|
RETRIEVAL NET TWISTER PLUS 22mm 6141
|
Facility
|
IP
|
$1,304.00
|
|
| Hospital Charge Code |
3955316
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$664.52 |
| Max. Negotiated Rate |
$1,247.67 |
| Rate for Payer: Aetna Commercial |
$1,220.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,166.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$718.76
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$1,247.67
|
| Rate for Payer: Health EOS Commercial |
$1,206.98
|
| Rate for Payer: HFN Commercial |
$1,247.67
|
| Rate for Payer: Multiplan Commercial |
$1,084.93
|
| Rate for Payer: Preferred Network Access Commercial |
$1,247.67
|
| Rate for Payer: Quartz Beloit One Network |
$664.52
|
| Rate for Payer: Quartz Commercial |
$813.70
|
| Rate for Payer: WEA Trust Commercial |
$745.89
|
| Rate for Payer: WPS Commercial |
$1,004.47
|
|
|
RETRIEVAL NET TWISTER PLUS 22mm 6141
|
Facility
|
OP
|
$1,304.00
|
|
| Hospital Charge Code |
3955316
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$379.72 |
| Max. Negotiated Rate |
$1,247.67 |
| Rate for Payer: Aetna Commercial |
$1,220.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,166.30
|
| Rate for Payer: Aetna Managed Medicare |
$379.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$881.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$678.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$650.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$718.76
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$1,247.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$758.93
|
| Rate for Payer: Health EOS Commercial |
$1,206.98
|
| Rate for Payer: HFN Commercial |
$1,247.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,017.12
|
| Rate for Payer: Multiplan Commercial |
$1,084.93
|
| Rate for Payer: NAPHCARE Commercial |
$813.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,247.67
|
| Rate for Payer: Quartz Beloit One Network |
$664.52
|
| Rate for Payer: Quartz Commercial |
$881.50
|
| Rate for Payer: Quartz Medicare Advantage |
$813.70
|
| Rate for Payer: The Alliance Commercial |
$678.08
|
| Rate for Payer: WEA Trust Commercial |
$745.89
|
| Rate for Payer: WPS Commercial |
$1,004.47
|
|
|
RETRIEVAL NET TWISTER PLUS 26mm 6142
|
Facility
|
OP
|
$1,304.00
|
|
| Hospital Charge Code |
3549504
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$379.72 |
| Max. Negotiated Rate |
$1,247.67 |
| Rate for Payer: Aetna Commercial |
$1,220.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,166.30
|
| Rate for Payer: Aetna Managed Medicare |
$379.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$881.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$678.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$650.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$718.76
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$1,247.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$758.93
|
| Rate for Payer: Health EOS Commercial |
$1,206.98
|
| Rate for Payer: HFN Commercial |
$1,247.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,017.12
|
| Rate for Payer: Multiplan Commercial |
$1,084.93
|
| Rate for Payer: NAPHCARE Commercial |
$813.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,247.67
|
| Rate for Payer: Quartz Beloit One Network |
$664.52
|
| Rate for Payer: Quartz Commercial |
$881.50
|
| Rate for Payer: Quartz Medicare Advantage |
$813.70
|
| Rate for Payer: The Alliance Commercial |
$678.08
|
| Rate for Payer: WEA Trust Commercial |
$745.89
|
| Rate for Payer: WPS Commercial |
$1,004.47
|
|
|
RETRIEVAL NET TWISTER PLUS 26mm 6142
|
Facility
|
IP
|
$1,304.00
|
|
| Hospital Charge Code |
3549504
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$664.52 |
| Max. Negotiated Rate |
$1,247.67 |
| Rate for Payer: Aetna Commercial |
$1,220.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,166.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$718.76
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$1,247.67
|
| Rate for Payer: Health EOS Commercial |
$1,206.98
|
| Rate for Payer: HFN Commercial |
$1,247.67
|
| Rate for Payer: Multiplan Commercial |
$1,084.93
|
| Rate for Payer: Preferred Network Access Commercial |
$1,247.67
|
| Rate for Payer: Quartz Beloit One Network |
$664.52
|
| Rate for Payer: Quartz Commercial |
$813.70
|
| Rate for Payer: WEA Trust Commercial |
$745.89
|
| Rate for Payer: WPS Commercial |
$1,004.47
|
|
|
RETRIEVER SUTURE HEWSON 71111579
|
Facility
|
OP
|
$946.00
|
|
| Hospital Charge Code |
2965971
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$275.48 |
| Max. Negotiated Rate |
$905.13 |
| Rate for Payer: Aetna Commercial |
$885.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$846.10
