|
RETRIEVAL NET DISPOSABLE 711052
|
Facility
|
OP
|
$1,418.00
|
|
| Hospital Charge Code |
2973731
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$397.04 |
| Max. Negotiated Rate |
$5,672.00 |
| Rate for Payer: Aetna Commercial |
$1,276.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,219.48
|
| Rate for Payer: Aetna Managed Medicare |
$397.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$921.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$709.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$680.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$751.54
|
| Rate for Payer: Cash Price |
$425.40
|
| Rate for Payer: Cigna Commercial |
$1,304.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$793.51
|
| Rate for Payer: Health EOS Commercial |
$1,262.02
|
| Rate for Payer: HFN Commercial |
$1,304.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,063.50
|
| Rate for Payer: Multiplan Commercial |
$1,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$850.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,304.56
|
| Rate for Payer: Quartz Beloit One Network |
$694.82
|
| Rate for Payer: Quartz Commercial |
$921.70
|
| Rate for Payer: Quartz Medicare Advantage |
$850.80
|
| Rate for Payer: The Alliance Commercial |
$5,672.00
|
| Rate for Payer: WEA Trust Commercial |
$779.90
|
| Rate for Payer: WPS Commercial |
$1,050.31
|
|
|
RETRIEVAL NET DISPOSABLE 711052
|
Facility
|
IP
|
$1,418.00
|
|
| Hospital Charge Code |
2973731
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$694.82 |
| Max. Negotiated Rate |
$1,304.56 |
| Rate for Payer: Aetna Commercial |
$1,276.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,219.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$751.54
|
| Rate for Payer: Cash Price |
$425.40
|
| Rate for Payer: Cigna Commercial |
$1,304.56
|
| Rate for Payer: Health EOS Commercial |
$1,262.02
|
| Rate for Payer: HFN Commercial |
$1,304.56
|
| Rate for Payer: Multiplan Commercial |
$1,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$850.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,304.56
|
| Rate for Payer: Quartz Beloit One Network |
$694.82
|
| Rate for Payer: Quartz Commercial |
$850.80
|
| Rate for Payer: WEA Trust Commercial |
$779.90
|
| Rate for Payer: WPS Commercial |
$1,050.31
|
|
|
RETRIEVAL NET TWISTER PLUS 22mm 6141
|
Facility
|
IP
|
$1,304.00
|
|
| Hospital Charge Code |
3955316
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$638.96 |
| Max. Negotiated Rate |
$1,199.68 |
| Rate for Payer: Aetna Commercial |
$1,173.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,121.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$691.12
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$1,199.68
|
| Rate for Payer: Health EOS Commercial |
$1,160.56
|
| Rate for Payer: HFN Commercial |
$1,199.68
|
| Rate for Payer: Multiplan Commercial |
$1,043.20
|
| Rate for Payer: NAPHCARE Commercial |
$782.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,199.68
|
| Rate for Payer: Quartz Beloit One Network |
$638.96
|
| Rate for Payer: Quartz Commercial |
$782.40
|
| Rate for Payer: WEA Trust Commercial |
$717.20
|
| Rate for Payer: WPS Commercial |
$965.87
|
|
|
RETRIEVAL NET TWISTER PLUS 22mm 6141
|
Facility
|
OP
|
$1,304.00
|
|
| Hospital Charge Code |
3955316
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$365.12 |
| Max. Negotiated Rate |
$5,216.00 |
| Rate for Payer: Aetna Commercial |
$1,173.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,121.44
|
| Rate for Payer: Aetna Managed Medicare |
$365.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$847.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$652.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$625.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$691.12
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$1,199.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$729.72
|
| Rate for Payer: Health EOS Commercial |
$1,160.56
|
| Rate for Payer: HFN Commercial |
$1,199.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$978.00
|
| Rate for Payer: Multiplan Commercial |
$1,043.20
|
| Rate for Payer: NAPHCARE Commercial |
$782.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,199.68
|
| Rate for Payer: Quartz Beloit One Network |
$638.96
|
| Rate for Payer: Quartz Commercial |
$847.60
|
| Rate for Payer: Quartz Medicare Advantage |
$782.40
|
| Rate for Payer: The Alliance Commercial |
