|
GRAFT VASCULAR PROPATEN HEPARIN THIN WALL 6MM X 50CM 40CM RINGS HT064050A
|
Facility
|
OP
|
$11,512.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3553529
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,223.36 |
| Max. Negotiated Rate |
$46,048.00 |
| Rate for Payer: Aetna Commercial |
$10,360.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,900.32
|
| Rate for Payer: Aetna Managed Medicare |
$3,223.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,482.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,756.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,525.76
|
| 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: Dean Health DHI/DHP/ASO |
$6,442.12
|
| Rate for Payer: Health EOS Commercial |
$10,245.68
|
| Rate for Payer: HFN Commercial |
$10,591.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,634.00
|
| 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 |
$7,482.80
|
| Rate for Payer: Quartz Medicare Advantage |
$6,907.20
|
| Rate for Payer: The Alliance Commercial |
$46,048.00
|
| Rate for Payer: WEA Trust Commercial |
$6,331.60
|
| Rate for Payer: WPS Commercial |
$8,526.94
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN THIN WALL 7MM X 50CM 40CM RINGS HT074050A
|
Facility
|
IP
|
$9,686.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5563708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,746.14 |
| Max. Negotiated Rate |
$8,911.12 |
| Rate for Payer: Aetna Commercial |
$8,717.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,329.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,133.58
|
| Rate for Payer: Cash Price |
$2,905.80
|
| Rate for Payer: Cigna Commercial |
$8,911.12
|
| Rate for Payer: Health EOS Commercial |
$8,620.54
|
| Rate for Payer: HFN Commercial |
$8,911.12
|
| Rate for Payer: Multiplan Commercial |
$7,748.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,811.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,911.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,746.14
|
| Rate for Payer: Quartz Commercial |
$5,811.60
|
| Rate for Payer: WEA Trust Commercial |
$5,327.30
|
| Rate for Payer: WPS Commercial |
$7,174.42
|
|
|
GRAFT VASCULAR PROPATEN HEPARIN THIN WALL 7MM X 50CM 40CM RINGS HT074050A
|
Facility
|
OP
|
$9,686.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
5563708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,712.08 |
| Max. Negotiated Rate |
$38,744.00 |
| Rate for Payer: Aetna Commercial |
$8,717.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,329.96
|
| Rate for Payer: Aetna Managed Medicare |
$2,712.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,295.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,843.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,649.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,133.58
|
| Rate for Payer: Cash Price |
$2,905.80
|
| Rate for Payer: Cigna Commercial |
$8,911.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,420.29
|
| Rate for Payer: Health EOS Commercial |
$8,620.54
|
| Rate for Payer: HFN Commercial |
$8,911.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,264.50
|
| Rate for Payer: Multiplan Commercial |
$7,748.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,811.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,911.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,746.14
|
| Rate for Payer: Quartz Commercial |
$6,295.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,811.60
|
| Rate for Payer: The Alliance Commercial |
$38,744.00
|
| Rate for Payer: WEA Trust Commercial |
$5,327.30
|
| Rate for Payer: WPS Commercial |
$7,174.42
|
|
|
GRAFT XENMATRIX AB 10CM X 15CM 1151015
|
Facility
|
IP
|
$161.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$78.89 |
| Max. Negotiated Rate |
$148.12 |
| Rate for Payer: Aetna Commercial |
$144.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$138.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.33
|
| Rate for Payer: Cash Price |
$48.30
|
| Rate for Payer: Cigna Commercial |
$148.12
|
| Rate for Payer: Health EOS Commercial |
$143.29
|
| Rate for Payer: HFN Commercial |
$148.12
|
| Rate for Payer: Multiplan Commercial |
$128.80
|
| Rate for Payer: NAPHCARE Commercial |
$96.60
|
| Rate for Payer: Preferred Network Access Commercial |
$148.12
|
| Rate for Payer: Quartz Beloit One Network |
$78.89
|
| Rate for Payer: Quartz Commercial |
$96.60
|
| Rate for Payer: WEA Trust Commercial |
$88.55
|
| Rate for Payer: WPS Commercial |
$119.25
|
|
|
GRAFT XENMATRIX AB 10CM X 15CM 1151015
|
Facility
|
OP
|
$161.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$45.08 |
| Max. Negotiated Rate |
$644.00 |
| Rate for Payer: The Alliance Commercial |
$644.00
|
| Rate for Payer: WEA Trust Commercial |
$88.55
|
| Rate for Payer: WPS Commercial |
$119.25
|
| Rate for Payer: Aetna Commercial |
$144.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$138.46
|
| Rate for Payer: Aetna Managed Medicare |
$45.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.33
|
| Rate for Payer: Cash Price |
$48.30
|
| Rate for Payer: Cigna Commercial |
$148.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.10
