aetna Commercial |
$3,871.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,699.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,280.06
|
| Rate for Payer: Cash Price |
$1,290.60
|
| Rate for Payer: Cigna Commercial |
$3,957.84
|
| Rate for Payer: Health EOS Commercial |
$3,828.78
|
| Rate for Payer: HFN Commercial |
$3,957.84
|
| Rate for Payer: Multiplan Commercial |
$3,441.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,581.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,957.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,107.98
|
| Rate for Payer: Quartz Commercial |
$2,581.20
|
| Rate for Payer: WEA Trust Commercial |
$2,366.10
|
| Rate for Payer: WPS Commercial |
$3,186.49
|
|
|
GRAFT PRIMATRIX 6X6 MESH 607-005-660
|
Facility
|
OP
|
$4,302.00
|
|
| Hospital Charge Code |
3075851
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,204.56 |
| Max. Negotiated Rate |
$17,208.00 |
| Rate for Payer: Aetna Commercial |
$3,871.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,699.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,204.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,796.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,151.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,064.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,280.06
|
| Rate for Payer: Cash Price |
$1,290.60
|
| Rate for Payer: Cigna Commercial |
$3,957.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,407.40
|
| Rate for Payer: Health EOS Commercial |
$3,828.78
|
| Rate for Payer: HFN Commercial |
$3,957.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,226.50
|
| Rate for Payer: Multiplan Commercial |
$3,441.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,581.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,957.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,107.98
|
| Rate for Payer: Quartz Commercial |
$2,796.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,581.20
|
| Rate for Payer: The Alliance Commercial |
$17,208.00
|
| Rate for Payer: WEA Trust Commercial |
$2,366.10
|
| Rate for Payer: WPS Commercial |
$3,186.49
|
|
|
GRAFT PROCOL 6MM X 40CM VASCULAR BIOPROSTHESIS HJL016-40-N
|
Facility
|
OP
|
$11,202.00
|
|
| Hospital Charge Code |
5414997
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,136.56 |
| Max. Negotiated Rate |
$44,808.00 |
| Rate for Payer: Aetna Commercial |
$10,081.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,633.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,136.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,281.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,601.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,376.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,937.06
|
| Rate for Payer: Cash Price |
$3,360.60
|
| Rate for Payer: Cigna Commercial |
$10,305.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,268.64
|
| Rate for Payer: Health EOS Commercial |
$9,969.78
|
| Rate for Payer: HFN Commercial |
$10,305.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,401.50
|
| Rate for Payer: Multiplan Commercial |
$8,961.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,721.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,305.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,488.98
|
| Rate for Payer: Quartz Commercial |
$7,281.30
|
| Rate for Payer: Quartz Medicare Advantage |
$6,721.20
|
| Rate for Payer: The Alliance Commercial |
$44,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,161.10
|
| Rate for Payer: WPS Commercial |
$8,297.32
|
|
|
GRAFT PROCOL 6MM X 40CM VASCULAR BIOPROSTHESIS HJL016-40-N
|
Facility
|
IP
|
$11,202.00
|
|
| Hospital Charge Code |
5414997
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,488.98 |
| Max. Negotiated Rate |
$10,305.84 |
| Rate for Payer: Aetna Commercial |
$10,081.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,633.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,937.06
|
| Rate for Payer: Cash Price |
$3,360.60
|
| Rate for Payer: Cigna Commercial |
$10,305.84
|
| Rate for Payer: Health EOS Commercial |
$9,969.78
|
| Rate for Payer: HFN Commercial |
$10,305.84
|
| Rate for Payer: Multiplan Commercial |
$8,961.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,721.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,305.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,488.98
|
| Rate for Payer: Quartz Commercial |
$6,721.20
|
| Rate for Payer: WEA Trust Commercial |
$6,161.10
|
| Rate for Payer: WPS Commercial |
$8,297.32
|
|
|
GRAFT PROPATEN HEPARIN THIN WALL 5MM X 90CM 70CM RINGS HT057090A
|
Facility
|
IP
|
$18,210.00
|
|
| Hospital Charge Code |
3553515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,922.90 |
| Max. Negotiated Rate |