$5,216.00
|
| Rate for Payer: WEA Trust Commercial |
$717.20
|
| Rate for Payer: WPS Commercial |
$965.87
|
|
|
RETRIEVAL NET TWISTER PLUS 26mm 6142
|
Facility
|
OP
|
$1,304.00
|
|
| Hospital Charge Code |
3549504
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$365.12 |
| Max. Negotiated Rate |
$5,216.00 |
| Rate for Payer: Aetna Commercial |
$1,173.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,121.44
|
| Rate for Payer: Aetna Managed Medicare |
$365.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$847.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$652.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$625.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$691.12
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$1,199.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$729.72
|
| Rate for Payer: Health EOS Commercial |
$1,160.56
|
| Rate for Payer: HFN Commercial |
$1,199.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$978.00
|
| Rate for Payer: Multiplan Commercial |
$1,043.20
|
| Rate for Payer: NAPHCARE Commercial |
$782.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,199.68
|
| Rate for Payer: Quartz Beloit One Network |
$638.96
|
| Rate for Payer: Quartz Commercial |
$847.60
|
| Rate for Payer: Quartz Medicare Advantage |
$782.40
|
| Rate for Payer: The Alliance Commercial |
$5,216.00
|
| Rate for Payer: WEA Trust Commercial |
$717.20
|
| Rate for Payer: WPS Commercial |
$965.87
|
|
|
RETRIEVAL NET TWISTER PLUS 26mm 6142
|
Facility
|
IP
|
$1,304.00
|
|
| Hospital Charge Code |
3549504
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$638.96 |
| Max. Negotiated Rate |
$1,199.68 |
| Rate for Payer: Aetna Commercial |
$1,173.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,121.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$691.12
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$1,199.68
|
| Rate for Payer: Health EOS Commercial |
$1,160.56
|
| Rate for Payer: HFN Commercial |
$1,199.68
|
| Rate for Payer: Multiplan Commercial |
$1,043.20
|
| Rate for Payer: NAPHCARE Commercial |
$782.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,199.68
|
| Rate for Payer: Quartz Beloit One Network |
$638.96
|
| Rate for Payer: Quartz Commercial |
$782.40
|
| Rate for Payer: WEA Trust Commercial |
$717.20
|
| Rate for Payer: WPS Commercial |
$965.87
|
|
|
RETRIEVER SUTURE HEWSON 71111579
|
Facility
|
IP
|
$946.00
|
|
| Hospital Charge Code |
2965971
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$463.54 |
| Max. Negotiated Rate |
$870.32 |
| Rate for Payer: Aetna Commercial |
$851.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$813.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$501.38
|
| Rate for Payer: Cash Price |
$283.80
|
| Rate for Payer: Cigna Commercial |
$870.32
|
| Rate for Payer: Health EOS Commercial |
$841.94
|
| Rate for Payer: HFN Commercial |
$870.32
|
| Rate for Payer: Multiplan Commercial |
$756.80
|
| Rate for Payer: NAPHCARE Commercial |
$567.60
|
| Rate for Payer: Preferred Network Access Commercial |
$870.32
|
| Rate for Payer: Quartz Beloit One Network |
$463.54
|
| Rate for Payer: Quartz Commercial |
$567.60
|
| Rate for Payer: WEA Trust Commercial |
$520.30
|
| Rate for Payer: WPS Commercial |
$700.70
|
|
|
RETRIEVER SUTURE HEWSON 71111579
|
Facility
|
OP
|
$946.00
|
|
| Hospital Charge Code |
2965971
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$264.88 |
| Max. Negotiated Rate |
$3,784.00 |
| Rate for Payer: Aetna Commercial |
$851.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$813.56
|
| Rate for Payer: Aetna Managed Medicare |
$264.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$614.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$473.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$454.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$501.38
|
| Rate for Payer: Cash Price |
$283.80
|
| Rate for Payer: Cigna Commercial |
$870.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$529.38
|
| Rate for Payer: Health EOS Commercial |
$841.94
|
| Rate for Payer: HFN Commercial |
$870.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$709.50
|
| Rate for Payer: Multiplan Commercial |
$756.80
|
| Rate for Payer: NAPHCARE Commercial |
$567.60
|
| Rate for Payer: Preferred Network Access Commercial |
$870.32
|
| Rate for Payer: Quartz Beloit One Network |
$463.54
|
| Rate for Payer: Quartz Commercial |
$614.90
|