|
| Rate for Payer: Health EOS Commercial |
$143.29
|
| Rate for Payer: HFN Commercial |
$148.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.75
|
| Rate for Payer: Multiplan Commercial |
$128.80
|
| Rate for Payer: NAPHCARE Commercial |
$96.60
|
| Rate for Payer: Preferred Network Access Commercial |
$148.12
|
| Rate for Payer: Quartz Beloit One Network |
$78.89
|
| Rate for Payer: Quartz Commercial |
$104.65
|
| Rate for Payer: Quartz Medicare Advantage |
$96.60
|
|
|
GRAFT XENMATRIX AB 15CM X 20CM 1151520
|
Facility
|
OP
|
$38,946.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4595246
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,904.88 |
| Max. Negotiated Rate |
$155,784.00 |
| Rate for Payer: Aetna Commercial |
$35,051.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,493.56
|
| Rate for Payer: Aetna Managed Medicare |
$10,904.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,314.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,473.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,694.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,641.38
|
| Rate for Payer: Cash Price |
$11,683.80
|
| Rate for Payer: Cigna Commercial |
$35,830.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21,794.18
|
| Rate for Payer: Health EOS Commercial |
$34,661.94
|
| Rate for Payer: HFN Commercial |
$35,830.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,209.50
|
| Rate for Payer: Multiplan Commercial |
$31,156.80
|
| Rate for Payer: NAPHCARE Commercial |
$23,367.60
|
| Rate for Payer: Preferred Network Access Commercial |
$35,830.32
|
| Rate for Payer: Quartz Beloit One Network |
$19,083.54
|
| Rate for Payer: Quartz Commercial |
$25,314.90
|
| Rate for Payer: Quartz Medicare Advantage |
$23,367.60
|
| Rate for Payer: The Alliance Commercial |
$155,784.00
|
| Rate for Payer: WEA Trust Commercial |
$21,420.30
|
| Rate for Payer: WPS Commercial |
$28,847.30
|
|
|
GRAFT XENMATRIX AB 15CM X 20CM 1151520
|
Facility
|
IP
|
$38,946.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4595246
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19,083.54 |
| Max. Negotiated Rate |
$35,830.32 |
| Rate for Payer: Aetna Commercial |
$35,051.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,493.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,641.38
|
| Rate for Payer: Cash Price |
$11,683.80
|
| Rate for Payer: Cigna Commercial |
$35,830.32
|
| Rate for Payer: Health EOS Commercial |
$34,661.94
|
| Rate for Payer: HFN Commercial |
$35,830.32
|
| Rate for Payer: Multiplan Commercial |
$31,156.80
|
| Rate for Payer: NAPHCARE Commercial |
$23,367.60
|
| Rate for Payer: Preferred Network Access Commercial |
$35,830.32
|
| Rate for Payer: Quartz Beloit One Network |
$19,083.54
|
| Rate for Payer: Quartz Commercial |
$23,367.60
|
| Rate for Payer: WEA Trust Commercial |
$21,420.30
|
| Rate for Payer: WPS Commercial |
$28,847.30
|
|
|
GRAFT XENMATRIX AB 20CM X 25CM 1152025
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998775
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$77.91 |
| Max. Negotiated Rate |
$146.28 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$95.40
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
GRAFT XENMATRIX AB 20CM X 25CM 1152025
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
4998775
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.52 |
| Max. Negotiated Rate |
$636.00 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Aetna Managed Medicare |
$44.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.25
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$103.35
|
| Rate for Payer: Quartz Medicare Advantage |
$95.40
|
| Rate for Payer: The Alliance Commercial |
$636.00
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
Gram Stain Report
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 87205
|
| Hospital Charge Code |
634217
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Aetna Managed Medicare |
$4.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7.47
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7.09
|
| Rate for Payer: Anthem Medicaid |
$4.41
|
| Rate for Payer: Anthem Medicare Advantage |
$4.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.27
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.96
|
| Rate for Payer: Dean Health Medicaid |
$4.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.27
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.27
|
| Rate for Payer: Managed Health Services Medicaid |
$4.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.27
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$6.40
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4.41
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$65.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4.27
|
| Rate for Payer: The Alliance Commercial |
$17.08
|
| Rate for Payer: United Healthcare Medicaid |
$4.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.27
|
| Rate for Payer: United Healthcare PPO |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: Wellcare Medicare |
$4.27
|
