|
GRAFT STRETCH THIN WALL 10MM X 40CM ST1004
|
Facility
|
OP
|
$6,979.00
|
|
| Hospital Charge Code |
3553532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,954.12 |
| Max. Negotiated Rate |
$27,916.00 |
| Rate for Payer: Aetna Commercial |
$6,281.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,001.94
|
| Rate for Payer: Aetna Managed Medicare |
$1,954.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,536.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,489.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,349.92
|
| 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: Dean Health DHI/DHP/ASO |
$3,905.45
|
| Rate for Payer: Health EOS Commercial |
$6,211.31
|
| Rate for Payer: HFN Commercial |
$6,420.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,234.25
|
| 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 |
$4,536.35
|
| Rate for Payer: Quartz Medicare Advantage |
$4,187.40
|
| Rate for Payer: The Alliance Commercial |
$27,916.00
|
| Rate for Payer: WEA Trust Commercial |
$3,838.45
|
| Rate for Payer: WPS Commercial |
$5,169.35
|
|
|
GRAFT STRETCH THIN WALL 10MM X 80CM ST1008
|
Facility
|
IP
|
$8,513.00
|
|
| Hospital Charge Code |
3553534
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,171.37 |
| Max. Negotiated Rate |
$7,831.96 |
| Rate for Payer: Aetna Commercial |
$7,661.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,321.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,511.89
|
| Rate for Payer: Cash Price |
$2,553.90
|
| Rate for Payer: Cigna Commercial |
$7,831.96
|
| Rate for Payer: Health EOS Commercial |
$7,576.57
|
| Rate for Payer: HFN Commercial |
$7,831.96
|
| Rate for Payer: Multiplan Commercial |
$6,810.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,107.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,831.96
|
| Rate for Payer: Quartz Beloit One Network |
$4,171.37
|
| Rate for Payer: Quartz Commercial |
$5,107.80
|
| Rate for Payer: WEA Trust Commercial |
$4,682.15
|
| Rate for Payer: WPS Commercial |
$6,305.58
|
|
|
GRAFT STRETCH THIN WALL 10MM X 80CM ST1008
|
Facility
|
OP
|
$8,513.00
|
|
| Hospital Charge Code |
3553534
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,383.64 |
| Max. Negotiated Rate |
$34,052.00 |
| Rate for Payer: Aetna Commercial |
$7,661.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,321.18
|
| Rate for Payer: Aetna Managed Medicare |
$2,383.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,533.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,256.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,086.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,511.89
|
| Rate for Payer: Cash Price |
$2,553.90
|
| Rate for Payer: Cigna Commercial |
$7,831.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,763.87
|
| Rate for Payer: Health EOS Commercial |
$7,576.57
|
| Rate for Payer: HFN Commercial |
$7,831.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,384.75
|
| Rate for Payer: Multiplan Commercial |
$6,810.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,107.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,831.96
|
| Rate for Payer: Quartz Beloit One Network |
$4,171.37
|
| Rate for Payer: Quartz Commercial |
$5,533.45
|
| Rate for Payer: Quartz Medicare Advantage |
$5,107.80
|
| Rate for Payer: The Alliance Commercial |
$34,052.00
|
| Rate for Payer: WEA Trust Commercial |
$4,682.15
|
| Rate for Payer: WPS Commercial |
$6,305.58
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-001-006
|
Facility
|
IP
|
$18,299.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299214
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,966.51 |
| Max. Negotiated Rate |
$16,835.08 |
| Rate for Payer: Aetna Commercial |
$16,469.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,737.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,698.47
|
| Rate for Payer: Cash Price |
$5,489.70
|
| Rate for Payer: Cigna Commercial |
$16,835.08
|
| Rate for Payer: Health EOS Commercial |
$16,286.11
|
| Rate for Payer: HFN Commercial |
$16,835.08
|
| Rate for Payer: Multiplan Commercial |
$14,639.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,979.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,835.08
|
| Rate for Payer: Quartz Beloit One Network |
$8,966.51
|
| Rate for Payer: Quartz Commercial |
$10,979.40
|
| Rate for Payer: WEA Trust Commercial |
$10,064.45
|
| Rate for Payer: WPS Commercial |
$13,554.07
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-001-006
|
Facility
|
OP
|
$18,299.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299214
