|
KIT 5MS DISP INSTRUMENT SINGLE USE P06 S0001
|
Facility
|
OP
|
$3,990.00
|
|
| Hospital Charge Code |
6172203
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,161.89 |
| Max. Negotiated Rate |
$3,817.63 |
| Rate for Payer: Aetna Commercial |
$3,734.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,568.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,161.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,697.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,074.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,991.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,199.29
|
| Rate for Payer: Cash Price |
$1,197.00
|
| Rate for Payer: Cigna Commercial |
$3,817.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,322.18
|
| Rate for Payer: Health EOS Commercial |
$3,693.14
|
| Rate for Payer: HFN Commercial |
$3,817.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,112.20
|
| Rate for Payer: Multiplan Commercial |
$3,319.68
|
| Rate for Payer: NAPHCARE Commercial |
$2,489.76
|
| Rate for Payer: Preferred Network Access Commercial |
$3,817.63
|
| Rate for Payer: Quartz Beloit One Network |
$2,033.30
|
| Rate for Payer: Quartz Commercial |
$2,697.24
|
| Rate for Payer: Quartz Medicare Advantage |
$2,489.76
|
| Rate for Payer: The Alliance Commercial |
$2,074.80
|
| Rate for Payer: WEA Trust Commercial |
$2,282.28
|
| Rate for Payer: WPS Commercial |
$3,073.50
|
|
|
KIT 5MS DISP INSTRUMENT SINGLE USE P06 S0001
|
Facility
|
IP
|
$3,990.00
|
|
| Hospital Charge Code |
6172203
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,033.30 |
| Max. Negotiated Rate |
$3,817.63 |
| Rate for Payer: Aetna Commercial |
$3,734.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,568.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,199.29
|
| Rate for Payer: Cash Price |
$1,197.00
|
| Rate for Payer: Cigna Commercial |
$3,817.63
|
| Rate for Payer: Health EOS Commercial |
$3,693.14
|
| Rate for Payer: HFN Commercial |
$3,817.63
|
| Rate for Payer: Multiplan Commercial |
$3,319.68
|
| Rate for Payer: Preferred Network Access Commercial |
$3,817.63
|
| Rate for Payer: Quartz Beloit One Network |
$2,033.30
|
| Rate for Payer: Quartz Commercial |
$2,489.76
|
| Rate for Payer: WEA Trust Commercial |
$2,282.28
|
| Rate for Payer: WPS Commercial |
$3,073.50
|
|
|
KIT 7.5 40cc IAB
|
Facility
|
OP
|
$8,800.00
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
2973729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,562.56 |
| Max. Negotiated Rate |
$8,419.84 |
| Rate for Payer: Aetna Commercial |
$8,236.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,870.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,562.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,948.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,576.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,392.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,850.56
|
| Rate for Payer: Cash Price |
$2,640.00
|
| Rate for Payer: Cigna Commercial |
$8,419.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,121.60
|
| Rate for Payer: Health EOS Commercial |
$8,145.28
|
| Rate for Payer: HFN Commercial |
$8,419.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,864.00
|
| Rate for Payer: Multiplan Commercial |
$7,321.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,491.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,419.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,484.48
|
| Rate for Payer: Quartz Commercial |
$5,948.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,491.20
|
| Rate for Payer: The Alliance Commercial |
$4,576.00
|
| Rate for Payer: WEA Trust Commercial |
$5,033.60
|
| Rate for Payer: WPS Commercial |
$6,778.64
|
|
|
KIT 7.5 40cc IAB
|
Facility
|
IP
|
$8,800.00
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
2973729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,484.48 |
| Max. Negotiated Rate |
$8,419.84 |
| Rate for Payer: Aetna Commercial |
$8,236.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,870.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,850.56