| Rate for Payer: WMAP Medicaid |
$4.41
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
Gram Stain Report
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
CPT 87205
|
| Hospital Charge Code |
634217
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.07 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$95.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.00
|
| Rate for Payer: Health EOS Commercial |
$91.00
|
| Rate for Payer: HFN Commercial |
$95.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.07
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: Preferred Network Access Commercial |
$95.00
|
| Rate for Payer: Quartz Beloit One Network |
$44.00
|
| Rate for Payer: Quartz Commercial |
$57.00
|
| Rate for Payer: The Alliance Commercial |
$50.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
Gram Stain Report
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 87205
|
| Hospital Charge Code |
634217
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$60.00
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
GranuFoam Bridge Dressing
|
Facility
|
IP
|
$905.00
|
|
| Hospital Charge Code |
3006909
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$443.45 |
| Max. Negotiated Rate |
$832.60 |
| Rate for Payer: Aetna Commercial |
$814.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$778.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$479.65
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$832.60
|
| Rate for Payer: Health EOS Commercial |
$805.45
|
| Rate for Payer: HFN Commercial |
$832.60
|
| Rate for Payer: Multiplan Commercial |
$724.00
|
| Rate for Payer: NAPHCARE Commercial |
$543.00
|
| Rate for Payer: Preferred Network Access Commercial |
$832.60
|
| Rate for Payer: Quartz Beloit One Network |
$443.45
|
| Rate for Payer: Quartz Commercial |
$543.00
|
| Rate for Payer: WEA Trust Commercial |
$497.75
|
| Rate for Payer: WPS Commercial |
$670.33
|
|
|
GranuFoam Bridge Dressing
|
Facility
|
OP
|
$905.00
|
|
| Hospital Charge Code |
3006909
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$253.40 |
| Max. Negotiated Rate |
$3,620.00 |
| Rate for Payer: Aetna Commercial |
$814.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$778.30
|
| Rate for Payer: Aetna Managed Medicare |
$253.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$588.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$452.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$434.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$479.65
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$832.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$506.44
|
| Rate for Payer: Health EOS Commercial |
$805.45
|
| Rate for Payer: HFN Commercial |
$832.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$678.75
|
| Rate for Payer: Multiplan Commercial |
$724.00
|
| Rate for Payer: NAPHCARE Commercial |
$543.00
|
| Rate for Payer: Preferred Network Access Commercial |
$832.60
|
| Rate for Payer: Quartz Beloit One Network |
$443.45
|
| Rate for Payer: Quartz Commercial |
$588.25
|
| Rate for Payer: Quartz Medicare Advantage |
$543.00
|
| Rate for Payer: The Alliance Commercial |
$3,620.00
|
| Rate for Payer: WEA Trust Commercial |
$497.75
|
| Rate for Payer: WPS Commercial |
$670.33
|
|
|
GranuFoam Silver/medium
|
Facility
|
OP
|
$1,127.00
|
|
| Hospital Charge Code |
3006922
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$315.56 |
| Max. Negotiated Rate |
$4,508.00 |
| Rate for Payer: Aetna Commercial |
$1,014.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.22
|
| Rate for Payer: Aetna Managed Medicare |
$315.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$540.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.31
|
| Rate for Payer: Cash Price |
$338.10
|
| Rate for Payer: Cigna Commercial |
$1,036.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.67
|
| Rate for Payer: Health EOS Commercial |
$1,003.03
|
| Rate for Payer: HFN Commercial |
$1,036.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.25
|
| Rate for Payer: Multiplan Commercial |
$901.60
|
| Rate for Payer: NAPHCARE Commercial |
$676.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,036.84
|
| Rate for Payer: Quartz Beloit One Network |
$552.23
|
| Rate for Payer: Quartz Commercial |
$732.55
|
| Rate for Payer: Quartz Medicare Advantage |
$676.20
|
| Rate for Payer: The Alliance Commercial |
$4,508.00
|
| Rate for Payer: WEA Trust Commercial |
$619.85
|
| Rate for Payer: WPS Commercial |
$834.77
|
|
|
GranuFoam Silver/medium
|
Facility
|
IP
|
$1,127.00
|
|
| Hospital Charge Code |
3006922
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$552.23 |
| Max. Negotiated Rate |
$1,036.84 |
| Rate for Payer: Aetna Commercial |
$1,014.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.31
|
| Rate for Payer: Cash Price |
$338.10
|
| Rate for Payer: Cigna Commercial |
$1,036.84
|
| Rate for Payer: Health EOS Commercial |
$1,003.03
|
| Rate for Payer: HFN Commercial |
$1,036.84
|
| Rate for Payer: Multiplan Commercial |
$901.60
|
| Rate for Payer: NAPHCARE Commercial |
$676.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,036.84