| Rate for Payer: Quartz Medicare Advantage |
$567.60
|
| Rate for Payer: The Alliance Commercial |
$3,784.00
|
| Rate for Payer: WEA Trust Commercial |
$520.30
|
| Rate for Payer: WPS Commercial |
$700.70
|
|
|
RETRIVEVAL CONE #FBRC
|
Facility
|
OP
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2973570
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,818.48 |
| Max. Negotiated Rate |
$40,264.00 |
| Rate for Payer: Aetna Commercial |
$9,059.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,656.76
|
| Rate for Payer: Aetna Managed Medicare |
$2,818.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,542.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,033.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,831.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,334.98
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,260.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,632.93
|
| Rate for Payer: Health EOS Commercial |
$8,958.74
|
| Rate for Payer: HFN Commercial |
$9,260.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,549.50
|
| Rate for Payer: Multiplan Commercial |
$8,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,039.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,260.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.34
|
| Rate for Payer: Quartz Commercial |
$6,542.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,039.60
|
| Rate for Payer: The Alliance Commercial |
$40,264.00
|
| Rate for Payer: WEA Trust Commercial |
$5,536.30
|
| Rate for Payer: WPS Commercial |
$7,455.89
|
|
|
RETRIVEVAL CONE #FBRC
|
Facility
|
IP
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2973570
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,932.34 |
| Max. Negotiated Rate |
$9,260.72 |
| Rate for Payer: Aetna Commercial |
$9,059.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,656.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,334.98
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,260.72
|
| Rate for Payer: Health EOS Commercial |
$8,958.74
|
| Rate for Payer: HFN Commercial |
$9,260.72
|
| Rate for Payer: Multiplan Commercial |
$8,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,039.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,260.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.34
|
| Rate for Payer: Quartz Commercial |
$6,039.60
|
| Rate for Payer: WEA Trust Commercial |
$5,536.30
|
| Rate for Payer: WPS Commercial |
$7,455.89
|
|
|
RETROBULBAR INJECTION MEDICATION SPX 67500
|
Professional
|
Both
|
$371.00
|
|
|
Service Code
|
CPT 67500
|
| Hospital Charge Code |
5455099
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.33 |
| Max. Negotiated Rate |
$352.45 |
| Rate for Payer: Aetna Commercial |
$352.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$319.06
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$352.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.60
|
| Rate for Payer: Health EOS Commercial |
$337.61
|
| Rate for Payer: HFN Commercial |
$352.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$208.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$208.98
|
| Rate for Payer: Multiplan Commercial |
$296.80
|
| Rate for Payer: Preferred Network Access Commercial |
$352.45
|
| Rate for Payer: Quartz Beloit One Network |
$163.24
|
| Rate for Payer: Quartz Commercial |
$211.47
|
| Rate for Payer: The Alliance Commercial |
$185.50
|
| Rate for Payer: United Healthcare Medicaid |
$52.33
|
| Rate for Payer: WEA Trust Commercial |
$204.05
|
| Rate for Payer: WPS Commercial |
$274.80
|
|
|
RETROCUTTER 10MM AR-1240R-10S
|
Facility
|
OP
|
$3,404.00
|
|
| Hospital Charge Code |
3072635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$953.12 |
| Max. Negotiated Rate |
$13,616.00 |
| Rate for Payer: Aetna Commercial |
$3,063.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,927.44
|
| Rate for Payer: Aetna Managed Medicare |
$953.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,212.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,702.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,633.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,804.12
|
| Rate for Payer: Cash Price |
$1,021.20
|
| Rate for Payer: Cigna Commercial |
$3,131.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,904.88
|
| Rate for Payer: Health EOS Commercial |
$3,029.56
|
| Rate for Payer: HFN Commercial |
$3,131.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,553.00