|
| Rate for Payer: Cash Price |
$2,640.00
|
| Rate for Payer: Cigna Commercial |
$8,419.84
|
| Rate for Payer: Health EOS Commercial |
$8,145.28
|
| Rate for Payer: HFN Commercial |
$8,419.84
|
| Rate for Payer: Multiplan Commercial |
$7,321.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,419.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,484.48
|
| Rate for Payer: Quartz Commercial |
$5,491.20
|
| Rate for Payer: WEA Trust Commercial |
$5,033.60
|
| Rate for Payer: WPS Commercial |
$6,778.64
|
|
|
KIT ABLATION DISPOSIBLE ESTECH
|
Facility
|
IP
|
$15,253.00
|
|
| Hospital Charge Code |
2965112
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7,772.93 |
| Max. Negotiated Rate |
$14,594.07 |
| Rate for Payer: Aetna Commercial |
$14,276.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,642.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.45
|
| Rate for Payer: Cash Price |
$4,575.90
|
| Rate for Payer: Cigna Commercial |
$14,594.07
|
| Rate for Payer: Health EOS Commercial |
$14,118.18
|
| Rate for Payer: HFN Commercial |
$14,594.07
|
| Rate for Payer: Multiplan Commercial |
$12,690.50
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.07
|
| Rate for Payer: Quartz Beloit One Network |
$7,772.93
|
| Rate for Payer: Quartz Commercial |
$9,517.87
|
| Rate for Payer: WEA Trust Commercial |
$8,724.72
|
| Rate for Payer: WPS Commercial |
$11,749.39
|
|
|
KIT ABLATION DISPOSIBLE ESTECH
|
Facility
|
OP
|
$15,253.00
|
|
| Hospital Charge Code |
2965112
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,441.67 |
| Max. Negotiated Rate |
$14,594.07 |
| Rate for Payer: Aetna Commercial |
$14,276.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,642.28
|
| Rate for Payer: Aetna Managed Medicare |
$4,441.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,311.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,931.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,614.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.45
|
| Rate for Payer: Cash Price |
$4,575.90
|
| Rate for Payer: Cigna Commercial |
$14,594.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,877.25
|
| Rate for Payer: Health EOS Commercial |
$14,118.18
|
| Rate for Payer: HFN Commercial |
$14,594.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,897.34
|
| Rate for Payer: Multiplan Commercial |
$12,690.50
|
| Rate for Payer: NAPHCARE Commercial |
$9,517.87
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.07
|
| Rate for Payer: Quartz Beloit One Network |
$7,772.93
|
| Rate for Payer: Quartz Commercial |
$10,311.03
|
| Rate for Payer: Quartz Medicare Advantage |
$9,517.87
|
| Rate for Payer: The Alliance Commercial |
$7,931.56
|
| Rate for Payer: WEA Trust Commercial |
$8,724.72
|
| Rate for Payer: WPS Commercial |
$11,749.39
|
|
|
KIT ACCELERATOR II FILTER/TUBING B5558-F
|
Facility
|
OP
|
$1,025.00
|
|
| Hospital Charge Code |
2965391
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$298.48 |
| Max. Negotiated Rate |
$980.72 |
| Rate for Payer: Aetna Commercial |
$959.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$916.76
|
| Rate for Payer: Aetna Managed Medicare |
$298.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$692.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$533.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$511.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$564.98
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: Cigna Commercial |
$980.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$596.55
|
| Rate for Payer: Health EOS Commercial |
$948.74
|
| Rate for Payer: HFN Commercial |
$980.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$799.50
|
| Rate for Payer: Multiplan Commercial |
$852.80
|
| Rate for Payer: NAPHCARE Commercial |
$639.60
|
| Rate for Payer: Preferred Network Access Commercial |
$980.72
|
| Rate for Payer: Quartz Beloit One Network |
$522.34
|
| Rate for Payer: Quartz Commercial |
$692.90
|
| Rate for Payer: Quartz Medicare Advantage |
$639.60
