|
GRAFT STRATTICE 20 X 20CM (400 SQ CM) 2020002
|
Facility
|
OP
|
$56,516.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,824.48 |
| Max. Negotiated Rate |
$226,064.00 |
| Rate for Payer: Aetna Commercial |
$50,864.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48,603.76
|
| Rate for Payer: Aetna Managed Medicare |
$15,824.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36,735.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28,258.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,127.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29,953.48
|
| Rate for Payer: Cash Price |
$16,954.80
|
| Rate for Payer: Cigna Commercial |
$51,994.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,626.35
|
| Rate for Payer: Health EOS Commercial |
$50,299.24
|
| Rate for Payer: HFN Commercial |
$51,994.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42,387.00
|
| Rate for Payer: Multiplan Commercial |
$45,212.80
|
| Rate for Payer: NAPHCARE Commercial |
$33,909.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51,994.72
|
| Rate for Payer: Quartz Beloit One Network |
$27,692.84
|
| Rate for Payer: Quartz Commercial |
$36,735.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33,909.60
|
| Rate for Payer: The Alliance Commercial |
$226,064.00
|
| Rate for Payer: WEA Trust Commercial |
$31,083.80
|
| Rate for Payer: WPS Commercial |
$41,861.40
|
|
|
GRAFT STRATTICE 20 X 20CM (400 SQ CM) 2020002
|
Facility
|
IP
|
$56,516.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$27,692.84 |
| Max. Negotiated Rate |
$51,994.72 |
| Rate for Payer: Aetna Commercial |
$50,864.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48,603.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29,953.48
|
| Rate for Payer: Cash Price |
$16,954.80
|
| Rate for Payer: Cigna Commercial |
$51,994.72
|
| Rate for Payer: Health EOS Commercial |
$50,299.24
|
| Rate for Payer: HFN Commercial |
$51,994.72
|
| Rate for Payer: Multiplan Commercial |
$45,212.80
|
| Rate for Payer: NAPHCARE Commercial |
$33,909.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51,994.72
|
| Rate for Payer: Quartz Beloit One Network |
$27,692.84
|
| Rate for Payer: Quartz Commercial |
$33,909.60
|
| Rate for Payer: WEA Trust Commercial |
$31,083.80
|
| Rate for Payer: WPS Commercial |
$41,861.40
|
|
|
GRAFT STRATTICE 6 X 8CM PLIABLE (48 SQ CM) 0608001
|
Facility
|
OP
|
$7,042.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965269
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,971.76 |
| Max. Negotiated Rate |
$28,168.00 |
| Rate for Payer: Aetna Commercial |
$6,337.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,056.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,971.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,577.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,521.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,380.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,732.26
|
| Rate for Payer: Cash Price |
$2,112.60
|
| Rate for Payer: Cigna Commercial |
$6,478.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,940.70
|
| Rate for Payer: Health EOS Commercial |
$6,267.38
|
| Rate for Payer: HFN Commercial |
$6,478.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,281.50
|
| Rate for Payer: Multiplan Commercial |
$5,633.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,225.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,478.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,450.58
|
| Rate for Payer: Quartz Commercial |
$4,577.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,225.20
|
| Rate for Payer: The Alliance Commercial |
$28,168.00
|
| Rate for Payer: WEA Trust Commercial |
$3,873.10
|
| Rate for Payer: WPS Commercial |
$5,216.01
|
|
|
GRAFT STRATTICE 6 X 8CM PLIABLE (48 SQ CM) 0608001
|
Facility
|
IP
|
$7,042.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965269
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,450.58 |
| Max. Negotiated Rate |
$6,478.64 |
| Rate for Payer: Aetna Commercial |
$6,337.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,056.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,732.26
|
| Rate for Payer: Cash Price |
$2,112.60
|
| Rate for Payer: Cigna Commercial |
$6,478.64