|
| Rate for Payer: Multiplan Commercial |
$2,723.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,042.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,131.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,667.96
|
| Rate for Payer: Quartz Commercial |
$2,212.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,042.40
|
| Rate for Payer: The Alliance Commercial |
$13,616.00
|
| Rate for Payer: WEA Trust Commercial |
$1,872.20
|
| Rate for Payer: WPS Commercial |
$2,521.34
|
|
|
RETROCUTTER 10MM AR-1240R-10S
|
Facility
|
IP
|
$3,404.00
|
|
| Hospital Charge Code |
3072635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,667.96 |
| Max. Negotiated Rate |
$3,131.68 |
| Rate for Payer: Aetna Commercial |
$3,063.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,927.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,804.12
|
| Rate for Payer: Cash Price |
$1,021.20
|
| Rate for Payer: Cigna Commercial |
$3,131.68
|
| Rate for Payer: Health EOS Commercial |
$3,029.56
|
| Rate for Payer: HFN Commercial |
$3,131.68
|
| Rate for Payer: Multiplan Commercial |
$2,723.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,042.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,131.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,667.96
|
| Rate for Payer: Quartz Commercial |
$2,042.40
|
| Rate for Payer: WEA Trust Commercial |
$1,872.20
|
| Rate for Payer: WPS Commercial |
$2,521.34
|
|
|
RETROPERITONEAL LYMPH NODE DISSECTION, RADICAL
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960351
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,248.80 |
| Max. Negotiated Rate |
$17,840.00 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,248.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,899.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,230.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,140.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,495.82
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,899.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,676.00
|
| Rate for Payer: The Alliance Commercial |
$17,840.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
RETROPERITONEAL LYMPH NODE DISSECTION, RADICAL
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960351
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,185.40 |
| Max. Negotiated Rate |
$4,103.20 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,676.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
REVASCULARIZATION ILIAC ART ANGIOP EA IPSI VSL 37222-22
|
Facility
|
IP
|
$3,578.00
|
|
|
Service Code
|
CPT 37222 22
|
| Hospital Charge Code |
6173793
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,753.22 |
| Max. Negotiated Rate |
$3,291.76 |
| Rate for Payer: Aetna Commercial |
$3,220.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,077.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,896.34
|
| Rate for Payer: Cash Price |
$1,073.40
|
| Rate for Payer: Cigna Commercial |
$3,291.76
|
| Rate for Payer: Health EOS Commercial |
$3,184.42
|
| Rate for Payer: HFN Commercial |
$3,291.76
|
| Rate for Payer: Multiplan Commercial |
$2,862.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,146.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,291.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,753.22
|
| Rate for Payer: Quartz Commercial |
$2,146.80
|
| Rate for Payer: WEA Trust Commercial |
$1,967.90
|
| Rate for Payer: WPS Commercial |
$2,650.22
|
|
|
REVASCULARIZATION ILIAC ART ANGIOP EA IPSI VSL 37222-22
|
Facility
|
OP
|
$3,578.00
|
|
|
Service Code
|
CPT 37222 22
|
| Hospital Charge Code |
6173793
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,001.84 |
| Max. Negotiated Rate |
$14,312.00 |
| Rate for Payer: Aetna Commercial |
$3,220.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,077.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,001.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,325.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,789.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,717.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,896.34
|
| Rate for Payer: Cash Price |
$1,073.40
|
| Rate for Payer: Cash Price |
$1,073.40
|
| Rate for Payer: Cigna Commercial |
$3,291.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$3,184.42
|
| Rate for Payer: HFN Commercial |
$3,291.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,683.50
|
| Rate for Payer: Multiplan Commercial |