|
| Rate for Payer: Aetna Managed Medicare |
$275.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$639.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$491.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$472.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$521.44
|
| Rate for Payer: Cash Price |
$283.80
|
| Rate for Payer: Cigna Commercial |
$905.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$550.57
|
| Rate for Payer: Health EOS Commercial |
$875.62
|
| Rate for Payer: HFN Commercial |
$905.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$737.88
|
| Rate for Payer: Multiplan Commercial |
$787.07
|
| Rate for Payer: NAPHCARE Commercial |
$590.30
|
| Rate for Payer: Preferred Network Access Commercial |
$905.13
|
| Rate for Payer: Quartz Beloit One Network |
$482.08
|
| Rate for Payer: Quartz Commercial |
$639.50
|
| Rate for Payer: Quartz Medicare Advantage |
$590.30
|
| Rate for Payer: The Alliance Commercial |
$491.92
|
| Rate for Payer: WEA Trust Commercial |
$541.11
|
| Rate for Payer: WPS Commercial |
$728.70
|
|
|
RETRIEVER SUTURE HEWSON 71111579
|
Facility
|
IP
|
$946.00
|
|
| Hospital Charge Code |
2965971
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$482.08 |
| Max. Negotiated Rate |
$905.13 |
| Rate for Payer: Aetna Commercial |
$885.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$846.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$521.44
|
| Rate for Payer: Cash Price |
$283.80
|
| Rate for Payer: Cigna Commercial |
$905.13
|
| Rate for Payer: Health EOS Commercial |
$875.62
|
| Rate for Payer: HFN Commercial |
$905.13
|
| Rate for Payer: Multiplan Commercial |
$787.07
|
| Rate for Payer: Preferred Network Access Commercial |
$905.13
|
| Rate for Payer: Quartz Beloit One Network |
$482.08
|
| Rate for Payer: Quartz Commercial |
$590.30
|
| Rate for Payer: WEA Trust Commercial |
$541.11
|
| Rate for Payer: WPS Commercial |
$728.70
|
|
|
RETRIVEVAL CONE #FBRC
|
Facility
|
OP
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2973570
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,931.22 |
| Max. Negotiated Rate |
$9,631.15 |
| Rate for Payer: Aetna Commercial |
$9,421.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,003.03
|
| Rate for Payer: Aetna Managed Medicare |
$2,931.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,804.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,234.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,024.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,548.38
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,631.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,858.41
|
| Rate for Payer: Health EOS Commercial |
$9,317.09
|
| Rate for Payer: HFN Commercial |
$9,631.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,851.48
|
| Rate for Payer: Multiplan Commercial |
$8,374.91
|
| Rate for Payer: NAPHCARE Commercial |
$6,281.18
|
| Rate for Payer: Preferred Network Access Commercial |
$9,631.15
|
| Rate for Payer: Quartz Beloit One Network |
$5,129.63
|
| Rate for Payer: Quartz Commercial |
$6,804.62
|
| Rate for Payer: Quartz Medicare Advantage |
$6,281.18
|
| Rate for Payer: The Alliance Commercial |
$5,234.32
|
| Rate for Payer: WEA Trust Commercial |
$5,757.75
|
| Rate for Payer: WPS Commercial |
$7,753.84
|
|
|
RETRIVEVAL CONE #FBRC
|
Facility
|
IP
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2973570
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,129.63 |
| Max. Negotiated Rate |
$9,631.15 |
| Rate for Payer: Aetna Commercial |
$9,421.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,003.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,548.38
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,631.15
|
| Rate for Payer: Health EOS Commercial |
$9,317.09
|
| Rate for Payer: HFN Commercial |
$9,631.15
|
| Rate for Payer: Multiplan Commercial |
$8,374.91
|
| Rate for Payer: Preferred Network Access Commercial |
$9,631.15
|
| Rate for Payer: Quartz Beloit One Network |
$5,129.63
|
| Rate for Payer: Quartz Commercial |
$6,281.18
|
| Rate for Payer: WEA Trust Commercial |
$5,757.75
|
| Rate for Payer: WPS Commercial |
$7,753.84
|
|
|
RETROBULBAR INJECTION MEDICATION SPX 67500
|
Professional
|
Both
|
$371.00
|
|
|
Service Code
|
CPT 67500
|
| Hospital Charge Code |
5455099
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.42 |
| Max. Negotiated Rate |
$366.55 |
| Rate for Payer: Aetna Commercial |
$366.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.82
|
| Rate for Payer: Aetna Managed Medicare |
$54.78
|
| Rate for Payer: Anthem Medicare Advantage |
$54.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$54.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$54.78