|
| Rate for Payer: Health EOS Commercial |
$6,267.38
|
| Rate for Payer: HFN Commercial |
$6,478.64
|
| Rate for Payer: Multiplan Commercial |
$5,633.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,225.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,478.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,450.58
|
| Rate for Payer: Quartz Commercial |
$4,225.20
|
| Rate for Payer: WEA Trust Commercial |
$3,873.10
|
| Rate for Payer: WPS Commercial |
$5,216.01
|
|
|
GRAFT STRATTICE 8 X 16CM PLIABLE (128 SQ CM) 0816001
|
Facility
|
IP
|
$18,086.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965270
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,862.14 |
| Max. Negotiated Rate |
$16,639.12 |
| Rate for Payer: Aetna Commercial |
$16,277.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,553.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,585.58
|
| Rate for Payer: Cash Price |
$5,425.80
|
| Rate for Payer: Cigna Commercial |
$16,639.12
|
| Rate for Payer: Health EOS Commercial |
$16,096.54
|
| Rate for Payer: HFN Commercial |
$16,639.12
|
| Rate for Payer: Multiplan Commercial |
$14,468.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,851.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,639.12
|
| Rate for Payer: Quartz Beloit One Network |
$8,862.14
|
| Rate for Payer: Quartz Commercial |
$10,851.60
|
| Rate for Payer: WEA Trust Commercial |
$9,947.30
|
| Rate for Payer: WPS Commercial |
$13,396.30
|
|
|
GRAFT STRATTICE 8 X 16CM PLIABLE (128 SQ CM) 0816001
|
Facility
|
OP
|
$18,086.00
|
|
|
Service Code
|
HCPCS Q4130
|
| Hospital Charge Code |
2965270
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,064.08 |
| Max. Negotiated Rate |
$72,344.00 |
| Rate for Payer: Aetna Commercial |
$16,277.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,553.96
|
| Rate for Payer: Aetna Managed Medicare |
$5,064.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,755.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,681.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,585.58
|
| Rate for Payer: Cash Price |
$5,425.80
|
| Rate for Payer: Cigna Commercial |
$16,639.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,120.93
|
| Rate for Payer: Health EOS Commercial |
$16,096.54
|
| Rate for Payer: HFN Commercial |
$16,639.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,564.50
|
| Rate for Payer: Multiplan Commercial |
$14,468.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,851.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,639.12
|
| Rate for Payer: Quartz Beloit One Network |
$8,862.14
|
| Rate for Payer: Quartz Commercial |
$11,755.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,851.60
|
| Rate for Payer: The Alliance Commercial |
$72,344.00
|
| Rate for Payer: WEA Trust Commercial |
$9,947.30
|
| Rate for Payer: WPS Commercial |
$13,396.30
|
|
|
GRAFT STRAVIX 2CM X 2CM (4 SQ CM) FROZEN PS60006
|
Facility
|
OP
|
$1,560.08
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
6252143
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.49 |
| Max. Negotiated Rate |
$6,240.32 |
| Rate for Payer: Aetna Commercial |
$1,404.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,341.67
|
| Rate for Payer: Aetna Managed Medicare |
$436.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,014.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$780.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$748.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$826.84
|
| Rate for Payer: Cash Price |
$468.02
|
| Rate for Payer: Cash Price |
$468.02
|
| Rate for Payer: Cigna Commercial |
$1,435.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.49
|
| Rate for Payer: Health EOS Commercial |
$1,388.47
|
| Rate for Payer: HFN Commercial |
$1,435.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,170.06
|
| Rate for Payer: Multiplan Commercial |
$1,248.06
|
| Rate for Payer: NAPHCARE Commercial |
$936.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,435.27
|
| Rate for Payer: Quartz Beloit One Network |
$764.44
|
| Rate for Payer: Quartz Commercial |
$1,014.05
|
| Rate for Payer: Quartz Medicare Advantage |
$936.05
|
| Rate for Payer: The Alliance Commercial |
$6,240.32
|
| Rate for Payer: WEA Trust Commercial |
