|
SNARE CAPTIVATOR COLD M00561100
|
Facility
|
IP
|
$401.00
|
|
| Hospital Charge Code |
5496943
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$196.49 |
| Max. Negotiated Rate |
$368.92 |
| Rate for Payer: Aetna Commercial |
$360.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.53
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$368.92
|
| Rate for Payer: Health EOS Commercial |
$356.89
|
| Rate for Payer: HFN Commercial |
$368.92
|
| Rate for Payer: Multiplan Commercial |
$320.80
|
| Rate for Payer: NAPHCARE Commercial |
$240.60
|
| Rate for Payer: Preferred Network Access Commercial |
$368.92
|
| Rate for Payer: Quartz Beloit One Network |
$196.49
|
| Rate for Payer: Quartz Commercial |
$240.60
|
| Rate for Payer: WEA Trust Commercial |
$220.55
|
| Rate for Payer: WPS Commercial |
$297.02
|
|
|
SNARE CAPTIVATOR II 25MM RIOUNDED - STIFF M00561190
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
5603658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$202.40 |
| Rate for Payer: Aetna Commercial |
$198.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.60
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$202.40
|
| Rate for Payer: Health EOS Commercial |
$195.80
|
| Rate for Payer: HFN Commercial |
$202.40
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: NAPHCARE Commercial |
$132.00
|
| Rate for Payer: Preferred Network Access Commercial |
$202.40
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$132.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: WPS Commercial |
$162.95
|
|
|
SNARE CAPTIVATOR II 25MM RIOUNDED - STIFF M00561190
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
5603658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$880.00 |
| Rate for Payer: Aetna Commercial |
$198.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.20
|
| Rate for Payer: Aetna Managed Medicare |
$61.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$143.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$105.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.60
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$202.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.11
|
| Rate for Payer: Health EOS Commercial |
$195.80
|
| Rate for Payer: HFN Commercial |
$202.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$165.00
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: NAPHCARE Commercial |
$132.00
|
| Rate for Payer: Preferred Network Access Commercial |
$202.40
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$143.00
|
| Rate for Payer: Quartz Medicare Advantage |
$132.00
|
| Rate for Payer: The Alliance Commercial |
$880.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: WPS Commercial |
$162.95
|
|
|
SNARE EXACTO COLD CUT BX00711115
|
Facility
|
IP
|
$366.00
|
|
| Hospital Charge Code |
5349237
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$179.34 |
| Max. Negotiated Rate |
$336.72 |
| Rate for Payer: Aetna Commercial |
$329.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$314.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$193.98
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Cigna Commercial |
$336.72
|
| Rate for Payer: Health EOS Commercial |
$325.74
|
| Rate for Payer: HFN Commercial |
$336.72
|
| Rate for Payer: Multiplan Commercial |
$292.80
|
| Rate for Payer: NAPHCARE Commercial |
$219.60
|
| Rate for Payer: Preferred Network Access Commercial |
$336.72
|
| Rate for Payer: Quartz Beloit One Network |
$179.34
|
| Rate for Payer: Quartz Commercial |
$219.60
|
| Rate for Payer: WEA Trust Commercial |
$201.30
|
| Rate for Payer: WPS Commercial |
$271.10
|
|
|
SNARE EXACTO COLD CUT BX00711115
|
Facility
|
OP
|
$366.00
|
|
| Hospital Charge Code |
5349237
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$102.48 |
| Max. Negotiated Rate |
$1,464.00 |
| Rate for Payer: Aetna Commercial |
$329.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$314.76
|
| Rate for Payer: Aetna Managed Medicare |
$102.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$237.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$183.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$175.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$193.98
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Cigna Commercial |
$336.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$204.81
|
| Rate for Payer: Health EOS Commercial |
$325.74
|
| Rate for Payer: HFN Commercial |
$336.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$274.50
|
| Rate for Payer: Multiplan Commercial |
$292.80
|
| Rate for Payer: NAPHCARE Commercial |
$219.60
|
| Rate for Payer: Preferred Network Access Commercial |
$336.72
|
| Rate for Payer: Quartz Beloit One Network |
$179.34
|
| Rate for Payer: Quartz Commercial |
$237.90
|
| Rate for Payer: Quartz Medicare Advantage |
$219.60
|
| Rate for Payer: The Alliance Commercial |
$1,464.00
|
| Rate for Payer: WEA Trust Commercial |
$201.30
|
| Rate for Payer: WPS Commercial |
$271.10
|
|
|
SNARE HEXAGONAL CAPTIVATOR M00562341
|
Facility
|
OP
|
$317.00
|
|
| Hospital Charge Code |
5264815
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$88.76 |
| Max. Negotiated Rate |
$1,268.00 |
| Rate for Payer: Aetna Commercial |
$285.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$272.62
|
| Rate for Payer: Aetna Managed Medicare |