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,123.72 |
| Max. Negotiated Rate |
$73,196.00 |
| Rate for Payer: Aetna Commercial |
$16,469.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,737.14
|
| Rate for Payer: Aetna Managed Medicare |
$5,123.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,894.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,149.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,783.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,698.47
|
| Rate for Payer: Cash Price |
$5,489.70
|
| Rate for Payer: Cigna Commercial |
$16,835.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,240.12
|
| Rate for Payer: Health EOS Commercial |
$16,286.11
|
| Rate for Payer: HFN Commercial |
$16,835.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,724.25
|
| Rate for Payer: Multiplan Commercial |
$14,639.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,979.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,835.08
|
| Rate for Payer: Quartz Beloit One Network |
$8,966.51
|
| Rate for Payer: Quartz Commercial |
$11,894.35
|
| Rate for Payer: Quartz Medicare Advantage |
$10,979.40
|
| Rate for Payer: The Alliance Commercial |
$73,196.00
|
| Rate for Payer: WEA Trust Commercial |
$10,064.45
|
| Rate for Payer: WPS Commercial |
$13,554.07
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-004-100
|
Facility
|
IP
|
$20,134.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
2967343
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,865.66 |
| Max. Negotiated Rate |
$18,523.28 |
| Rate for Payer: Aetna Commercial |
$18,120.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,315.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,671.02
|
| Rate for Payer: Cash Price |
$6,040.20
|
| Rate for Payer: Cigna Commercial |
$18,523.28
|
| Rate for Payer: Health EOS Commercial |
$17,919.26
|
| Rate for Payer: HFN Commercial |
$18,523.28
|
| Rate for Payer: Multiplan Commercial |
$16,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,080.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,523.28
|
| Rate for Payer: Quartz Beloit One Network |
$9,865.66
|
| Rate for Payer: Quartz Commercial |
$12,080.40
|
| Rate for Payer: WEA Trust Commercial |
$11,073.70
|
| Rate for Payer: WPS Commercial |
$14,913.25
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-004-100
|
Facility
|
OP
|
$20,134.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
2967343
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,637.52 |
| Max. Negotiated Rate |
$80,536.00 |
| Rate for Payer: Aetna Commercial |
$18,120.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,315.24
|
| Rate for Payer: Aetna Managed Medicare |
$5,637.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,087.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,067.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,664.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,671.02
|
| Rate for Payer: Cash Price |
$6,040.20
|
| Rate for Payer: Cigna Commercial |
$18,523.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,266.99
|
| Rate for Payer: Health EOS Commercial |
$17,919.26
|
| Rate for Payer: HFN Commercial |
$18,523.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,100.50
|
| Rate for Payer: Multiplan Commercial |
$16,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,080.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,523.28
|
| Rate for Payer: Quartz Beloit One Network |
$9,865.66
|
| Rate for Payer: Quartz Commercial |
$13,087.10
|
| Rate for Payer: Quartz Medicare Advantage |
$12,080.40
|
| Rate for Payer: The Alliance Commercial |
$80,536.00
|
| Rate for Payer: WEA Trust Commercial |
$11,073.70
|
| Rate for Payer: WPS Commercial |
$14,913.25
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-200-006
|
Facility
|
OP
|
$20,134.00
|
|
| Hospital Charge Code |
2967341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,637.52 |
| Max. Negotiated Rate |
$80,536.00 |
| Rate for Payer: Aetna Commercial |
$18,120.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,315.24
|
| Rate for Payer: Aetna Managed Medicare |
$5,637.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,087.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,067.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,664.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,671.02
|
| Rate for Payer: Cash Price |
$6,040.20
|
| Rate for Payer: Cigna Commercial |
$18,523.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,266.99
|
| Rate for Payer: Health EOS Commercial |
$17,919.26
|
| Rate for Payer: HFN Commercial |