$858.04
|
| Rate for Payer: WPS Commercial |
$358.06
|
|
|
GRAFT STRAVIX 2CM X 2CM (4 SQ CM) FROZEN PS60006
|
Facility
|
IP
|
$1,560.08
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
6252143
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$764.44 |
| Max. Negotiated Rate |
$1,435.27 |
| Rate for Payer: Aetna Commercial |
$1,404.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,341.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$826.84
|
| Rate for Payer: Cash Price |
$468.02
|
| Rate for Payer: Cigna Commercial |
$1,435.27
|
| Rate for Payer: Health EOS Commercial |
$1,388.47
|
| Rate for Payer: HFN Commercial |
$1,435.27
|
| Rate for Payer: Multiplan Commercial |
$1,248.06
|
| Rate for Payer: NAPHCARE Commercial |
$936.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,435.27
|
| Rate for Payer: Quartz Beloit One Network |
$764.44
|
| Rate for Payer: Quartz Commercial |
$936.05
|
| Rate for Payer: WEA Trust Commercial |
$858.04
|
| Rate for Payer: WPS Commercial |
$1,155.55
|
|
|
GRAFT STRAVIX 2CM X 4CM (8 SQ CM) FROZEN PS60005
|
Facility
|
OP
|
$9,974.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5415470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.49 |
| Max. Negotiated Rate |
$39,896.00 |
| Rate for Payer: Aetna Commercial |
$8,976.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,577.64
|
| Rate for Payer: Aetna Managed Medicare |
$2,792.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,483.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,987.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,787.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,286.22
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cigna Commercial |
$9,176.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.49
|
| Rate for Payer: Health EOS Commercial |
$8,876.86
|
| Rate for Payer: HFN Commercial |
$9,176.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,480.50
|
| Rate for Payer: Multiplan Commercial |
$7,979.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,984.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,176.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,887.26
|
| Rate for Payer: Quartz Commercial |
$6,483.10
|
| Rate for Payer: Quartz Medicare Advantage |
$5,984.40
|
| Rate for Payer: The Alliance Commercial |
$39,896.00
|
| Rate for Payer: WEA Trust Commercial |
$5,485.70
|
| Rate for Payer: WPS Commercial |
$358.06
|
|
|
GRAFT STRAVIX 2CM X 4CM (8 SQ CM) FROZEN PS60005
|
Facility
|
IP
|
$9,974.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5415470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,887.26 |
| Max. Negotiated Rate |
$9,176.08 |
| Rate for Payer: Aetna Commercial |
$8,976.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,577.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,286.22
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cigna Commercial |
$9,176.08
|
| Rate for Payer: Health EOS Commercial |
$8,876.86
|
| Rate for Payer: HFN Commercial |
$9,176.08
|
| Rate for Payer: Multiplan Commercial |
$7,979.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,984.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,176.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,887.26
|
| Rate for Payer: Quartz Commercial |
$5,984.40
|
| Rate for Payer: WEA Trust Commercial |
$5,485.70
|
| Rate for Payer: WPS Commercial |
$7,387.74
|
|
|
GRAFT STRAVIX 3CM X 6CM (18 SQ CM) FROZEN PS60008
|
Facility
|
IP
|
$17,819.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5415471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,731.31 |
| Max. Negotiated Rate |
$16,393.48 |
| Rate for Payer: Aetna Commercial |
$16,037.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,324.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,444.07
|
| Rate for Payer: Cash Price |
$5,345.70
|
| Rate for Payer: Cigna Commercial |
$16,393.48
|
| Rate for Payer: Health EOS Commercial |
$15,858.91
|
| Rate for Payer: HFN Commercial |
$16,393.48
|
| Rate for Payer: Multiplan Commercial |
$14,255.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,691.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,393.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,731.31
|
| Rate for Payer: Quartz Commercial |