|
| Rate for Payer: Quartz Beloit One Network |
$552.23
|
| Rate for Payer: Quartz Commercial |
$676.20
|
| Rate for Payer: WEA Trust Commercial |
$619.85
|
| Rate for Payer: WPS Commercial |
$834.77
|
|
|
GRANULES CHRONOS LARGE 10CC 710.026.975
|
Facility
|
IP
|
$6,765.00
|
|
| Hospital Charge Code |
2966235
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,314.85 |
| Max. Negotiated Rate |
$6,223.80 |
| Rate for Payer: Aetna Commercial |
$6,088.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,817.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,585.45
|
| Rate for Payer: Cash Price |
$2,029.50
|
| Rate for Payer: Cigna Commercial |
$6,223.80
|
| Rate for Payer: Health EOS Commercial |
$6,020.85
|
| Rate for Payer: HFN Commercial |
$6,223.80
|
| Rate for Payer: Multiplan Commercial |
$5,412.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,059.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,223.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,314.85
|
| Rate for Payer: Quartz Commercial |
$4,059.00
|
| Rate for Payer: WEA Trust Commercial |
$3,720.75
|
| Rate for Payer: WPS Commercial |
$5,010.84
|
|
|
GRANULES CHRONOS LARGE 10CC 710.026.975
|
Facility
|
OP
|
$6,765.00
|
|
| Hospital Charge Code |
2966235
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,894.20 |
| Max. Negotiated Rate |
$27,060.00 |
| Rate for Payer: Aetna Commercial |
$6,088.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,817.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,894.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,397.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,382.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,247.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,585.45
|
| Rate for Payer: Cash Price |
$2,029.50
|
| Rate for Payer: Cigna Commercial |
$6,223.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,785.69
|
| Rate for Payer: Health EOS Commercial |
$6,020.85
|
| Rate for Payer: HFN Commercial |
$6,223.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,073.75
|
| Rate for Payer: Multiplan Commercial |
$5,412.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,059.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,223.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,314.85
|
| Rate for Payer: Quartz Commercial |
$4,397.25
|
| Rate for Payer: Quartz Medicare Advantage |
$4,059.00
|
| Rate for Payer: The Alliance Commercial |
$27,060.00
|
| Rate for Payer: WEA Trust Commercial |
$3,720.75
|
| Rate for Payer: WPS Commercial |
$5,010.84
|
|
|
GRANULES CHRONOS-MEDIUM 5CC 710.014.97S
|
Facility
|
IP
|
$4,672.00
|
|
| Hospital Charge Code |
2966234
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,289.28 |
| Max. Negotiated Rate |
$4,298.24 |
| Rate for Payer: Aetna Commercial |
$4,204.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,017.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,476.16
|
| Rate for Payer: Cash Price |
$1,401.60
|
| Rate for Payer: Cigna Commercial |
$4,298.24
|
| Rate for Payer: Health EOS Commercial |
$4,158.08
|
| Rate for Payer: HFN Commercial |
$4,298.24
|
| Rate for Payer: Multiplan Commercial |
$3,737.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,803.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,298.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,289.28
|
| Rate for Payer: Quartz Commercial |
$2,803.20
|
| Rate for Payer: WEA Trust Commercial |
$2,569.60
|
| Rate for Payer: WPS Commercial |
$3,460.55
|
|
|
GRANULES CHRONOS-MEDIUM 5CC 710.014.97S
|
Facility
|
OP
|
$4,672.00
|
|
| Hospital Charge Code |
2966234
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,308.16 |
| Max. Negotiated Rate |
$18,688.00 |
| Rate for Payer: Aetna Commercial |
$4,204.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,017.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,308.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,036.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,336.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,242.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,476.16
|
| Rate for Payer: Cash Price |
$1,401.60
|
| Rate for Payer: Cigna Commercial |
$4,298.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,614.45
|
| Rate for Payer: Health EOS Commercial |
$4,158.08
|
| Rate for Payer: HFN Commercial |
$4,298.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,504.00
|
| Rate for Payer: Multiplan Commercial |
$3,737.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,803.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,298.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,289.28
|
| Rate for Payer: Quartz Commercial |
$3,036.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,803.20
|
| Rate for Payer: The Alliance Commercial |
$18,688.00
|
| Rate for Payer: WEA Trust Commercial |
$2,569.60
|
| Rate for Payer: WPS Commercial |
$3,460.55
|
|
|
GRASPER 2.3 MINI-LAP ALLIGATOR
|
Facility
|
OP
|
$3,035.00
|
|
| Hospital Charge Code |
2962862
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$849.80 |
| Max. Negotiated Rate |
$12,140.00 |