|
| Rate for Payer: The Alliance Commercial |
$533.00
|
| Rate for Payer: WEA Trust Commercial |
$586.30
|
| Rate for Payer: WPS Commercial |
$789.56
|
|
|
KIT ACCELERATOR II FILTER/TUBING B5558-F
|
Facility
|
IP
|
$1,025.00
|
|
| Hospital Charge Code |
2965391
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$522.34 |
| Max. Negotiated Rate |
$980.72 |
| Rate for Payer: Aetna Commercial |
$959.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$916.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$564.98
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: Cigna Commercial |
$980.72
|
| Rate for Payer: Health EOS Commercial |
$948.74
|
| Rate for Payer: HFN Commercial |
$980.72
|
| Rate for Payer: Multiplan Commercial |
$852.80
|
| Rate for Payer: Preferred Network Access Commercial |
$980.72
|
| Rate for Payer: Quartz Beloit One Network |
$522.34
|
| Rate for Payer: Quartz Commercial |
$639.60
|
| Rate for Payer: WEA Trust Commercial |
$586.30
|
| Rate for Payer: WPS Commercial |
$789.56
|
|
|
KIT ACCESS PORT VG & APS
|
Facility
|
OP
|
$5,903.00
|
|
| Hospital Charge Code |
2964637
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,718.95 |
| Max. Negotiated Rate |
$5,647.99 |
| Rate for Payer: Aetna Commercial |
$5,525.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,279.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,718.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,990.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,069.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,946.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,253.73
|
| Rate for Payer: Cash Price |
$1,770.90
|
| Rate for Payer: Cigna Commercial |
$5,647.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,435.55
|
| Rate for Payer: Health EOS Commercial |
$5,463.82
|
| Rate for Payer: HFN Commercial |
$5,647.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,604.34
|
| Rate for Payer: Multiplan Commercial |
$4,911.30
|
| Rate for Payer: NAPHCARE Commercial |
$3,683.47
|
| Rate for Payer: Preferred Network Access Commercial |
$5,647.99
|
| Rate for Payer: Quartz Beloit One Network |
$3,008.17
|
| Rate for Payer: Quartz Commercial |
$3,990.43
|
| Rate for Payer: Quartz Medicare Advantage |
$3,683.47
|
| Rate for Payer: The Alliance Commercial |
$3,069.56
|
| Rate for Payer: WEA Trust Commercial |
$3,376.52
|
| Rate for Payer: WPS Commercial |
$4,547.08
|
|
|
KIT ACCESS PORT VG & APS
|
Facility
|
IP
|
$5,903.00
|
|
| Hospital Charge Code |
2964637
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,008.17 |
| Max. Negotiated Rate |
$5,647.99 |
| Rate for Payer: Aetna Commercial |
$5,525.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,279.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,253.73
|
| Rate for Payer: Cash Price |
$1,770.90
|
| Rate for Payer: Cigna Commercial |
$5,647.99
|
| Rate for Payer: Health EOS Commercial |
$5,463.82
|
| Rate for Payer: HFN Commercial |
$5,647.99
|
| Rate for Payer: Multiplan Commercial |
$4,911.30
|
| Rate for Payer: Preferred Network Access Commercial |
$5,647.99
|
| Rate for Payer: Quartz Beloit One Network |
$3,008.17
|
| Rate for Payer: Quartz Commercial |
$3,683.47
|
| Rate for Payer: WEA Trust Commercial |
$3,376.52
|
| Rate for Payer: WPS Commercial |
$4,547.08
|
|
|
KIT ACL DISPOSABLE 232400
|
Facility
|
OP
|
$6,041.00
|
|
| Hospital Charge Code |
3072461
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,759.14 |
| Max. Negotiated Rate |
$5,780.03 |
| Rate for Payer: Aetna Commercial |
$5,654.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,403.07
|
| Rate for Payer: Aetna Managed Medicare |
$1,759.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,083.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,141.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,015.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,329.80
|
| Rate for Payer: Cash Price |
$1,812.30
|
| Rate for Payer: Cigna Commercial |
$5,780.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,515.86
|