$10,691.40
|
| Rate for Payer: WEA Trust Commercial |
$9,800.45
|
| Rate for Payer: WPS Commercial |
$13,198.53
|
|
|
GRAFT STRAVIX 3CM X 6CM (18 SQ CM) FROZEN PS60008
|
Facility
|
OP
|
$17,819.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5415471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.49 |
| Max. Negotiated Rate |
$71,276.00 |
| Rate for Payer: Aetna Commercial |
$16,037.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,324.34
|
| Rate for Payer: Aetna Managed Medicare |
$4,989.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,582.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,909.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,553.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,444.07
|
| Rate for Payer: Cash Price |
$5,345.70
|
| Rate for Payer: Cash Price |
$5,345.70
|
| Rate for Payer: Cigna Commercial |
$16,393.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.49
|
| Rate for Payer: Health EOS Commercial |
$15,858.91
|
| Rate for Payer: HFN Commercial |
$16,393.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,364.25
|
| Rate for Payer: Multiplan Commercial |
$14,255.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,691.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,393.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,731.31
|
| Rate for Payer: Quartz Commercial |
$11,582.35
|
| Rate for Payer: Quartz Medicare Advantage |
$10,691.40
|
| Rate for Payer: The Alliance Commercial |
$71,276.00
|
| Rate for Payer: WEA Trust Commercial |
$9,800.45
|
| Rate for Payer: WPS Commercial |
$358.06
|
|
|
GRAFT STRAVIX MESHED 3CM X 6CM (18 SQ CM) FROZEN PS60036
|
Facility
|
IP
|
$15,841.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5885642
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,762.09 |
| Max. Negotiated Rate |
$14,573.72 |
| Rate for Payer: Aetna Commercial |
$14,256.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,623.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,395.73
|
| Rate for Payer: Cash Price |
$4,752.30
|
| Rate for Payer: Cigna Commercial |
$14,573.72
|
| Rate for Payer: Health EOS Commercial |
$14,098.49
|
| Rate for Payer: HFN Commercial |
$14,573.72
|
| Rate for Payer: Multiplan Commercial |
$12,672.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,504.60
|
| Rate for Payer: Preferred Network Access Commercial |
$14,573.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,762.09
|
| Rate for Payer: Quartz Commercial |
$9,504.60
|
| Rate for Payer: WEA Trust Commercial |
$8,712.55
|
| Rate for Payer: WPS Commercial |
$11,733.43
|
|
|
GRAFT STRAVIX MESHED 3CM X 6CM (18 SQ CM) FROZEN PS60036
|
Facility
|
OP
|
$15,841.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5885642
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.49 |
| Max. Negotiated Rate |
$63,364.00 |
| Rate for Payer: Aetna Commercial |
$14,256.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,623.26
|
| Rate for Payer: Aetna Managed Medicare |
$4,435.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,296.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,920.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,603.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,395.73
|
| Rate for Payer: Cash Price |
$4,752.30
|
| Rate for Payer: Cash Price |
$4,752.30
|
| Rate for Payer: Cigna Commercial |
$14,573.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.49
|
| Rate for Payer: Health EOS Commercial |
$14,098.49
|
| Rate for Payer: HFN Commercial |
$14,573.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,880.75
|
| Rate for Payer: Multiplan Commercial |
$12,672.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,504.60
|
| Rate for Payer: Preferred Network Access Commercial |
$14,573.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,762.09
|
| Rate for Payer: Quartz Commercial |
$10,296.65
|
| Rate for Payer: Quartz Medicare Advantage |
$9,504.60
|
| Rate for Payer: The Alliance Commercial |
$63,364.00
|
| Rate for Payer: WEA Trust Commercial |
$8,712.55
|
| Rate for Payer: WPS Commercial |
$358.06
|
|
|
GRAFT STRAVIX PL 2CM X 4CM (8 SQ CM) SHELF STABLE PS61024
|
Facility
|
OP
|
$8,086.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5881629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.49 |