|
| 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 |
$366.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.78
|
| Rate for Payer: Health EOS Commercial |
$351.11
|
| Rate for Payer: HFN Commercial |
$366.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$217.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$54.78
|
| Rate for Payer: Multiplan Commercial |
$308.67
|
| Rate for Payer: NAPHCARE Commercial |
$82.17
|
| Rate for Payer: Preferred Network Access Commercial |
$366.55
|
| Rate for Payer: Quartz Beloit One Network |
$169.77
|
| Rate for Payer: Quartz Commercial |
$219.93
|
| Rate for Payer: Quartz Medicare Advantage |
$54.78
|
| Rate for Payer: The Alliance Commercial |
$232.80
|
| Rate for Payer: United Healthcare Medicaid |
$54.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$54.78
|
| Rate for Payer: WEA Trust Commercial |
$212.21
|
| Rate for Payer: WPS Commercial |
$246.50
|
|
|
RETROCUTTER 10MM AR-1240R-10S
|
Facility
|
IP
|
$3,404.00
|
|
| Hospital Charge Code |
3072635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,734.68 |
| Max. Negotiated Rate |
$3,256.95 |
| Rate for Payer: Aetna Commercial |
$3,186.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,044.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,876.28
|
| Rate for Payer: Cash Price |
$1,021.20
|
| Rate for Payer: Cigna Commercial |
$3,256.95
|
| Rate for Payer: Health EOS Commercial |
$3,150.74
|
| Rate for Payer: HFN Commercial |
$3,256.95
|
| Rate for Payer: Multiplan Commercial |
$2,832.13
|
| Rate for Payer: Preferred Network Access Commercial |
$3,256.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,734.68
|
| Rate for Payer: Quartz Commercial |
$2,124.10
|
| Rate for Payer: WEA Trust Commercial |
$1,947.09
|
| Rate for Payer: WPS Commercial |
$2,622.10
|
|
|
RETROCUTTER 10MM AR-1240R-10S
|
Facility
|
OP
|
$3,404.00
|
|
| Hospital Charge Code |
3072635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$991.24 |
| Max. Negotiated Rate |
$3,256.95 |
| Rate for Payer: Aetna Commercial |
$3,186.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,044.54
|
| Rate for Payer: Aetna Managed Medicare |
$991.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,301.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,770.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,699.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,876.28
|
| Rate for Payer: Cash Price |
$1,021.20
|
| Rate for Payer: Cigna Commercial |
$3,256.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,981.13
|
| Rate for Payer: Health EOS Commercial |
$3,150.74
|
| Rate for Payer: HFN Commercial |
$3,256.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,655.12
|
| Rate for Payer: Multiplan Commercial |
$2,832.13
|
| Rate for Payer: NAPHCARE Commercial |
$2,124.10
|
| Rate for Payer: Preferred Network Access Commercial |
$3,256.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,734.68
|
| Rate for Payer: Quartz Commercial |
$2,301.10
|
| Rate for Payer: Quartz Medicare Advantage |
$2,124.10
|
| Rate for Payer: The Alliance Commercial |
$1,770.08
|
| Rate for Payer: WEA Trust Commercial |
$1,947.09
|
| Rate for Payer: WPS Commercial |
$2,622.10
|
|
|
RETROPERITONEAL LYMPH NODE DISSECTION, RADICAL
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960351
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,298.75 |
| Max. Negotiated Rate |
$4,267.33 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,298.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,014.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,319.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,226.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,267.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,595.72
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,478.80
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: NAPHCARE Commercial |
$2,783.04
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$3,014.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,783.04
|
| Rate for Payer: The Alliance Commercial |
$2,319.20
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
RETROPERITONEAL LYMPH NODE DISSECTION, RADICAL
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960351
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,272.82 |
| Max. Negotiated Rate |
$4,267.33 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,267.33
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$2,783.04
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
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 |
$1,823.35 |
| Max. Negotiated Rate |
$3,423.43 |
| Rate for Payer: Aetna Commercial |