| Rate for Payer: Health EOS Commercial |
$5,591.55
|
| Rate for Payer: HFN Commercial |
$5,780.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,711.98
|
| Rate for Payer: Multiplan Commercial |
$5,026.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,769.58
|
| Rate for Payer: Preferred Network Access Commercial |
$5,780.03
|
| Rate for Payer: Quartz Beloit One Network |
$3,078.49
|
| Rate for Payer: Quartz Commercial |
$4,083.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,769.58
|
| Rate for Payer: The Alliance Commercial |
$3,141.32
|
| Rate for Payer: WEA Trust Commercial |
$3,455.45
|
| Rate for Payer: WPS Commercial |
$4,653.38
|
|
|
KIT ACL DISPOSABLE 232400
|
Facility
|
IP
|
$6,041.00
|
|
| Hospital Charge Code |
3072461
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,078.49 |
| Max. Negotiated Rate |
$5,780.03 |
| Rate for Payer: Aetna Commercial |
$5,654.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,403.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,329.80
|
| Rate for Payer: Cash Price |
$1,812.30
|
| Rate for Payer: Cigna Commercial |
$5,780.03
|
| Rate for Payer: Health EOS Commercial |
$5,591.55
|
| Rate for Payer: HFN Commercial |
$5,780.03
|
| Rate for Payer: Multiplan Commercial |
$5,026.11
|
| Rate for Payer: Preferred Network Access Commercial |
$5,780.03
|
| Rate for Payer: Quartz Beloit One Network |
$3,078.49
|
| Rate for Payer: Quartz Commercial |
$3,769.58
|
| Rate for Payer: WEA Trust Commercial |
$3,455.45
|
| Rate for Payer: WPS Commercial |
$4,653.38
|
|
|
KIT ALLEN SHOULDER SUSPENSION A-21200-A7
|
Facility
|
IP
|
$735.00
|
|
| Hospital Charge Code |
2964624
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$374.56 |
| Max. Negotiated Rate |
$703.25 |
| Rate for Payer: Aetna Commercial |
$687.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.13
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$703.25
|
| Rate for Payer: Health EOS Commercial |
$680.32
|
| Rate for Payer: HFN Commercial |
$703.25
|
| Rate for Payer: Multiplan Commercial |
$611.52
|
| Rate for Payer: Preferred Network Access Commercial |
$703.25
|
| Rate for Payer: Quartz Beloit One Network |
$374.56
|
| Rate for Payer: Quartz Commercial |
$458.64
|
| Rate for Payer: WEA Trust Commercial |
$420.42
|
| Rate for Payer: WPS Commercial |
$566.17
|
|
|
KIT ALLEN SHOULDER SUSPENSION A-21200-A7
|
Facility
|
OP
|
$735.00
|
|
| Hospital Charge Code |
2964624
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$214.03 |
| Max. Negotiated Rate |
$703.25 |
| Rate for Payer: Aetna Commercial |
$687.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.38
|
| Rate for Payer: Aetna Managed Medicare |
$214.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$496.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$382.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$366.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.13
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$703.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$427.77
|
| Rate for Payer: Health EOS Commercial |
$680.32
|
| Rate for Payer: HFN Commercial |
$703.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$573.30
|
| Rate for Payer: Multiplan Commercial |
$611.52
|
| Rate for Payer: NAPHCARE Commercial |
$458.64
|
| Rate for Payer: Preferred Network Access Commercial |
$703.25
|
| Rate for Payer: Quartz Beloit One Network |
$374.56
|
| Rate for Payer: Quartz Commercial |
$496.86
|
| Rate for Payer: Quartz Medicare Advantage |
$458.64
|
| Rate for Payer: The Alliance Commercial |
$382.20
|
| Rate for Payer: WEA Trust Commercial |
$420.42
|
| Rate for Payer: WPS Commercial |
$566.17
|
|
|
KIT ANCHOR FIBERTAK SUTURE AR-3600DC
|
Facility
|
IP
|
$3,535.00
|
|
| Hospital Charge Code |
4520259
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,801.44 |
| Max. Negotiated Rate |
$3,382.29 |
| Rate for Payer: Aetna Commercial |
$3,308.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,161.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,948.49
|
| Rate for Payer: Cash Price |