$88.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$206.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$158.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$152.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$168.01
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$291.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.39
|
| Rate for Payer: Health EOS Commercial |
$282.13
|
| Rate for Payer: HFN Commercial |
$291.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.75
|
| Rate for Payer: Multiplan Commercial |
$253.60
|
| Rate for Payer: NAPHCARE Commercial |
$190.20
|
| Rate for Payer: Preferred Network Access Commercial |
$291.64
|
| Rate for Payer: Quartz Beloit One Network |
$155.33
|
| Rate for Payer: Quartz Commercial |
$206.05
|
| Rate for Payer: Quartz Medicare Advantage |
$190.20
|
| Rate for Payer: The Alliance Commercial |
$1,268.00
|
| Rate for Payer: WEA Trust Commercial |
$174.35
|
| Rate for Payer: WPS Commercial |
$234.80
|
|
|
SNARE HEXAGONAL CAPTIVATOR M00562341
|
Facility
|
IP
|
$317.00
|
|
| Hospital Charge Code |
5264815
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$155.33 |
| Max. Negotiated Rate |
$291.64 |
| Rate for Payer: Aetna Commercial |
$285.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$272.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$168.01
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$291.64
|
| Rate for Payer: Health EOS Commercial |
$282.13
|
| Rate for Payer: HFN Commercial |
$291.64
|
| Rate for Payer: Multiplan Commercial |
$253.60
|
| Rate for Payer: NAPHCARE Commercial |
$190.20
|
| Rate for Payer: Preferred Network Access Commercial |
$291.64
|
| Rate for Payer: Quartz Beloit One Network |
$155.33
|
| Rate for Payer: Quartz Commercial |
$190.20
|
| Rate for Payer: WEA Trust Commercial |
$174.35
|
| Rate for Payer: WPS Commercial |
$234.80
|
|
|
Snare Kit 10mm
|
Facility
|
OP
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2950270
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,120.56 |
| Max. Negotiated Rate |
$16,008.00 |
| Rate for Payer: Aetna Commercial |
$3,601.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,120.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,601.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,001.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,920.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,121.06
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,681.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,239.52
|
| Rate for Payer: Health EOS Commercial |
$3,561.78
|
| Rate for Payer: HFN Commercial |
$3,681.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,001.50
|
| Rate for Payer: Multiplan Commercial |
$3,201.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,401.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,681.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,960.98
|
| Rate for Payer: Quartz Commercial |
$2,601.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,401.20
|
| Rate for Payer: The Alliance Commercial |
$16,008.00
|
| Rate for Payer: WEA Trust Commercial |
$2,201.10
|
| Rate for Payer: WPS Commercial |
$2,964.28
|
|
|
Snare Kit 10mm
|
Professional
|
Both
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2950270
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,760.88 |
| Max. Negotiated Rate |
$3,801.90 |
| Rate for Payer: Aetna Commercial |
$3,801.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.72
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,801.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,001.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,401.20
|
| Rate for Payer: Health EOS Commercial |
$3,641.82
|
| Rate for Payer: HFN Commercial |
$3,801.90
|
| Rate for Payer: Multiplan Commercial |
$3,201.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,801.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,760.88
|
| Rate for Payer: Quartz Commercial |
$2,281.14
|
| Rate for Payer: The Alliance Commercial |
$2,001.00
|
| Rate for Payer: WEA Trust Commercial |
$2,201.10
|
| Rate for Payer: WPS Commercial |
$2,964.28
|
|
|
Snare Kit 10mm
|
Facility
|
IP
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2950270
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,960.98 |
| Max. Negotiated Rate |
$3,681.84 |
| Rate for Payer: Aetna Commercial |
$3,601.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,121.06
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,681.84
|
| Rate for Payer: Health EOS Commercial |
$3,561.78
|
| Rate for Payer: HFN Commercial |
$3,681.84
|
| Rate for Payer: Multiplan Commercial |
$3,201.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,401.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,681.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,960.98
|
| Rate for Payer: Quartz Commercial |
$2,401.20
|
| Rate for Payer: WEA Trust Commercial |
$2,201.10
|
| Rate for Payer: WPS Commercial |
$2,964.28
|
|
|
SNARE KIT 10mm GOOSENECK
|
Facility
|
OP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973399
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,763.44 |
| Max. Negotiated Rate |
$25,192.00 |
| Rate for Payer: Aetna Commercial |