$3,349.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,200.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,972.19
|
| Rate for Payer: Cash Price |
$1,073.40
|
| Rate for Payer: Cigna Commercial |
$3,423.43
|
| Rate for Payer: Health EOS Commercial |
$3,311.80
|
| Rate for Payer: HFN Commercial |
$3,423.43
|
| Rate for Payer: Multiplan Commercial |
$2,976.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,423.43
|
| Rate for Payer: Quartz Beloit One Network |
$1,823.35
|
| Rate for Payer: Quartz Commercial |
$2,232.67
|
| Rate for Payer: WEA Trust Commercial |
$2,046.62
|
| Rate for Payer: WPS Commercial |
$2,756.13
|
|
|
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 |
$1,041.91 |
| Max. Negotiated Rate |
$12,349.86 |
| Rate for Payer: Aetna Commercial |
$3,349.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,200.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,041.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,418.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,860.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,786.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,972.19
|
| Rate for Payer: Cash Price |
$1,073.40
|
| Rate for Payer: Cash Price |
$1,073.40
|
| Rate for Payer: Cigna Commercial |
$3,423.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Health EOS Commercial |
$3,311.80
|
| Rate for Payer: HFN Commercial |
$3,423.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,790.84
|
| Rate for Payer: Multiplan Commercial |
$2,976.90
|
| Rate for Payer: NAPHCARE Commercial |
$2,232.67
|
| Rate for Payer: Preferred Network Access Commercial |
$3,423.43
|
| Rate for Payer: Quartz Beloit One Network |
$1,823.35
|
| Rate for Payer: Quartz Commercial |
$2,418.73
|
| Rate for Payer: Quartz Medicare Advantage |
$2,232.67
|
| Rate for Payer: The Alliance Commercial |
$1,860.56
|
| Rate for Payer: WEA Trust Commercial |
$2,046.62
|
| Rate for Payer: WPS Commercial |
$2,756.13
|
|
|
REVEAL KIT XT 5929
|
Facility
|
OP
|
$14,997.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
3103301
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,367.13 |
| Max. Negotiated Rate |
$14,349.13 |
| Rate for Payer: Aetna Commercial |
$14,037.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,413.32
|
| Rate for Payer: Aetna Managed Medicare |
$4,367.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,137.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,798.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,486.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,266.35
|
| Rate for Payer: Cash Price |
$4,499.10
|
| Rate for Payer: Cigna Commercial |
$14,349.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,728.25
|
| Rate for Payer: Health EOS Commercial |
$13,881.22
|
| Rate for Payer: HFN Commercial |
$14,349.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,697.66
|
| Rate for Payer: Multiplan Commercial |
$12,477.50
|
| Rate for Payer: NAPHCARE Commercial |
$9,358.13
|
| Rate for Payer: Preferred Network Access Commercial |
$14,349.13
|
| Rate for Payer: Quartz Beloit One Network |
$7,642.47
|
| Rate for Payer: Quartz Commercial |
$10,137.97
|
| Rate for Payer: Quartz Medicare Advantage |
$9,358.13
|
| Rate for Payer: The Alliance Commercial |
$7,798.44
|
| Rate for Payer: WEA Trust Commercial |
$8,578.28
|
| Rate for Payer: WPS Commercial |
$11,552.19
|
|
|
REVEAL KIT XT 5929
|
Facility
|
IP
|
$14,997.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
3103301
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,642.47 |
| Max. Negotiated Rate |
$14,349.13 |
| Rate for Payer: Aetna Commercial |
$14,037.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,413.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,266.35
|
| Rate for Payer: Cash Price |
$4,499.10
|
| Rate for Payer: Cigna Commercial |
$14,349.13
|
| Rate for Payer: Health EOS Commercial |
$13,881.22
|
| Rate for Payer: HFN Commercial |
$14,349.13
|
| Rate for Payer: Multiplan Commercial |
$12,477.50
|
| Rate for Payer: Preferred Network Access Commercial |
$14,349.13
|
| Rate for Payer: Quartz Beloit One Network |
$7,642.47
|
| Rate for Payer: Quartz Commercial |
$9,358.13
|
| Rate for Payer: WEA Trust Commercial |
$8,578.28
|
| Rate for Payer: WPS Commercial |
$11,552.19
|
|
|
REVEAL KIT XT 9539
|
Facility
|
OP
|
$14,997.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
3103300
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,367.13 |
| Max. Negotiated Rate |
$14,349.13 |
| Rate for Payer: Aetna Commercial |
$14,037.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,413.32
|
| Rate for Payer: Aetna Managed Medicare |