$18,523.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,100.50
|
| Rate for Payer: Multiplan Commercial |
$16,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,080.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,523.28
|
| Rate for Payer: Quartz Beloit One Network |
$9,865.66
|
| Rate for Payer: Quartz Commercial |
$13,087.10
|
| Rate for Payer: Quartz Medicare Advantage |
$12,080.40
|
| Rate for Payer: The Alliance Commercial |
$80,536.00
|
| Rate for Payer: WEA Trust Commercial |
$11,073.70
|
| Rate for Payer: WPS Commercial |
$14,913.25
|
|
|
GRAFT SURGIMEND 10 X 15CM 606-200-006
|
Facility
|
IP
|
$20,134.00
|
|
| Hospital Charge Code |
2967341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,865.66 |
| Max. Negotiated Rate |
$18,523.28 |
| Rate for Payer: Aetna Commercial |
$18,120.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,315.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,671.02
|
| Rate for Payer: Cash Price |
$6,040.20
|
| Rate for Payer: Cigna Commercial |
$18,523.28
|
| Rate for Payer: Health EOS Commercial |
$17,919.26
|
| Rate for Payer: HFN Commercial |
$18,523.28
|
| Rate for Payer: Multiplan Commercial |
$16,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,080.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,523.28
|
| Rate for Payer: Quartz Beloit One Network |
$9,865.66
|
| Rate for Payer: Quartz Commercial |
$12,080.40
|
| Rate for Payer: WEA Trust Commercial |
$11,073.70
|
| Rate for Payer: WPS Commercial |
$14,913.25
|
|
|
GRAFT SURGIMEND 16 X 20CM 606-001-008
|
Facility
|
IP
|
$39,035.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299217
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19,127.15 |
| Max. Negotiated Rate |
$35,912.20 |
| Rate for Payer: Aetna Commercial |
$35,131.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,570.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,688.55
|
| Rate for Payer: Cash Price |
$11,710.50
|
| Rate for Payer: Cigna Commercial |
$35,912.20
|
| Rate for Payer: Health EOS Commercial |
$34,741.15
|
| Rate for Payer: HFN Commercial |
$35,912.20
|
| Rate for Payer: Multiplan Commercial |
$31,228.00
|
| Rate for Payer: NAPHCARE Commercial |
$23,421.00
|
| Rate for Payer: Preferred Network Access Commercial |
$35,912.20
|
| Rate for Payer: Quartz Beloit One Network |
$19,127.15
|
| Rate for Payer: Quartz Commercial |
$23,421.00
|
| Rate for Payer: WEA Trust Commercial |
$21,469.25
|
| Rate for Payer: WPS Commercial |
$28,913.22
|
|
|
GRAFT SURGIMEND 16 X 20CM 606-001-008
|
Facility
|
OP
|
$39,035.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299217
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,929.80 |
| Max. Negotiated Rate |
$156,140.00 |
| Rate for Payer: Aetna Commercial |
$35,131.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,570.10
|
| Rate for Payer: Aetna Managed Medicare |
$10,929.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,372.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,517.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,736.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,688.55
|
| Rate for Payer: Cash Price |
$11,710.50
|
| Rate for Payer: Cigna Commercial |
$35,912.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21,843.99
|
| Rate for Payer: Health EOS Commercial |
$34,741.15
|
| Rate for Payer: HFN Commercial |
$35,912.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,276.25
|
| Rate for Payer: Multiplan Commercial |
$31,228.00
|
| Rate for Payer: NAPHCARE Commercial |
$23,421.00
|
| Rate for Payer: Preferred Network Access Commercial |
$35,912.20
|
| Rate for Payer: Quartz Beloit One Network |
$19,127.15
|
| Rate for Payer: Quartz Commercial |
$25,372.75
|
| Rate for Payer: Quartz Medicare Advantage |
$23,421.00
|
| Rate for Payer: The Alliance Commercial |
$156,140.00
|
| Rate for Payer: WEA Trust Commercial |
$21,469.25
|
| Rate for Payer: WPS Commercial |
$28,913.22
|
|
|
GRAFT SURGIMEND 25 X 40CM 606-001-016
|
Facility
|
IP
|
$134,184.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299215
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$65,750.16 |
| Max. Negotiated Rate |
$123,449.28 |
| Rate for Payer: Aetna Commercial |
$120,765.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115,398.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71,117.52
|
| Rate for Payer: Cash Price |
$40,255.20
|
| Rate for Payer: Cigna Commercial |
$123,449.28
|
| Rate for Payer: Health EOS Commercial |
$119,423.76
|
| Rate for Payer: HFN Commercial |
$123,449.28
|
| Rate for Payer: Multiplan Commercial |
$107,347.20
|