| Max. Negotiated Rate |
$32,344.00 |
| Rate for Payer: Aetna Commercial |
$7,277.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,953.96
|
| Rate for Payer: Aetna Managed Medicare |
$2,264.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,255.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,881.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,285.58
|
| Rate for Payer: Cash Price |
$2,425.80
|
| Rate for Payer: Cash Price |
$2,425.80
|
| Rate for Payer: Cigna Commercial |
$7,439.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.49
|
| Rate for Payer: Health EOS Commercial |
$7,196.54
|
| Rate for Payer: HFN Commercial |
$7,439.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,064.50
|
| Rate for Payer: Multiplan Commercial |
$6,468.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,851.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,439.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,962.14
|
| Rate for Payer: Quartz Commercial |
$5,255.90
|
| Rate for Payer: Quartz Medicare Advantage |
$4,851.60
|
| Rate for Payer: The Alliance Commercial |
$32,344.00
|
| Rate for Payer: WEA Trust Commercial |
$4,447.30
|
| Rate for Payer: WPS Commercial |
$358.06
|
|
|
GRAFT STRAVIX PL 2CM X 4CM (8 SQ CM) SHELF STABLE PS61024
|
Facility
|
IP
|
$8,086.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5881629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,962.14 |
| Max. Negotiated Rate |
$7,439.12 |
| Rate for Payer: Aetna Commercial |
$7,277.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,953.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,285.58
|
| Rate for Payer: Cash Price |
$2,425.80
|
| Rate for Payer: Cigna Commercial |
$7,439.12
|
| Rate for Payer: Health EOS Commercial |
$7,196.54
|
| Rate for Payer: HFN Commercial |
$7,439.12
|
| Rate for Payer: Multiplan Commercial |
$6,468.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,851.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,439.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,962.14
|
| Rate for Payer: Quartz Commercial |
$4,851.60
|
| Rate for Payer: WEA Trust Commercial |
$4,447.30
|
| Rate for Payer: WPS Commercial |
$5,989.30
|
|
|
GRAFT STRAVIX PL 3CM X 6CM (18 SQ CM) SHELF STABLE PS61036
|
Facility
|
IP
|
$14,044.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5881628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,881.56 |
| Max. Negotiated Rate |
$12,920.48 |
| Rate for Payer: Aetna Commercial |
$12,639.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,077.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,443.32
|
| Rate for Payer: Cash Price |
$4,213.20
|
| Rate for Payer: Cigna Commercial |
$12,920.48
|
| Rate for Payer: Health EOS Commercial |
$12,499.16
|
| Rate for Payer: HFN Commercial |
$12,920.48
|
| Rate for Payer: Multiplan Commercial |
$11,235.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,426.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,920.48
|
| Rate for Payer: Quartz Beloit One Network |
$6,881.56
|
| Rate for Payer: Quartz Commercial |
$8,426.40
|
| Rate for Payer: WEA Trust Commercial |
$7,724.20
|
| Rate for Payer: WPS Commercial |
$10,402.39
|
|
|
GRAFT STRAVIX PL 3CM X 6CM (18 SQ CM) SHELF STABLE PS61036
|
Facility
|
OP
|
$14,044.00
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
5881628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.49 |
| Max. Negotiated Rate |
$56,176.00 |
| Rate for Payer: Aetna Commercial |
$12,639.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,077.84
|
| Rate for Payer: Aetna Managed Medicare |
$3,932.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,128.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,022.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,741.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,443.32
|
| Rate for Payer: Cash Price |
$4,213.20
|
| Rate for Payer: Cash Price |
$4,213.20
|
| Rate for Payer: Cigna Commercial |
$12,920.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.49
|
| Rate for Payer: Health EOS Commercial |
$12,499.16
|
| Rate for Payer: HFN Commercial |
$12,920.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,533.00
|