$1,060.50
|
| Rate for Payer: Cigna Commercial |
$3,382.29
|
| Rate for Payer: Health EOS Commercial |
$3,272.00
|
| Rate for Payer: HFN Commercial |
$3,382.29
|
| Rate for Payer: Multiplan Commercial |
$2,941.12
|
| Rate for Payer: Preferred Network Access Commercial |
$3,382.29
|
| Rate for Payer: Quartz Beloit One Network |
$1,801.44
|
| Rate for Payer: Quartz Commercial |
$2,205.84
|
| Rate for Payer: WEA Trust Commercial |
$2,022.02
|
| Rate for Payer: WPS Commercial |
$2,723.01
|
|
|
KIT ANCHOR FIBERTAK SUTURE AR-3600DC
|
Facility
|
OP
|
$3,535.00
|
|
| Hospital Charge Code |
4520259
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,029.39 |
| Max. Negotiated Rate |
$3,382.29 |
| Rate for Payer: Aetna Commercial |
$3,308.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,161.70
|
| Rate for Payer: Aetna Managed Medicare |
$1,029.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,389.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,838.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,764.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,948.49
|
| Rate for Payer: Cash Price |
$1,060.50
|
| Rate for Payer: Cigna Commercial |
$3,382.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,057.37
|
| Rate for Payer: Health EOS Commercial |
$3,272.00
|
| Rate for Payer: HFN Commercial |
$3,382.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,757.30
|
| Rate for Payer: Multiplan Commercial |
$2,941.12
|
| Rate for Payer: NAPHCARE Commercial |
$2,205.84
|
| Rate for Payer: Preferred Network Access Commercial |
$3,382.29
|
| Rate for Payer: Quartz Beloit One Network |
$1,801.44
|
| Rate for Payer: Quartz Commercial |
$2,389.66
|
| Rate for Payer: Quartz Medicare Advantage |
$2,205.84
|
| Rate for Payer: The Alliance Commercial |
$1,838.20
|
| Rate for Payer: WEA Trust Commercial |
$2,022.02
|
| Rate for Payer: WPS Commercial |
$2,723.01
|
|
|
KIT ANCHOR FIBERTAK SUTURE DX W 1.3MM FIBERWIRE SUTURE TAPE & NEEDLE AR-8990DS
|
Facility
|
IP
|
$4,182.00
|
|
| Hospital Charge Code |
5583386
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,131.15 |
| Max. Negotiated Rate |
$4,001.34 |
| Rate for Payer: Aetna Commercial |
$3,914.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,740.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,305.12
|
| Rate for Payer: Cash Price |
$1,254.60
|
| Rate for Payer: Cigna Commercial |
$4,001.34
|
| Rate for Payer: Health EOS Commercial |
$3,870.86
|
| Rate for Payer: HFN Commercial |
$4,001.34
|
| Rate for Payer: Multiplan Commercial |
$3,479.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,001.34
|
| Rate for Payer: Quartz Beloit One Network |
$2,131.15
|
| Rate for Payer: Quartz Commercial |
$2,609.57
|
| Rate for Payer: WEA Trust Commercial |
$2,392.10
|
| Rate for Payer: WPS Commercial |
$3,221.39
|
|
|
KIT ANCHOR FIBERTAK SUTURE DX W 1.3MM FIBERWIRE SUTURE TAPE & NEEDLE AR-8990DS
|
Facility
|
OP
|
$4,182.00
|
|
| Hospital Charge Code |
5583386
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,217.80 |
| Max. Negotiated Rate |
$4,001.34 |
| Rate for Payer: Aetna Commercial |
$3,914.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,740.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,217.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,827.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,174.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,087.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,305.12
|
| Rate for Payer: Cash Price |
$1,254.60
|
| Rate for Payer: Cigna Commercial |
$4,001.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,433.92
|
| Rate for Payer: Health EOS Commercial |
$3,870.86
|
| Rate for Payer: HFN Commercial |
$4,001.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,261.96
|
| Rate for Payer: Multiplan Commercial |
$3,479.42
|
| Rate for Payer: NAPHCARE Commercial |
$2,609.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,001.34
|
| Rate for Payer: Quartz Beloit One Network |
$2,131.15
|
| Rate for Payer: Quartz Commercial |
$2,827.03