$5,668.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,416.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,763.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,093.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,149.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,023.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,337.94
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$5,794.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,524.36
|
| Rate for Payer: Health EOS Commercial |
$5,605.22
|
| Rate for Payer: HFN Commercial |
$5,794.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,723.50
|
| Rate for Payer: Multiplan Commercial |
$5,038.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,778.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,794.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,086.02
|
| Rate for Payer: Quartz Commercial |
$4,093.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,778.80
|
| Rate for Payer: The Alliance Commercial |
$25,192.00
|
| Rate for Payer: WEA Trust Commercial |
$3,463.90
|
| Rate for Payer: WPS Commercial |
$4,664.93
|
|
|
SNARE KIT 10mm GOOSENECK
|
Facility
|
IP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973399
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,086.02 |
| Max. Negotiated Rate |
$5,794.16 |
| Rate for Payer: Aetna Commercial |
$5,668.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,416.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,337.94
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$5,794.16
|
| Rate for Payer: Health EOS Commercial |
$5,605.22
|
| Rate for Payer: HFN Commercial |
$5,794.16
|
| Rate for Payer: Multiplan Commercial |
$5,038.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,778.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,794.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,086.02
|
| Rate for Payer: Quartz Commercial |
$3,778.80
|
| Rate for Payer: WEA Trust Commercial |
$3,463.90
|
| Rate for Payer: WPS Commercial |
$4,664.93
|
|
|
Snare Kit 15mm
|
Facility
|
OP
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549104
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,120.56 |
| Max. Negotiated Rate |
$16,008.00 |
| Rate for Payer: Aetna Commercial |
$3,601.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,120.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,601.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,001.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,920.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,121.06
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,681.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,239.52
|
| Rate for Payer: Health EOS Commercial |
$3,561.78
|
| Rate for Payer: HFN Commercial |
$3,681.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,001.50
|
| Rate for Payer: Multiplan Commercial |
$3,201.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,401.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,681.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,960.98
|
| Rate for Payer: Quartz Commercial |
$2,601.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,401.20
|
| Rate for Payer: The Alliance Commercial |
$16,008.00
|
| Rate for Payer: WEA Trust Commercial |
$2,201.10
|
| Rate for Payer: WPS Commercial |
$2,964.28
|
|
|
Snare Kit 15mm
|
Professional
|
Both
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549104
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,760.88 |
| Max. Negotiated Rate |
$3,801.90 |
| Rate for Payer: Aetna Commercial |
$3,801.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.72
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,801.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,001.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,401.20
|
| Rate for Payer: Health EOS Commercial |
$3,641.82
|
| Rate for Payer: HFN Commercial |
$3,801.90
|
| Rate for Payer: Multiplan Commercial |
$3,201.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,801.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,760.88
|
| Rate for Payer: Quartz Commercial |
$2,281.14
|
| Rate for Payer: The Alliance Commercial |
$2,001.00
|
| Rate for Payer: WEA Trust Commercial |
$2,201.10
|
| Rate for Payer: WPS Commercial |
$2,964.28
|
|
|
Snare Kit 15mm
|
Facility
|
IP
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549104
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,960.98 |
| Max. Negotiated Rate |
$3,681.84 |
| Rate for Payer: Aetna Commercial |
$3,601.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,121.06
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,681.84
|
| Rate for Payer: Health EOS Commercial |
$3,561.78
|
| Rate for Payer: HFN Commercial |
$3,681.84
|
| Rate for Payer: Multiplan Commercial |
$3,201.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,401.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,681.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,960.98
|
| Rate for Payer: Quartz Commercial |
$2,401.20
|
| Rate for Payer: WEA Trust Commercial |
$2,201.10
|
| Rate for Payer: WPS Commercial |
$2,964.28
|
|
|
SNARE KIT 2mm GOOSENECK
|
Facility
|
IP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973675
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,086.02 |
| Max. Negotiated Rate |
$5,794.16 |
| Rate for Payer: Aetna Commercial |