| Rate for Payer: Multiplan Commercial |
$11,235.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,426.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,920.48
|
| Rate for Payer: Quartz Beloit One Network |
$6,881.56
|
| Rate for Payer: Quartz Commercial |
$9,128.60
|
| Rate for Payer: Quartz Medicare Advantage |
$8,426.40
|
| Rate for Payer: The Alliance Commercial |
$56,176.00
|
| Rate for Payer: WEA Trust Commercial |
$7,724.20
|
| Rate for Payer: WPS Commercial |
$358.06
|
|
|
GRAFT STRETCH 4 - 6MM X 45CM PROPATEN IRH463845
|
Facility
|
OP
|
$7,499.00
|
|
| Hospital Charge Code |
3525506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,099.72 |
| Max. Negotiated Rate |
$29,996.00 |
| Rate for Payer: Aetna Commercial |
$6,749.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,449.14
|
| Rate for Payer: Aetna Managed Medicare |
$2,099.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,874.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,749.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,599.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,974.47
|
| Rate for Payer: Cash Price |
$2,249.70
|
| Rate for Payer: Cigna Commercial |
$6,899.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,196.44
|
| Rate for Payer: Health EOS Commercial |
$6,674.11
|
| Rate for Payer: HFN Commercial |
$6,899.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,624.25
|
| Rate for Payer: Multiplan Commercial |
$5,999.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,499.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,899.08
|
| Rate for Payer: Quartz Beloit One Network |
$3,674.51
|
| Rate for Payer: Quartz Commercial |
$4,874.35
|
| Rate for Payer: Quartz Medicare Advantage |
$4,499.40
|
| Rate for Payer: The Alliance Commercial |
$29,996.00
|
| Rate for Payer: WEA Trust Commercial |
$4,124.45
|
| Rate for Payer: WPS Commercial |
$5,554.51
|
|
|
GRAFT STRETCH 4 - 6MM X 45CM PROPATEN IRH463845
|
Facility
|
IP
|
$7,499.00
|
|
| Hospital Charge Code |
3525506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,674.51 |
| Max. Negotiated Rate |
$6,899.08 |
| Rate for Payer: Aetna Commercial |
$6,749.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,449.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,974.47
|
| Rate for Payer: Cash Price |
$2,249.70
|
| Rate for Payer: Cigna Commercial |
$6,899.08
|
| Rate for Payer: Health EOS Commercial |
$6,674.11
|
| Rate for Payer: HFN Commercial |
$6,899.08
|
| Rate for Payer: Multiplan Commercial |
$5,999.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,499.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,899.08
|
| Rate for Payer: Quartz Beloit One Network |
$3,674.51
|
| Rate for Payer: Quartz Commercial |
$4,499.40
|
| Rate for Payer: WEA Trust Commercial |
$4,124.45
|
| Rate for Payer: WPS Commercial |
$5,554.51
|
|
|
GRAFT STRETCH HEPARIN TAPER 4-6MM X 45CM 38CM IRH463845
|
Facility
|
OP
|
$7,994.00
|
|
| Hospital Charge Code |
3553535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,238.32 |
| Max. Negotiated Rate |
$31,976.00 |
| Rate for Payer: Aetna Commercial |
$7,194.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,874.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,238.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,196.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,997.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,837.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,236.82
|
| Rate for Payer: Cash Price |
$2,398.20
|
| Rate for Payer: Cigna Commercial |
$7,354.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,473.44
|
| Rate for Payer: Health EOS Commercial |
$7,114.66
|
| Rate for Payer: HFN Commercial |
$7,354.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,995.50
|
| Rate for Payer: Multiplan Commercial |
$6,395.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,796.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,354.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,917.06
|
| Rate for Payer: Quartz Commercial |
$5,196.10
|
| Rate for Payer: Quartz Medicare Advantage |
$4,796.40
|
| Rate for Payer: The Alliance Commercial |
$31,976.00
|
| Rate for Payer: WEA Trust Commercial |
$4,396.70
|
| Rate for Payer: WPS Commercial |