$16,753.20 |
| Rate for Payer: Aetna Commercial |
$16,389.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,660.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,651.30
|
| Rate for Payer: Cash Price |
$5,463.00
|
| Rate for Payer: Cigna Commercial |
$16,753.20
|
| Rate for Payer: Health EOS Commercial |
$16,206.90
|
| Rate for Payer: HFN Commercial |
$16,753.20
|
| Rate for Payer: Multiplan Commercial |
$14,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$10,926.00
|
| Rate for Payer: Preferred Network Access Commercial |
$16,753.20
|
| Rate for Payer: Quartz Beloit One Network |
$8,922.90
|
| Rate for Payer: Quartz Commercial |
$10,926.00
|
| Rate for Payer: WEA Trust Commercial |
$10,015.50
|
| Rate for Payer: WPS Commercial |
$13,488.15
|
|
|
GRAFT PROPATEN HEPARIN THIN WALL 5MM X 90CM 70CM RINGS HT057090A
|
Facility
|
OP
|
$18,210.00
|
|
| Hospital Charge Code |
3553515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,098.80 |
| Max. Negotiated Rate |
$72,840.00 |
| Rate for Payer: Aetna Commercial |
$16,389.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,660.60
|
| Rate for Payer: Aetna Managed Medicare |
$5,098.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,836.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,105.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,740.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,651.30
|
| Rate for Payer: Cash Price |
$5,463.00
|
| Rate for Payer: Cigna Commercial |
$16,753.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,190.32
|
| Rate for Payer: Health EOS Commercial |
$16,206.90
|
| Rate for Payer: HFN Commercial |
$16,753.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,657.50
|
| Rate for Payer: Multiplan Commercial |
$14,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$10,926.00
|
| Rate for Payer: Preferred Network Access Commercial |
$16,753.20
|
| Rate for Payer: Quartz Beloit One Network |
$8,922.90
|
| Rate for Payer: Quartz Commercial |
$11,836.50
|
| Rate for Payer: Quartz Medicare Advantage |
$10,926.00
|
| Rate for Payer: The Alliance Commercial |
$72,840.00
|
| Rate for Payer: WEA Trust Commercial |
$10,015.50
|
| Rate for Payer: WPS Commercial |
$13,488.15
|
|
|
GRAFT RESTORE ORTHOBIOLOGIC
|
Facility
|
OP
|
$14,929.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2965011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,180.12 |
| Max. Negotiated Rate |
$59,716.00 |
| Rate for Payer: Aetna Commercial |
$13,436.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,838.94
|
| Rate for Payer: Aetna Managed Medicare |
$4,180.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,703.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,464.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,165.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,912.37
|
| Rate for Payer: Cash Price |
$4,478.70
|
| Rate for Payer: Cigna Commercial |
$13,734.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,354.27
|
| Rate for Payer: Health EOS Commercial |
$13,286.81
|
| Rate for Payer: HFN Commercial |
$13,734.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,196.75
|
| Rate for Payer: Multiplan Commercial |
$11,943.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,957.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,734.68
|
| Rate for Payer: Quartz Beloit One Network |
$7,315.21
|
| Rate for Payer: Quartz Commercial |
$9,703.85
|
| Rate for Payer: Quartz Medicare Advantage |
$8,957.40
|
| Rate for Payer: The Alliance Commercial |
$59,716.00
|
| Rate for Payer: WEA Trust Commercial |
$8,210.95
|
| Rate for Payer: WPS Commercial |
$11,057.91
|
|
|
GRAFT RESTORE ORTHOBIOLOGIC
|
Facility
|
IP
|
$14,929.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2965011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,315.21 |
| Max. Negotiated Rate |
$13,734.68 |
| Rate for Payer: Aetna Commercial |
$13,436.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,838.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,912.37
|
| Rate for Payer: Cash Price |
$4,478.70
|
| Rate for Payer: Cigna Commercial |
$13,734.68
|
| Rate for Payer: Health EOS Commercial |
$13,286.81
|
| Rate for Payer: HFN Commercial |
$13,734.68
|
| Rate for Payer: Multiplan Commercial |
$11,943.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,957.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,734.68
|
| Rate for Payer: Quartz Beloit One Network |
$7,315.21
|
| Rate for Payer: Quartz Commercial |
$8,957.40
|
| Rate for Payer: WEA Trust Commercial |
$8,210.95
|
| Rate for Payer: WPS Commercial |
$11,057.91
|
|
|
GRAFT SPREADER AR-19007GS
|
Facility
|
OP
|
$3,580.55
|
|
| Hospital Charge Code |
6246219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,002.55 |