|
| Rate for Payer: Quartz Medicare Advantage |
$2,609.57
|
| Rate for Payer: The Alliance Commercial |
$2,174.64
|
| Rate for Payer: WEA Trust Commercial |
$2,392.10
|
| Rate for Payer: WPS Commercial |
$3,221.39
|
|
|
KIT ANCHOR FIBERTAK SUTURE KNOTLESS CURVED AR-3638DC
|
Facility
|
OP
|
$2,805.00
|
|
| Hospital Charge Code |
5459089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$816.82 |
| Max. Negotiated Rate |
$2,683.82 |
| Rate for Payer: Aetna Commercial |
$2,625.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,508.79
|
| Rate for Payer: Aetna Managed Medicare |
$816.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,896.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,458.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,400.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,546.12
|
| Rate for Payer: Cash Price |
$841.50
|
| Rate for Payer: Cigna Commercial |
$2,683.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,632.51
|
| Rate for Payer: Health EOS Commercial |
$2,596.31
|
| Rate for Payer: HFN Commercial |
$2,683.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,187.90
|
| Rate for Payer: Multiplan Commercial |
$2,333.76
|
| Rate for Payer: NAPHCARE Commercial |
$1,750.32
|
| Rate for Payer: Preferred Network Access Commercial |
$2,683.82
|
| Rate for Payer: Quartz Beloit One Network |
$1,429.43
|
| Rate for Payer: Quartz Commercial |
$1,896.18
|
| Rate for Payer: Quartz Medicare Advantage |
$1,750.32
|
| Rate for Payer: The Alliance Commercial |
$1,458.60
|
| Rate for Payer: WEA Trust Commercial |
$1,604.46
|
| Rate for Payer: WPS Commercial |
$2,160.69
|
|
|
KIT ANCHOR FIBERTAK SUTURE KNOTLESS CURVED AR-3638DC
|
Facility
|
IP
|
$2,805.00
|
|
| Hospital Charge Code |
5459089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,429.43 |
| Max. Negotiated Rate |
$2,683.82 |
| Rate for Payer: Aetna Commercial |
$2,625.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,508.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,546.12
|
| Rate for Payer: Cash Price |
$841.50
|
| Rate for Payer: Cigna Commercial |
$2,683.82
|
| Rate for Payer: Health EOS Commercial |
$2,596.31
|
| Rate for Payer: HFN Commercial |
$2,683.82
|
| Rate for Payer: Multiplan Commercial |
$2,333.76
|
| Rate for Payer: Preferred Network Access Commercial |
$2,683.82
|
| Rate for Payer: Quartz Beloit One Network |
$1,429.43
|
| Rate for Payer: Quartz Commercial |
$1,750.32
|
| Rate for Payer: WEA Trust Commercial |
$1,604.46
|
| Rate for Payer: WPS Commercial |
$2,160.69
|
|
|
KIT ANCHOR FIBERTAK SUTURE KNOTLESS STRAIGHT AR-3638DS
|
Facility
|
IP
|
$2,557.00
|
|
| Hospital Charge Code |
5659715
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,303.05 |
| Max. Negotiated Rate |
$2,446.54 |
| Rate for Payer: Aetna Commercial |
$2,393.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,286.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,409.42
|
| Rate for Payer: Cash Price |
$767.10
|
| Rate for Payer: Cigna Commercial |
$2,446.54
|
| Rate for Payer: Health EOS Commercial |
$2,366.76
|
| Rate for Payer: HFN Commercial |
$2,446.54
|
| Rate for Payer: Multiplan Commercial |
$2,127.42
|
| Rate for Payer: Preferred Network Access Commercial |
$2,446.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,303.05
|
| Rate for Payer: Quartz Commercial |
$1,595.57
|
| Rate for Payer: WEA Trust Commercial |
$1,462.60
|
| Rate for Payer: WPS Commercial |
$1,969.66
|
|
|
KIT ANCHOR FIBERTAK SUTURE KNOTLESS STRAIGHT AR-3638DS
|
Facility
|
OP
|
$2,557.00
|
|
| Hospital Charge Code |
5659715
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$744.60 |
| Max. Negotiated Rate |
$2,446.54 |
| Rate for Payer: Aetna Commercial |
$2,393.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,286.98
|
| Rate for Payer: Aetna Managed Medicare |
$744.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,728.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,329.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,276.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,409.42