| Rate for Payer: NAPHCARE Commercial |
$80,510.40
|
| Rate for Payer: Preferred Network Access Commercial |
$123,449.28
|
| Rate for Payer: Quartz Beloit One Network |
$65,750.16
|
| Rate for Payer: Quartz Commercial |
$80,510.40
|
| Rate for Payer: WEA Trust Commercial |
$73,801.20
|
| Rate for Payer: WPS Commercial |
$99,390.09
|
|
|
GRAFT SURGIMEND 25 X 40CM 606-001-016
|
Facility
|
OP
|
$134,184.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4299215
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$37,571.52 |
| Max. Negotiated Rate |
$536,736.00 |
| Rate for Payer: Aetna Commercial |
$120,765.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115,398.24
|
| Rate for Payer: Aetna Managed Medicare |
$37,571.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87,219.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67,092.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64,408.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71,117.52
|
| Rate for Payer: Cash Price |
$40,255.20
|
| Rate for Payer: Cigna Commercial |
$123,449.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75,089.37
|
| Rate for Payer: Health EOS Commercial |
$119,423.76
|
| Rate for Payer: HFN Commercial |
$123,449.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100,638.00
|
| Rate for Payer: Multiplan Commercial |
$107,347.20
|
| Rate for Payer: NAPHCARE Commercial |
$80,510.40
|
| Rate for Payer: Preferred Network Access Commercial |
$123,449.28
|
| Rate for Payer: Quartz Beloit One Network |
$65,750.16
|
| Rate for Payer: Quartz Commercial |
$87,219.60
|
| Rate for Payer: Quartz Medicare Advantage |
$80,510.40
|
| Rate for Payer: The Alliance Commercial |
$536,736.00
|
| Rate for Payer: WEA Trust Commercial |
$73,801.20
|
| Rate for Payer: WPS Commercial |
$99,390.09
|
|
|
GRAFT SURGIMEND 8 X 16CM 606-004-103
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.36 |
| Max. Negotiated Rate |
$4,848.00 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Aetna Managed Medicare |
$339.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$787.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$606.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$581.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$678.24
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$909.00
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$787.80
|
| Rate for Payer: Quartz Medicare Advantage |
$727.20
|
| Rate for Payer: The Alliance Commercial |
$4,848.00
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
GRAFT SURGIMEND 8 X 16CM 606-004-103
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$593.88 |
| Max. Negotiated Rate |
$1,115.04 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$727.20
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
Graft Theraskin per sq cm Q4121
|
Professional
|
Both
|
$172.00
|
|
|
Service Code
|
HCPCS Q4121
|
| Hospital Charge Code |
4506680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.13 |
| Max. Negotiated Rate |
$163.40 |
| Rate for Payer: Aetna Commercial |
$163.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$163.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$86.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.13
|
| Rate for Payer: Health EOS Commercial |
$156.52
|
| Rate for Payer: HFN Commercial |
$163.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$154.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.61
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: Preferred Network Access Commercial |
$163.40
|
| Rate for Payer: Quartz Beloit One Network |
$75.68
|
| Rate for Payer: Quartz Commercial |
$98.04
|
| Rate for Payer: The Alliance Commercial |
$86.00
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$115.34
|
|
|
Graft Theraskin per sq cm Q4121
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
HCPCS Q4121
|
| Hospital Charge Code |
4506680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.28 |
| Max. Negotiated Rate |
$158.24 |
| Rate for Payer: Aetna Commercial |
$154.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.16
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$158.24
|
| Rate for Payer: Health EOS Commercial |
$153.08
|
| Rate for Payer: HFN Commercial |
$158.24
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: NAPHCARE Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$158.24
|
| Rate for Payer: Quartz Beloit One Network |
$84.28
|
| Rate for Payer: Quartz Commercial |
$103.20
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$127.40
|
|
|
Graft Theraskin per sq cm Q4121