$4,367.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,137.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,798.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,486.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,266.35
|
| Rate for Payer: Cash Price |
$4,499.10
|
| Rate for Payer: Cigna Commercial |
$14,349.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,728.25
|
| Rate for Payer: Health EOS Commercial |
$13,881.22
|
| Rate for Payer: HFN Commercial |
$14,349.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,697.66
|
| Rate for Payer: Multiplan Commercial |
$12,477.50
|
| Rate for Payer: NAPHCARE Commercial |
$9,358.13
|
| Rate for Payer: Preferred Network Access Commercial |
$14,349.13
|
| Rate for Payer: Quartz Beloit One Network |
$7,642.47
|
| Rate for Payer: Quartz Commercial |
$10,137.97
|
| Rate for Payer: Quartz Medicare Advantage |
$9,358.13
|
| Rate for Payer: The Alliance Commercial |
$7,798.44
|
| Rate for Payer: WEA Trust Commercial |
$8,578.28
|
| Rate for Payer: WPS Commercial |
$11,552.19
|
|
|
REVEAL KIT XT 9539
|
Facility
|
IP
|
$14,997.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
3103300
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,642.47 |
| Max. Negotiated Rate |
$14,349.13 |
| Rate for Payer: Aetna Commercial |
$14,037.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,413.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,266.35
|
| Rate for Payer: Cash Price |
$4,499.10
|
| Rate for Payer: Cigna Commercial |
$14,349.13
|
| Rate for Payer: Health EOS Commercial |
$13,881.22
|
| Rate for Payer: HFN Commercial |
$14,349.13
|
| Rate for Payer: Multiplan Commercial |
$12,477.50
|
| Rate for Payer: Preferred Network Access Commercial |
$14,349.13
|
| Rate for Payer: Quartz Beloit One Network |
$7,642.47
|
| Rate for Payer: Quartz Commercial |
$9,358.13
|
| Rate for Payer: WEA Trust Commercial |
$8,578.28
|
| Rate for Payer: WPS Commercial |
$11,552.19
|
|
|
Reveal Linq Loop Recorder
|
Facility
|
OP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
4125535
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$5,068.63 |
| Max. Negotiated Rate |
$16,654.06 |
| Rate for Payer: Aetna Commercial |
$16,292.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,567.93
|
| Rate for Payer: Aetna Managed Medicare |
$5,068.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,766.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,051.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,689.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,594.19
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,654.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,130.29
|
| Rate for Payer: Health EOS Commercial |
$16,110.99
|
| Rate for Payer: HFN Commercial |
$16,654.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,576.68
|
| Rate for Payer: Multiplan Commercial |
$14,481.79
|
| Rate for Payer: NAPHCARE Commercial |
$10,861.34
|
| Rate for Payer: Preferred Network Access Commercial |
$16,654.06
|
| Rate for Payer: Quartz Beloit One Network |
$8,870.10
|
| Rate for Payer: Quartz Commercial |
$11,766.46
|
| Rate for Payer: Quartz Medicare Advantage |
$10,861.34
|
| Rate for Payer: The Alliance Commercial |
$9,051.12
|
| Rate for Payer: WEA Trust Commercial |
$9,956.23
|
| Rate for Payer: WPS Commercial |
$13,407.84
|
|
|
Reveal Linq Loop Recorder
|
Facility
|
IP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
4125535
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$8,870.10 |
| Max. Negotiated Rate |
$16,654.06 |
| Rate for Payer: Aetna Commercial |
$16,292.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,567.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,594.19
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,654.06
|
| Rate for Payer: Health EOS Commercial |
$16,110.99
|
| Rate for Payer: HFN Commercial |
$16,654.06
|
| Rate for Payer: Multiplan Commercial |
$14,481.79
|
| Rate for Payer: Preferred Network Access Commercial |
$16,654.06
|
| Rate for Payer: Quartz Beloit One Network |
$8,870.10
|
| Rate for Payer: Quartz Commercial |
$10,861.34
|
| Rate for Payer: WEA Trust Commercial |
$9,956.23
|
| Rate for Payer: WPS Commercial |
$13,407.84
|
|
|
REVISE EXTERNAL EAR 69300
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
CPT 69300
|
| Hospital Charge Code |
3015265
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$411.84 |
| Max. Negotiated Rate |
$2,424.62 |
| Rate for Payer: Aetna Commercial |
$889.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$804.96
|
| Rate for Payer: Aetna Managed Medicare |
$414.02
|
| Rate for Payer: Anthem Medicare Advantage |
$414.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$414.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$414.02
|
| 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 |