|
| Rate for Payer: Cash Price |
$767.10
|
| Rate for Payer: Cigna Commercial |
$2,446.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,488.17
|
| Rate for Payer: Health EOS Commercial |
$2,366.76
|
| Rate for Payer: HFN Commercial |
$2,446.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,994.46
|
| Rate for Payer: Multiplan Commercial |
$2,127.42
|
| Rate for Payer: NAPHCARE Commercial |
$1,595.57
|
| Rate for Payer: Preferred Network Access Commercial |
$2,446.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,303.05
|
| Rate for Payer: Quartz Commercial |
$1,728.53
|
| Rate for Payer: Quartz Medicare Advantage |
$1,595.57
|
| Rate for Payer: The Alliance Commercial |
$1,329.64
|
| Rate for Payer: WEA Trust Commercial |
$1,462.60
|
| Rate for Payer: WPS Commercial |
$1,969.66
|
|
|
KIT ANCHOR FIBERTAK SUTURE RC DOUBLOAD TAPE BL/W BLK/W AR-3650DS
|
Facility
|
IP
|
$2,805.00
|
|
| Hospital Charge Code |
5385071
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,429.43 |
| Max. Negotiated Rate |
$2,683.82 |
| Rate for Payer: Aetna Commercial |
$2,625.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,508.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,546.12
|
| Rate for Payer: Cash Price |
$841.50
|
| Rate for Payer: Cigna Commercial |
$2,683.82
|
| Rate for Payer: Health EOS Commercial |
$2,596.31
|
| Rate for Payer: HFN Commercial |
$2,683.82
|
| Rate for Payer: Multiplan Commercial |
$2,333.76
|
| Rate for Payer: Preferred Network Access Commercial |
$2,683.82
|
| Rate for Payer: Quartz Beloit One Network |
$1,429.43
|
| Rate for Payer: Quartz Commercial |
$1,750.32
|
| Rate for Payer: WEA Trust Commercial |
$1,604.46
|
| Rate for Payer: WPS Commercial |
$2,160.69
|
|
|
KIT ANCHOR FIBERTAK SUTURE RC DOUBLOAD TAPE BL/W BLK/W AR-3650DS
|
Facility
|
OP
|
$2,805.00
|
|
| Hospital Charge Code |
5385071
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$816.82 |
| Max. Negotiated Rate |
$2,683.82 |
| Rate for Payer: Aetna Commercial |
$2,625.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,508.79
|
| Rate for Payer: Aetna Managed Medicare |
$816.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,896.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,458.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,400.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,546.12
|
| Rate for Payer: Cash Price |
$841.50
|
| Rate for Payer: Cigna Commercial |
$2,683.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,632.51
|
| Rate for Payer: Health EOS Commercial |
$2,596.31
|
| Rate for Payer: HFN Commercial |
$2,683.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,187.90
|
| Rate for Payer: Multiplan Commercial |
$2,333.76
|
| Rate for Payer: NAPHCARE Commercial |
$1,750.32
|
| Rate for Payer: Preferred Network Access Commercial |
$2,683.82
|
| Rate for Payer: Quartz Beloit One Network |
$1,429.43
|
| Rate for Payer: Quartz Commercial |
$1,896.18
|
| Rate for Payer: Quartz Medicare Advantage |
$1,750.32
|
| Rate for Payer: The Alliance Commercial |
$1,458.60
|
| Rate for Payer: WEA Trust Commercial |
$1,604.46
|
| Rate for Payer: WPS Commercial |
$2,160.69
|
|
|
KIT ANCHOR SWIVELOCK DX 3.5 AR-8979DS
|
Facility
|
IP
|
$4,182.00
|
|
| Hospital Charge Code |
5597552
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.15 |
| Max. Negotiated Rate |
$4,001.34 |
| Rate for Payer: Aetna Commercial |
$3,914.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,740.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,305.12
|
| Rate for Payer: Cash Price |
$1,254.60
|
| Rate for Payer: Cigna Commercial |
$4,001.34
|
| Rate for Payer: Health EOS Commercial |
$3,870.86
|
| Rate for Payer: HFN Commercial |
$4,001.34
|
| Rate for Payer: Multiplan Commercial |
$3,479.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,001.34
|
| Rate for Payer: Quartz Beloit One Network |
$2,131.15
|
| Rate for Payer: Quartz Commercial |
$2,609.57
|
| Rate for Payer: WEA Trust Commercial |
$2,392.10
|
| Rate for Payer: WPS Commercial |
$3,221.39
|
|