$2,862.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,146.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,291.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,753.22
|
| Rate for Payer: Quartz Commercial |
$2,325.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,146.80
|
| Rate for Payer: The Alliance Commercial |
$14,312.00
|
| Rate for Payer: WEA Trust Commercial |
$1,967.90
|
| Rate for Payer: WPS Commercial |
$2,650.22
|
|
|
REVEAL KIT XT 5929
|
Facility
|
OP
|
$14,997.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
3103301
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,199.16 |
| Max. Negotiated Rate |
$59,988.00 |
| Rate for Payer: Aetna Commercial |
$13,497.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,897.42
|
| Rate for Payer: Aetna Managed Medicare |
$4,199.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,748.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,498.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,198.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,948.41
|
| Rate for Payer: Cash Price |
$4,499.10
|
| Rate for Payer: Cigna Commercial |
$13,797.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,392.32
|
| Rate for Payer: Health EOS Commercial |
$13,347.33
|
| Rate for Payer: HFN Commercial |
$13,797.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,247.75
|
| Rate for Payer: Multiplan Commercial |
$11,997.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,998.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,797.24
|
| Rate for Payer: Quartz Beloit One Network |
$7,348.53
|
| Rate for Payer: Quartz Commercial |
$9,748.05
|
| Rate for Payer: Quartz Medicare Advantage |
$8,998.20
|
| Rate for Payer: The Alliance Commercial |
$59,988.00
|
| Rate for Payer: WEA Trust Commercial |
$8,248.35
|
| Rate for Payer: WPS Commercial |
$11,108.28
|
|
|
REVEAL KIT XT 5929
|
Facility
|
IP
|
$14,997.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
3103301
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,348.53 |
| Max. Negotiated Rate |
$13,797.24 |
| Rate for Payer: Aetna Commercial |
$13,497.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,897.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,948.41
|
| Rate for Payer: Cash Price |
$4,499.10
|
| Rate for Payer: Cigna Commercial |
$13,797.24
|
| Rate for Payer: Health EOS Commercial |
$13,347.33
|
| Rate for Payer: HFN Commercial |
$13,797.24
|
| Rate for Payer: Multiplan Commercial |
$11,997.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,998.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,797.24
|
| Rate for Payer: Quartz Beloit One Network |
$7,348.53
|
| Rate for Payer: Quartz Commercial |
$8,998.20
|
| Rate for Payer: WEA Trust Commercial |
$8,248.35
|
| Rate for Payer: WPS Commercial |
$11,108.28
|
|
|
REVEAL KIT XT 9539
|
Facility
|
IP
|
$14,997.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
3103300
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,348.53 |
| Max. Negotiated Rate |
$13,797.24 |
| Rate for Payer: Aetna Commercial |
$13,497.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,897.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,948.41
|
| Rate for Payer: Cash Price |
$4,499.10
|
| Rate for Payer: Cigna Commercial |
$13,797.24
|
| Rate for Payer: Health EOS Commercial |
$13,347.33
|
| Rate for Payer: HFN Commercial |
$13,797.24
|
| Rate for Payer: Multiplan Commercial |
$11,997.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,998.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,797.24
|
| Rate for Payer: Quartz Beloit One Network |
$7,348.53
|
| Rate for Payer: Quartz Commercial |
$8,998.20
|
| Rate for Payer: WEA Trust Commercial |
$8,248.35
|
| Rate for Payer: WPS Commercial |
$11,108.28
|
|
|
REVEAL KIT XT 9539
|
Facility
|
OP
|
$14,997.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
3103300
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,199.16 |
| Max. Negotiated Rate |
$59,988.00 |
| Rate for Payer: Aetna Commercial |
$13,497.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,897.42
|
| Rate for Payer: Aetna Managed Medicare |
$4,199.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,748.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,498.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,198.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,948.41
|
| Rate for Payer: Cash Price |
$4,499.10
|