$5,668.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,416.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,337.94
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$5,794.16
|
| Rate for Payer: Health EOS Commercial |
$5,605.22
|
| Rate for Payer: HFN Commercial |
$5,794.16
|
| Rate for Payer: Multiplan Commercial |
$5,038.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,778.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,794.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,086.02
|
| Rate for Payer: Quartz Commercial |
$3,778.80
|
| Rate for Payer: WEA Trust Commercial |
$3,463.90
|
| Rate for Payer: WPS Commercial |
$4,664.93
|
|
|
SNARE KIT 2mm GOOSENECK
|
Facility
|
OP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973675
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,763.44 |
| Max. Negotiated Rate |
$25,192.00 |
| Rate for Payer: Aetna Commercial |
$5,668.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,416.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,763.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,093.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,149.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,023.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,337.94
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$5,794.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,524.36
|
| Rate for Payer: Health EOS Commercial |
$5,605.22
|
| Rate for Payer: HFN Commercial |
$5,794.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,723.50
|
| Rate for Payer: Multiplan Commercial |
$5,038.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,778.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,794.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,086.02
|
| Rate for Payer: Quartz Commercial |
$4,093.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,778.80
|
| Rate for Payer: The Alliance Commercial |
$25,192.00
|
| Rate for Payer: WEA Trust Commercial |
$3,463.90
|
| Rate for Payer: WPS Commercial |
$4,664.93
|
|
|
SNARE KIT 4mm GOOSENECK #SK400
|
Facility
|
OP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973661
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,763.44 |
| Max. Negotiated Rate |
$25,192.00 |
| Rate for Payer: Aetna Commercial |
$5,668.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,416.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,763.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,093.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,149.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,023.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,337.94
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$5,794.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,524.36
|
| Rate for Payer: Health EOS Commercial |
$5,605.22
|
| Rate for Payer: HFN Commercial |
$5,794.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,723.50
|
| Rate for Payer: Multiplan Commercial |
$5,038.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,778.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,794.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,086.02
|
| Rate for Payer: Quartz Commercial |
$4,093.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,778.80
|
| Rate for Payer: The Alliance Commercial |
$25,192.00
|
| Rate for Payer: WEA Trust Commercial |
$3,463.90
|
| Rate for Payer: WPS Commercial |
$4,664.93
|
|
|
SNARE KIT 4mm GOOSENECK #SK400
|
Facility
|
IP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973661
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,086.02 |
| Max. Negotiated Rate |
$5,794.16 |
| Rate for Payer: Aetna Commercial |
$5,668.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,416.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,337.94
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$5,794.16
|
| Rate for Payer: Health EOS Commercial |
$5,605.22
|
| Rate for Payer: HFN Commercial |
$5,794.16
|
| Rate for Payer: Multiplan Commercial |
$5,038.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,778.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,794.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,086.02
|
| Rate for Payer: Quartz Commercial |
$3,778.80
|
| Rate for Payer: WEA Trust Commercial |
$3,463.90
|
| Rate for Payer: WPS Commercial |
$4,664.93
|
|
|
Snare Kit 5mm
|
Facility
|
OP
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549102
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,120.56 |
| Max. Negotiated Rate |
$16,008.00 |
| Rate for Payer: Aetna Commercial |
$3,601.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,120.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,601.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,001.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,920.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,121.06
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,681.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,239.52
|
| Rate for Payer: Health EOS Commercial |
$3,561.78
|
| Rate for Payer: HFN Commercial |
$3,681.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,001.50
|
| Rate for Payer: Multiplan Commercial |
$3,201.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,401.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,681.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,960.98