$5,921.16
|
|
|
GRAFT STRETCH HEPARIN TAPER 4-6MM X 45CM 38CM IRH463845
|
Facility
|
IP
|
$7,994.00
|
|
| Hospital Charge Code |
3553535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,917.06 |
| Max. Negotiated Rate |
$7,354.48 |
| Rate for Payer: Aetna Commercial |
$7,194.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,874.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,236.82
|
| Rate for Payer: Cash Price |
$2,398.20
|
| Rate for Payer: Cigna Commercial |
$7,354.48
|
| Rate for Payer: Health EOS Commercial |
$7,114.66
|
| Rate for Payer: HFN Commercial |
$7,354.48
|
| Rate for Payer: Multiplan Commercial |
$6,395.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,796.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,354.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,917.06
|
| Rate for Payer: Quartz Commercial |
$4,796.40
|
| Rate for Payer: WEA Trust Commercial |
$4,396.70
|
| Rate for Payer: WPS Commercial |
$5,921.16
|
|
|
GRAFT STRETCH STD WALL 8MM X 10CM S0801
|
Facility
|
IP
|
$2,634.00
|
|
| Hospital Charge Code |
3553527
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,290.66 |
| Max. Negotiated Rate |
$2,423.28 |
| Rate for Payer: Aetna Commercial |
$2,370.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,265.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,396.02
|
| Rate for Payer: Cash Price |
$790.20
|
| Rate for Payer: Cigna Commercial |
$2,423.28
|
| Rate for Payer: Health EOS Commercial |
$2,344.26
|
| Rate for Payer: HFN Commercial |
$2,423.28
|
| Rate for Payer: Multiplan Commercial |
$2,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,580.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,423.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,290.66
|
| Rate for Payer: Quartz Commercial |
$1,580.40
|
| Rate for Payer: WEA Trust Commercial |
$1,448.70
|
| Rate for Payer: WPS Commercial |
$1,951.00
|
|
|
GRAFT STRETCH STD WALL 8MM X 10CM S0801
|
Facility
|
OP
|
$2,634.00
|
|
| Hospital Charge Code |
3553527
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$737.52 |
| Max. Negotiated Rate |
$10,536.00 |
| Rate for Payer: Aetna Commercial |
$2,370.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,265.24
|
| Rate for Payer: Aetna Managed Medicare |
$737.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,712.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,317.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,264.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,396.02
|
| Rate for Payer: Cash Price |
$790.20
|
| Rate for Payer: Cigna Commercial |
$2,423.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,473.99
|
| Rate for Payer: Health EOS Commercial |
$2,344.26
|
| Rate for Payer: HFN Commercial |
$2,423.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,975.50
|
| Rate for Payer: Multiplan Commercial |
$2,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,580.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,423.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,290.66
|
| Rate for Payer: Quartz Commercial |
$1,712.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,580.40
|
| Rate for Payer: The Alliance Commercial |
$10,536.00
|
| Rate for Payer: WEA Trust Commercial |
$1,448.70
|
| Rate for Payer: WPS Commercial |
$1,951.00
|
|
|
GRAFT STRETCH THIN WALL 10MM X 40CM ST1004
|
Facility
|
IP
|
$6,979.00
|
|
| Hospital Charge Code |
3553532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,419.71 |
| Max. Negotiated Rate |
$6,420.68 |
| Rate for Payer: Aetna Commercial |
$6,281.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,001.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,698.87
|
| Rate for Payer: Cash Price |
$2,093.70
|
| Rate for Payer: Cigna Commercial |
$6,420.68
|
| Rate for Payer: Health EOS Commercial |
$6,211.31
|
| Rate for Payer: HFN Commercial |
$6,420.68
|
| Rate for Payer: Multiplan Commercial |
$5,583.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,187.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,420.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,419.71
|
| Rate for Payer: Quartz Commercial |
$4,187.40
|
| Rate for Payer: WEA Trust Commercial |
$3,838.45
|
| Rate for Payer: WPS Commercial |
$5,169.35
|
|