| Rate for Payer: Aetna Commercial |
$2,731.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,610.10
|
| Rate for Payer: Aetna Managed Medicare |
$849.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,972.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,517.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,456.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,608.55
|
| Rate for Payer: Cash Price |
$910.50
|
| Rate for Payer: Cigna Commercial |
$2,792.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,698.39
|
| Rate for Payer: Health EOS Commercial |
$2,701.15
|
| Rate for Payer: HFN Commercial |
$2,792.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,276.25
|
| Rate for Payer: Multiplan Commercial |
$2,428.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,821.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,792.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,487.15
|
| Rate for Payer: Quartz Commercial |
$1,972.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,821.00
|
| Rate for Payer: The Alliance Commercial |
$12,140.00
|
| Rate for Payer: WEA Trust Commercial |
$1,669.25
|
| Rate for Payer: WPS Commercial |
$2,248.02
|
|
|
GRASPER 2.3 MINI-LAP ALLIGATOR
|
Facility
|
IP
|
$3,035.00
|
|
| Hospital Charge Code |
2962862
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,487.15 |
| Max. Negotiated Rate |
$2,792.20 |
| Rate for Payer: Aetna Commercial |
$2,731.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,610.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,608.55
|
| Rate for Payer: Cash Price |
$910.50
|
| Rate for Payer: Cigna Commercial |
$2,792.20
|
| Rate for Payer: Health EOS Commercial |
$2,701.15
|
| Rate for Payer: HFN Commercial |
$2,792.20
|
| Rate for Payer: Multiplan Commercial |
$2,428.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,821.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,792.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,487.15
|
| Rate for Payer: Quartz Commercial |
$1,821.00
|
| Rate for Payer: WEA Trust Commercial |
$1,669.25
|
| Rate for Payer: WPS Commercial |
$2,248.02
|
|
|
GRASPER FORCEP 3FR RAT TOOTH 210310 G14921
|
Facility
|
OP
|
$2,695.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2964982
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$754.60 |
| Max. Negotiated Rate |
$10,780.00 |
| Rate for Payer: Aetna Commercial |
$2,425.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,317.70
|
| Rate for Payer: Aetna Managed Medicare |
$754.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,751.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,347.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,293.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,428.35
|
| Rate for Payer: Cash Price |
$808.50
|
| Rate for Payer: Cigna Commercial |
$2,479.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,508.12
|
| Rate for Payer: Health EOS Commercial |
$2,398.55
|
| Rate for Payer: HFN Commercial |
$2,479.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,021.25
|
| Rate for Payer: Multiplan Commercial |
$2,156.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,617.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,479.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,320.55
|
| Rate for Payer: Quartz Commercial |
$1,751.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,617.00
|
| Rate for Payer: The Alliance Commercial |
$10,780.00
|
| Rate for Payer: WEA Trust Commercial |
$1,482.25
|
| Rate for Payer: WPS Commercial |
$1,996.19
|
|
|
GRASPER FORCEP 3FR RAT TOOTH 210310 G14921
|
Facility
|
IP
|
$2,695.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2964982
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,320.55 |
| Max. Negotiated Rate |
$2,479.40 |
| Rate for Payer: Aetna Commercial |
$2,425.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,317.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,428.35
|
| Rate for Payer: Cash Price |
$808.50
|
| Rate for Payer: Cigna Commercial |
$2,479.40
|
| Rate for Payer: Health EOS Commercial |
$2,398.55
|
| Rate for Payer: HFN Commercial |
$2,479.40
|
| Rate for Payer: Multiplan Commercial |
$2,156.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,617.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,479.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,320.55
|
| Rate for Payer: Quartz Commercial |
$1,617.00
|
| Rate for Payer: WEA Trust Commercial |
$1,482.25
|
| Rate for Payer: WPS Commercial |
$1,996.19
|
|
|
Gravity tubing changed - Peripheral IV Care:
|
Facility
|
OP
|
$76.00
|
|
| Hospital Charge Code |
3000018
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.28 |
| Max. Negotiated Rate |
$304.00 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Aetna Managed Medicare |
$21.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.53
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.00
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$49.40
|
| Rate for Payer: Quartz Medicare Advantage |
$45.60
|
| Rate for Payer: The Alliance Commercial |
$304.00
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