| Max. Negotiated Rate |
$14,322.20 |
| Rate for Payer: Aetna Commercial |
$3,222.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,079.27
|
| Rate for Payer: Aetna Managed Medicare |
$1,002.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,327.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,790.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,718.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,897.69
|
| Rate for Payer: Cash Price |
$1,074.16
|
| Rate for Payer: Cigna Commercial |
$3,294.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,003.68
|
| Rate for Payer: Health EOS Commercial |
$3,186.69
|
| Rate for Payer: HFN Commercial |
$3,294.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,685.41
|
| Rate for Payer: Multiplan Commercial |
$2,864.44
|
| Rate for Payer: NAPHCARE Commercial |
$2,148.33
|
| Rate for Payer: Preferred Network Access Commercial |
$3,294.11
|
| Rate for Payer: Quartz Beloit One Network |
$1,754.47
|
| Rate for Payer: Quartz Commercial |
$2,327.36
|
| Rate for Payer: Quartz Medicare Advantage |
$2,148.33
|
| Rate for Payer: The Alliance Commercial |
$14,322.20
|
| Rate for Payer: WEA Trust Commercial |
$1,969.30
|
| Rate for Payer: WPS Commercial |
$2,652.11
|
|
|
GRAFT SPREADER AR-19007GS
|
Facility
|
IP
|
$3,580.55
|
|
| Hospital Charge Code |
6246219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,754.47 |
| Max. Negotiated Rate |
$3,294.11 |
| Rate for Payer: Aetna Commercial |
$3,222.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,079.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,897.69
|
| Rate for Payer: Cash Price |
$1,074.16
|
| Rate for Payer: Cigna Commercial |
$3,294.11
|
| Rate for Payer: Health EOS Commercial |
$3,186.69
|
| Rate for Payer: HFN Commercial |
$3,294.11
|
| Rate for Payer: Multiplan Commercial |
$2,864.44
|
| Rate for Payer: NAPHCARE Commercial |
$2,148.33
|
| Rate for Payer: Preferred Network Access Commercial |
$3,294.11
|
| Rate for Payer: Quartz Beloit One Network |
$1,754.47
|
| Rate for Payer: Quartz Commercial |
$2,148.33
|
| Rate for Payer: WEA Trust Commercial |
$1,969.30
|
| Rate for Payer: WPS Commercial |
$2,652.11
|
|
|
GRAFT STRATTICE 10 X 10CM (100 SQ CM) 1010002
|
Facility
|
IP
|
$14,129.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3755521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,923.21 |
| Max. Negotiated Rate |
$12,998.68 |
| Rate for Payer: Aetna Commercial |
$12,716.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,150.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,488.37
|
| Rate for Payer: Cash Price |
$4,238.70
|
| Rate for Payer: Cigna Commercial |
$12,998.68
|
| Rate for Payer: Health EOS Commercial |
$12,574.81
|
| Rate for Payer: HFN Commercial |
$12,998.68
|
| Rate for Payer: Multiplan Commercial |
$11,303.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,477.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,998.68
|
| Rate for Payer: Quartz Beloit One Network |
$6,923.21
|
| Rate for Payer: Quartz Commercial |
$8,477.40
|
| Rate for Payer: WEA Trust Commercial |
$7,770.95
|
| Rate for Payer: WPS Commercial |
$10,465.35
|
|
|
GRAFT STRATTICE 10 X 10CM (100 SQ CM) 1010002
|
Facility
|
OP
|
$14,129.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3755521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,956.12 |
| Max. Negotiated Rate |
$56,516.00 |
| Rate for Payer: Aetna Commercial |
$12,716.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,150.94
|
| Rate for Payer: Aetna Managed Medicare |
$3,956.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,183.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,064.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,781.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,488.37
|
| Rate for Payer: Cash Price |
$4,238.70
|
| Rate for Payer: Cigna Commercial |
$12,998.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,906.59
|
| Rate for Payer: Health EOS Commercial |
$12,574.81
|
| Rate for Payer: HFN Commercial |
$12,998.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,596.75
|
| Rate for Payer: Multiplan Commercial |
$11,303.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,477.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,998.68
|
| Rate for Payer: Quartz Beloit One Network |
$6,923.21
|
| Rate for Payer: Quartz Commercial |
$9,183.85
|
| Rate for Payer: Quartz Medicare Advantage |
$8,477.40
|
| Rate for Payer: The Alliance Commercial |
$56,516.00
|
| Rate for Payer: WEA Trust Commercial |
$7,770.95
|
| Rate for Payer: WPS Commercial |
$10,465.35
|
|
|
GRAFT STRATTICE 10 X 16CM (160 SQ CM) 1016002
|
Facility
|
IP
|
$23,089.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965267
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,313.61 |