| Rate for Payer: Cigna Commercial |
$13,797.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,392.32
|
| Rate for Payer: Health EOS Commercial |
$13,347.33
|
| Rate for Payer: HFN Commercial |
$13,797.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,247.75
|
| Rate for Payer: Multiplan Commercial |
$11,997.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,998.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,797.24
|
| Rate for Payer: Quartz Beloit One Network |
$7,348.53
|
| Rate for Payer: Quartz Commercial |
$9,748.05
|
| Rate for Payer: Quartz Medicare Advantage |
$8,998.20
|
| Rate for Payer: The Alliance Commercial |
$59,988.00
|
| Rate for Payer: WEA Trust Commercial |
$8,248.35
|
| Rate for Payer: WPS Commercial |
$11,108.28
|
|
|
Reveal Linq Loop Recorder
|
Facility
|
OP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
4125535
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,873.68 |
| Max. Negotiated Rate |
$69,624.00 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Aetna Managed Medicare |
$4,873.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,313.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,703.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,354.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,740.40
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,054.50
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$11,313.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,443.60
|
| Rate for Payer: The Alliance Commercial |
$69,624.00
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
Reveal Linq Loop Recorder
|
Facility
|
IP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
4125535
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$8,528.94 |
| Max. Negotiated Rate |
$16,013.52 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$10,443.60
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
REVISE EXTERNAL EAR 69300
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
CPT 69300
|
| Hospital Charge Code |
3015265
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$396.00 |
| Max. Negotiated Rate |
$2,331.37 |
| Rate for Payer: Aetna Commercial |
$855.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$774.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$855.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,331.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$540.00
|
| Rate for Payer: Health EOS Commercial |
$819.00
|
| Rate for Payer: HFN Commercial |
$855.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,538.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,538.44
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: Preferred Network Access Commercial |
$855.00
|
| Rate for Payer: Quartz Beloit One Network |
$396.00
|
| Rate for Payer: Quartz Commercial |
$513.00
|
| Rate for Payer: The Alliance Commercial |
$450.00
|
| Rate for Payer: United Healthcare Medicaid |
$2,331.37
|
| Rate for Payer: WEA Trust Commercial |
$495.00
|
| Rate for Payer: WPS Commercial |
$666.63
|
|
|
REVISION KIT BONE DOWEL 10MM ABS-2850-10
|
Facility
|
OP
|
$5,164.00
|
|
| Hospital Charge Code |
5547230
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,445.92 |
| Max. Negotiated Rate |
$20,656.00 |
| Rate for Payer: Aetna Commercial |
$4,647.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,441.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,445.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,356.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,582.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,478.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,736.92
|
| Rate for Payer: Cash Price |
$1,549.20
|
| Rate for Payer: Cigna Commercial |
$4,750.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,889.77
|
| Rate for Payer: Health EOS Commercial |
$4,595.96
|
| Rate for Payer: HFN Commercial |
$4,750.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,873.00
|
| Rate for Payer: Multiplan Commercial |
$4,131.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,098.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,750.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,530.36
|
| Rate for Payer: Quartz Commercial |
$3,356.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,098.40
|
| Rate for Payer: The Alliance Commercial |
$20,656.00
|
| Rate for Payer: WEA Trust Commercial |
$2,840.20
|
| Rate for Payer: WPS Commercial |
$3,824.97
|
|