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS Q4121
|
| Hospital Charge Code |
4506680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.16 |
| Max. Negotiated Rate |
$688.00 |
| Rate for Payer: Aetna Commercial |
$154.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Aetna Managed Medicare |
$48.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$86.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.16
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$158.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.04
|
| Rate for Payer: Health EOS Commercial |
$153.08
|
| Rate for Payer: HFN Commercial |
$158.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.00
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: NAPHCARE Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$158.24
|
| Rate for Payer: Quartz Beloit One Network |
$84.28
|
| Rate for Payer: Quartz Commercial |
$111.80
|
| Rate for Payer: Quartz Medicare Advantage |
$103.20
|
| Rate for Payer: The Alliance Commercial |
$688.00
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$115.34
|
|
|
GRAFT TUTOPLAST PERICARDIUM 1.5 X 15.CM 68250
|
Facility
|
OP
|
$2,990.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6172005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.20 |
| Max. Negotiated Rate |
$11,960.00 |
| Rate for Payer: Aetna Commercial |
$2,691.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,571.40
|
| Rate for Payer: Aetna Managed Medicare |
$837.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,943.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,495.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,435.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.70
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,750.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,673.20
|
| Rate for Payer: Health EOS Commercial |
$2,661.10
|
| Rate for Payer: HFN Commercial |
$2,750.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,242.50
|
| Rate for Payer: Multiplan Commercial |
$2,392.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,794.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,750.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,465.10
|
| Rate for Payer: Quartz Commercial |
$1,943.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,794.00
|
| Rate for Payer: The Alliance Commercial |
$11,960.00
|
| Rate for Payer: WEA Trust Commercial |
$1,644.50
|
| Rate for Payer: WPS Commercial |
$2,214.69
|
|
|
GRAFT TUTOPLAST PERICARDIUM 1.5 X 15.CM 68250
|
Facility
|
IP
|
$2,990.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6172005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,465.10 |
| Max. Negotiated Rate |
$2,750.80 |
| Rate for Payer: Aetna Commercial |
$2,691.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,571.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.70
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,750.80
|
| Rate for Payer: Health EOS Commercial |
$2,661.10
|
| Rate for Payer: HFN Commercial |
$2,750.80
|
| Rate for Payer: Multiplan Commercial |
$2,392.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,794.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,750.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,465.10
|
| Rate for Payer: Quartz Commercial |
$1,794.00
|
| Rate for Payer: WEA Trust Commercial |
$1,644.50
|
| Rate for Payer: WPS Commercial |
$2,214.69
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN 6MM X 80CM 60CM RINGS HT066080A
|
Facility
|
IP
|
$16,630.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,148.70 |
| Max. Negotiated Rate |
$15,299.60 |
| Rate for Payer: Aetna Commercial |
$14,967.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,301.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,813.90
|
| Rate for Payer: Cash Price |
$4,989.00
|
| Rate for Payer: Cigna Commercial |
$15,299.60
|
| Rate for Payer: Health EOS Commercial |
$14,800.70
|
| Rate for Payer: HFN Commercial |
$15,299.60
|
| Rate for Payer: Multiplan Commercial |
$13,304.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,978.00
|
| Rate for Payer: Preferred Network Access Commercial |
$15,299.60
|
| Rate for Payer: Quartz Beloit One Network |
$8,148.70
|
| Rate for Payer: Quartz Commercial |
$9,978.00
|
| Rate for Payer: WEA Trust Commercial |
$9,146.50
|
| Rate for Payer: WPS Commercial |
$12,317.84
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN 6MM X 80CM 60CM RINGS HT066080A
|
Facility
|
OP
|
$16,630.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,656.40 |
| Max. Negotiated Rate |
$66,520.00 |
| Rate for Payer: Aetna Commercial |