| Max. Negotiated Rate |
$21,241.88 |
| Rate for Payer: Aetna Commercial |
$20,780.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,856.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,237.17
|
| Rate for Payer: Cash Price |
$6,926.70
|
| Rate for Payer: Cigna Commercial |
$21,241.88
|
| Rate for Payer: Health EOS Commercial |
$20,549.21
|
| Rate for Payer: HFN Commercial |
$21,241.88
|
| Rate for Payer: Multiplan Commercial |
$18,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21,241.88
|
| Rate for Payer: Quartz Beloit One Network |
$11,313.61
|
| Rate for Payer: Quartz Commercial |
$13,853.40
|
| Rate for Payer: WEA Trust Commercial |
$12,698.95
|
| Rate for Payer: WPS Commercial |
$17,102.02
|
|
|
GRAFT STRATTICE 10 X 16CM (160 SQ CM) 1016002
|
Facility
|
OP
|
$23,089.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965267
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,464.92 |
| Max. Negotiated Rate |
$92,356.00 |
| Rate for Payer: Aetna Commercial |
$20,780.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,856.54
|
| Rate for Payer: Aetna Managed Medicare |
$6,464.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,007.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,544.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,082.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,237.17
|
| Rate for Payer: Cash Price |
$6,926.70
|
| Rate for Payer: Cigna Commercial |
$21,241.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,920.60
|
| Rate for Payer: Health EOS Commercial |
$20,549.21
|
| Rate for Payer: HFN Commercial |
$21,241.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,316.75
|
| Rate for Payer: Multiplan Commercial |
$18,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21,241.88
|
| Rate for Payer: Quartz Beloit One Network |
$11,313.61
|
| Rate for Payer: Quartz Commercial |
$15,007.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13,853.40
|
| Rate for Payer: The Alliance Commercial |
$92,356.00
|
| Rate for Payer: WEA Trust Commercial |
$12,698.95
|
| Rate for Payer: WPS Commercial |
$17,102.02
|
|
|
GRAFT STRATTICE 10 X 20CM (200 SQ CM) 1020002
|
Facility
|
OP
|
$28,252.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
4174302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,910.56 |
| Max. Negotiated Rate |
$113,008.00 |
| Rate for Payer: Aetna Commercial |
$25,426.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24,296.72
|
| Rate for Payer: Aetna Managed Medicare |
$7,910.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,363.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,126.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,560.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,973.56
|
| Rate for Payer: Cash Price |
$8,475.60
|
| Rate for Payer: Cigna Commercial |
$25,991.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,809.82
|
| Rate for Payer: Health EOS Commercial |
$25,144.28
|
| Rate for Payer: HFN Commercial |
$25,991.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,189.00
|
| Rate for Payer: Multiplan Commercial |
$22,601.60
|
| Rate for Payer: NAPHCARE Commercial |
$16,951.20
|
| Rate for Payer: Preferred Network Access Commercial |
$25,991.84
|
| Rate for Payer: Quartz Beloit One Network |
$13,843.48
|
| Rate for Payer: Quartz Commercial |
$18,363.80
|
| Rate for Payer: Quartz Medicare Advantage |
$16,951.20
|
| Rate for Payer: The Alliance Commercial |
$113,008.00
|
| Rate for Payer: WEA Trust Commercial |
$15,538.60
|
| Rate for Payer: WPS Commercial |
$20,926.26
|
|
|
GRAFT STRATTICE 10 X 20CM (200 SQ CM) 1020002
|
Facility
|
IP
|
$28,252.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
4174302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,843.48 |
| Max. Negotiated Rate |
$25,991.84 |
| Rate for Payer: Aetna Commercial |
$25,426.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24,296.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,973.56
|
| Rate for Payer: Cash Price |
$8,475.60
|
| Rate for Payer: Cigna Commercial |
$25,991.84
|
| Rate for Payer: Health EOS Commercial |
$25,144.28
|
| Rate for Payer: HFN Commercial |
$25,991.84
|
| Rate for Payer: Multiplan Commercial |
$22,601.60
|
| Rate for Payer: NAPHCARE Commercial |
$16,951.20
|
| Rate for Payer: Preferred Network Access Commercial |
$25,991.84
|
| Rate for Payer: Quartz Beloit One Network |
$13,843.48
|
| Rate for Payer: Quartz Commercial |
$16,951.20
|
| Rate for Payer: WEA Trust Commercial |
$15,538.60
|
| Rate for Payer: WPS Commercial |
$20,926.26
|
|
|
GRAFT STRATTICE 15 X 25 FIRM (375 SQ CM) 1525002
|
Facility
|
OP
|
$52,984.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3153466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14,835.52 |