|
| Rate for Payer: Quartz Commercial |
$2,601.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,401.20
|
| Rate for Payer: The Alliance Commercial |
$16,008.00
|
| Rate for Payer: WEA Trust Commercial |
$2,201.10
|
| Rate for Payer: WPS Commercial |
$2,964.28
|
|
|
Snare Kit 5mm
|
Professional
|
Both
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549102
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,760.88 |
| Max. Negotiated Rate |
$3,801.90 |
| Rate for Payer: Aetna Commercial |
$3,801.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.72
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,801.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,001.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,401.20
|
| Rate for Payer: Health EOS Commercial |
$3,641.82
|
| Rate for Payer: HFN Commercial |
$3,801.90
|
| Rate for Payer: Multiplan Commercial |
$3,201.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,801.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,760.88
|
| Rate for Payer: Quartz Commercial |
$2,281.14
|
| Rate for Payer: The Alliance Commercial |
$2,001.00
|
| Rate for Payer: WEA Trust Commercial |
$2,201.10
|
| Rate for Payer: WPS Commercial |
$2,964.28
|
|
|
Snare Kit 5mm
|
Facility
|
IP
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549102
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,960.98 |
| Max. Negotiated Rate |
$3,681.84 |
| Rate for Payer: Aetna Commercial |
$3,601.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,121.06
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,681.84
|
| Rate for Payer: Health EOS Commercial |
$3,561.78
|
| Rate for Payer: HFN Commercial |
$3,681.84
|
| Rate for Payer: Multiplan Commercial |
$3,201.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,401.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,681.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,960.98
|
| Rate for Payer: Quartz Commercial |
$2,401.20
|
| Rate for Payer: WEA Trust Commercial |
$2,201.10
|
| Rate for Payer: WPS Commercial |
$2,964.28
|
|
|
SNARE KIT 5mm GOOSENECK #GN500
|
Facility
|
IP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973433
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,086.02 |
| Max. Negotiated Rate |
$5,794.16 |
| Rate for Payer: Aetna Commercial |
$5,668.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,416.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,337.94
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$5,794.16
|
| Rate for Payer: Health EOS Commercial |
$5,605.22
|
| Rate for Payer: HFN Commercial |
$5,794.16
|
| Rate for Payer: Multiplan Commercial |
$5,038.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,778.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,794.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,086.02
|
| Rate for Payer: Quartz Commercial |
$3,778.80
|
| Rate for Payer: WEA Trust Commercial |
$3,463.90
|
| Rate for Payer: WPS Commercial |
$4,664.93
|
|
|
SNARE KIT 5mm GOOSENECK #GN500
|
Facility
|
OP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973433
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,763.44 |
| Max. Negotiated Rate |
$25,192.00 |
| Rate for Payer: Aetna Commercial |
$5,668.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,416.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,763.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,093.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,149.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,023.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,337.94
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$5,794.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,524.36
|
| Rate for Payer: Health EOS Commercial |
$5,605.22
|
| Rate for Payer: HFN Commercial |
$5,794.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,723.50
|
| Rate for Payer: Multiplan Commercial |
$5,038.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,778.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,794.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,086.02
|
| Rate for Payer: Quartz Commercial |
$4,093.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,778.80
|
| Rate for Payer: The Alliance Commercial |
$25,192.00
|
| Rate for Payer: WEA Trust Commercial |
$3,463.90
|
| Rate for Payer: WPS Commercial |
$4,664.93
|
|
|
Snare Micro Kit 2mm
|
Professional
|
Both
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549096
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,760.88 |
| Max. Negotiated Rate |
$3,801.90 |
| Rate for Payer: Aetna Commercial |
$3,801.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.72
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,801.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,001.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,401.20
|
| Rate for Payer: Health EOS Commercial |
$3,641.82
|
| Rate for Payer: HFN Commercial |
$3,801.90
|
| Rate for Payer: Multiplan Commercial |
$3,201.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,801.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,760.88
|
| Rate for Payer: Quartz Commercial |
$2,281.14
|
| Rate for Payer: The Alliance Commercial |
$2,001.00
|
| Rate for Payer: WEA Trust Commercial |
$2,201.10
|
| Rate for Payer: WPS Commercial |
$2,964.28
|
|