$14,967.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,301.80
|
| Rate for Payer: Aetna Managed Medicare |
$4,656.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,809.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,315.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,982.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,813.90
|
| Rate for Payer: Cash Price |
$4,989.00
|
| Rate for Payer: Cigna Commercial |
$15,299.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,306.15
|
| Rate for Payer: Health EOS Commercial |
$14,800.70
|
| Rate for Payer: HFN Commercial |
$15,299.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,472.50
|
| Rate for Payer: Multiplan Commercial |
$13,304.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,978.00
|
| Rate for Payer: Preferred Network Access Commercial |
$15,299.60
|
| Rate for Payer: Quartz Beloit One Network |
$8,148.70
|
| Rate for Payer: Quartz Commercial |
$10,809.50
|
| Rate for Payer: Quartz Medicare Advantage |
$9,978.00
|
| Rate for Payer: The Alliance Commercial |
$66,520.00
|
| Rate for Payer: WEA Trust Commercial |
$9,146.50
|
| Rate for Payer: WPS Commercial |
$12,317.84
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN 7MM X 80CM 60CM RINGS HT076080A
|
Facility
|
OP
|
$15,991.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5286609
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,477.48 |
| Max. Negotiated Rate |
$63,964.00 |
| Rate for Payer: Aetna Commercial |
$14,391.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,752.26
|
| Rate for Payer: Aetna Managed Medicare |
$4,477.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,394.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,995.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,675.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,475.23
|
| Rate for Payer: Cash Price |
$4,797.30
|
| Rate for Payer: Cigna Commercial |
$14,711.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,948.56
|
| Rate for Payer: Health EOS Commercial |
$14,231.99
|
| Rate for Payer: HFN Commercial |
$14,711.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,993.25
|
| Rate for Payer: Multiplan Commercial |
$12,792.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$14,711.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,835.59
|
| Rate for Payer: Quartz Commercial |
$10,394.15
|
| Rate for Payer: Quartz Medicare Advantage |
$9,594.60
|
| Rate for Payer: The Alliance Commercial |
$63,964.00
|
| Rate for Payer: WEA Trust Commercial |
$8,795.05
|
| Rate for Payer: WPS Commercial |
$11,844.53
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN 7MM X 80CM 60CM RINGS HT076080A
|
Facility
|
IP
|
$15,991.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5286609
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,835.59 |
| Max. Negotiated Rate |
$14,711.72 |
| Rate for Payer: Aetna Commercial |
$14,391.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,752.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,475.23
|
| Rate for Payer: Cash Price |
$4,797.30
|
| Rate for Payer: Cigna Commercial |
$14,711.72
|
| Rate for Payer: Health EOS Commercial |
$14,231.99
|
| Rate for Payer: HFN Commercial |
$14,711.72
|
| Rate for Payer: Multiplan Commercial |
$12,792.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$14,711.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,835.59
|
| Rate for Payer: Quartz Commercial |
$9,594.60
|
| Rate for Payer: WEA Trust Commercial |
$8,795.05
|
| Rate for Payer: WPS Commercial |
$11,844.53
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN THIN WALL 6MM X 50CM 40CM RINGS HT064050A
|
Facility
|
IP
|
$11,512.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553529
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,640.88 |
| Max. Negotiated Rate |
$10,591.04 |
| Rate for Payer: Aetna Commercial |
$10,360.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,900.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,101.36
|
| Rate for Payer: Cash Price |
$3,453.60
|
| Rate for Payer: Cigna Commercial |
$10,591.04
|
| Rate for Payer: Health EOS Commercial |
$10,245.68
|
| Rate for Payer: HFN Commercial |
$10,591.04
|
| Rate for Payer: Multiplan Commercial |
$9,209.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,907.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,591.04
|
| Rate for Payer: Quartz Beloit One Network |
$5,640.88
|
| Rate for Payer: Quartz Commercial |
$6,907.20
|
| Rate for Payer: WEA Trust Commercial |
$6,331.60
|
| Rate for Payer: WPS Commercial |
$8,526.94
|
|