$889.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,424.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$414.02
|
| Rate for Payer: Health EOS Commercial |
$851.76
|
| Rate for Payer: HFN Commercial |
$889.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,599.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,599.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$414.02
|
| Rate for Payer: Multiplan Commercial |
$748.80
|
| Rate for Payer: NAPHCARE Commercial |
$621.04
|
| Rate for Payer: Preferred Network Access Commercial |
$889.20
|
| Rate for Payer: Quartz Beloit One Network |
$411.84
|
| Rate for Payer: Quartz Commercial |
$533.52
|
| Rate for Payer: Quartz Medicare Advantage |
$414.02
|
| Rate for Payer: The Alliance Commercial |
$1,759.60
|
| Rate for Payer: United Healthcare Medicaid |
$2,424.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$414.02
|
| Rate for Payer: WEA Trust Commercial |
$514.80
|
| Rate for Payer: WPS Commercial |
$1,863.11
|
|
|
REVISION KIT BONE DOWEL 10MM ABS-2850-10
|
Facility
|
OP
|
$5,164.00
|
|
| Hospital Charge Code |
5547230
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,503.76 |
| Max. Negotiated Rate |
$4,940.92 |
| Rate for Payer: Aetna Commercial |
$4,833.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,618.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,503.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,490.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,685.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,577.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,846.40
|
| Rate for Payer: Cash Price |
$1,549.20
|
| Rate for Payer: Cigna Commercial |
$4,940.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,005.45
|
| Rate for Payer: Health EOS Commercial |
$4,779.80
|
| Rate for Payer: HFN Commercial |
$4,940.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,027.92
|
| Rate for Payer: Multiplan Commercial |
$4,296.45
|
| Rate for Payer: NAPHCARE Commercial |
$3,222.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,940.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,631.57
|
| Rate for Payer: Quartz Commercial |
$3,490.86
|
| Rate for Payer: Quartz Medicare Advantage |
$3,222.34
|
| Rate for Payer: The Alliance Commercial |
$2,685.28
|
| Rate for Payer: WEA Trust Commercial |
$2,953.81
|
| Rate for Payer: WPS Commercial |
$3,977.83
|
|
|
REVISION KIT BONE DOWEL 10MM ABS-2850-10
|
Facility
|
IP
|
$5,164.00
|
|
| Hospital Charge Code |
5547230
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,631.57 |
| Max. Negotiated Rate |
$4,940.92 |
| Rate for Payer: Aetna Commercial |
$4,833.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,618.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,846.40
|
| Rate for Payer: Cash Price |
$1,549.20
|
| Rate for Payer: Cigna Commercial |
$4,940.92
|
| Rate for Payer: Health EOS Commercial |
$4,779.80
|
| Rate for Payer: HFN Commercial |
$4,940.92
|
| Rate for Payer: Multiplan Commercial |
$4,296.45
|
| Rate for Payer: Preferred Network Access Commercial |
$4,940.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,631.57
|
| Rate for Payer: Quartz Commercial |
$3,222.34
|
| Rate for Payer: WEA Trust Commercial |
$2,953.81
|
| Rate for Payer: WPS Commercial |
$3,977.83
|
|
|
REVISION KIT BONE DOWEL 12MM ABS-2850-12
|
Facility
|
OP
|
$5,164.00
|
|
| Hospital Charge Code |
6172044
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,503.76 |
| Max. Negotiated Rate |
$4,940.92 |
| Rate for Payer: Aetna Commercial |
$4,833.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,618.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,503.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,490.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,685.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,577.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,846.40
|
| Rate for Payer: Cash Price |
$1,549.20
|
| Rate for Payer: Cigna Commercial |
$4,940.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,005.45
|
| Rate for Payer: Health EOS Commercial |
$4,779.80
|
| Rate for Payer: HFN Commercial |
$4,940.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,027.92
|
| Rate for Payer: Multiplan Commercial |
$4,296.45
|
| Rate for Payer: NAPHCARE Commercial |
$3,222.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,940.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,631.57
|
| Rate for Payer: Quartz Commercial |
$3,490.86
|
| Rate for Payer: Quartz Medicare Advantage |
$3,222.34
|
| Rate for Payer: The Alliance Commercial |
$2,685.28
|
| Rate for Payer: WEA Trust Commercial |
$2,953.81
|
| Rate for Payer: WPS Commercial |
$3,977.83
|
|