| Max. Negotiated Rate |
$211,936.00 |
| Rate for Payer: Aetna Commercial |
$47,685.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45,566.24
|
| Rate for Payer: Aetna Managed Medicare |
$14,835.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34,439.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,492.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,432.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28,081.52
|
| Rate for Payer: Cash Price |
$15,895.20
|
| Rate for Payer: Cigna Commercial |
$48,745.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29,649.85
|
| Rate for Payer: Health EOS Commercial |
$47,155.76
|
| Rate for Payer: HFN Commercial |
$48,745.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39,738.00
|
| Rate for Payer: Multiplan Commercial |
$42,387.20
|
| Rate for Payer: NAPHCARE Commercial |
$31,790.40
|
| Rate for Payer: Preferred Network Access Commercial |
$48,745.28
|
| Rate for Payer: Quartz Beloit One Network |
$25,962.16
|
| Rate for Payer: Quartz Commercial |
$34,439.60
|
| Rate for Payer: Quartz Medicare Advantage |
$31,790.40
|
| Rate for Payer: The Alliance Commercial |
$211,936.00
|
| Rate for Payer: WEA Trust Commercial |
$29,141.20
|
| Rate for Payer: WPS Commercial |
$39,245.25
|
|
|
GRAFT STRATTICE 15 X 25 FIRM (375 SQ CM) 1525002
|
Facility
|
IP
|
$52,984.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3153466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,962.16 |
| Max. Negotiated Rate |
$48,745.28 |
| Rate for Payer: Aetna Commercial |
$47,685.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45,566.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28,081.52
|
| Rate for Payer: Cash Price |
$15,895.20
|
| Rate for Payer: Cigna Commercial |
$48,745.28
|
| Rate for Payer: Health EOS Commercial |
$47,155.76
|
| Rate for Payer: HFN Commercial |
$48,745.28
|
| Rate for Payer: Multiplan Commercial |
$42,387.20
|
| Rate for Payer: NAPHCARE Commercial |
$31,790.40
|
| Rate for Payer: Preferred Network Access Commercial |
$48,745.28
|
| Rate for Payer: Quartz Beloit One Network |
$25,962.16
|
| Rate for Payer: Quartz Commercial |
$31,790.40
|
| Rate for Payer: WEA Trust Commercial |
$29,141.20
|
| Rate for Payer: WPS Commercial |
$39,245.25
|
|
|
GRAFT STRATTICE 16 X 20 (320 SQ CM) FIRM 1620002
|
Facility
|
IP
|
$45,213.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3439505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,154.37 |
| Max. Negotiated Rate |
$41,595.96 |
| Rate for Payer: Aetna Commercial |
$40,691.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38,883.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23,962.89
|
| Rate for Payer: Cash Price |
$13,563.90
|
| Rate for Payer: Cigna Commercial |
$41,595.96
|
| Rate for Payer: Health EOS Commercial |
$40,239.57
|
| Rate for Payer: HFN Commercial |
$41,595.96
|
| Rate for Payer: Multiplan Commercial |
$36,170.40
|
| Rate for Payer: NAPHCARE Commercial |
$27,127.80
|
| Rate for Payer: Preferred Network Access Commercial |
$41,595.96
|
| Rate for Payer: Quartz Beloit One Network |
$22,154.37
|
| Rate for Payer: Quartz Commercial |
$27,127.80
|
| Rate for Payer: WEA Trust Commercial |
$24,867.15
|
| Rate for Payer: WPS Commercial |
$33,489.27
|
|
|
GRAFT STRATTICE 16 X 20 (320 SQ CM) FIRM 1620002
|
Facility
|
OP
|
$45,213.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
3439505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,659.64 |
| Max. Negotiated Rate |
$180,852.00 |
| Rate for Payer: Aetna Commercial |
$40,691.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38,883.18
|
| Rate for Payer: Aetna Managed Medicare |
$12,659.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,388.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,606.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,702.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23,962.89
|
| Rate for Payer: Cash Price |
$13,563.90
|
| Rate for Payer: Cigna Commercial |
$41,595.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25,301.19
|
| Rate for Payer: Health EOS Commercial |
$40,239.57
|
| Rate for Payer: HFN Commercial |
$41,595.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33,909.75
|
| Rate for Payer: Multiplan Commercial |
$36,170.40
|
| Rate for Payer: NAPHCARE Commercial |
$27,127.80
|
| Rate for Payer: Preferred Network Access Commercial |
$41,595.96
|
| Rate for Payer: Quartz Beloit One Network |
$22,154.37
|
| Rate for Payer: Quartz Commercial |
$29,388.45
|
| Rate for Payer: Quartz Medicare Advantage |
$27,127.80
|
| Rate for Payer: The Alliance Commercial |
$180,852.00
|
| Rate for Payer: WEA Trust Commercial |
$24,867.15
|
| Rate for Payer: WPS Commercial |
$33,489.27
|
|
