|
CATH KIT GLIDEPATH 19CM 5393190
|
Facility
|
OP
|
$3,350.00
|
|
| Hospital Charge Code |
4641059
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$975.52 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Aetna Managed Medicare |
$975.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,264.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,742.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,672.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,949.70
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,613.00
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,090.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,264.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,090.40
|
| Rate for Payer: The Alliance Commercial |
$1,742.00
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
CATH KIT GLIDEPATH 23CM 5393230
|
Facility
|
IP
|
$3,350.00
|
|
| Hospital Charge Code |
4641060
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,707.16 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,090.40
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
CATH KIT GLIDEPATH 23CM 5393230
|
Facility
|
OP
|
$3,350.00
|
|
| Hospital Charge Code |
4641060
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$975.52 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Aetna Managed Medicare |
$975.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,264.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,742.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,672.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,949.70
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,613.00
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,090.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,264.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,090.40
|
| Rate for Payer: The Alliance Commercial |
$1,742.00
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
CATH KIT GLIDEPATH 27CM 5393270
|
Facility
|
OP
|
$3,350.00
|
|
| Hospital Charge Code |
4641061
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$975.52 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Aetna Managed Medicare |
$975.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,264.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,742.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,672.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,949.70
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,613.00
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,090.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,264.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,090.40
|
| Rate for Payer: The Alliance Commercial |
$1,742.00
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
CATH KIT GLIDEPATH 27CM 5393270
|
Facility
|
IP
|
$3,350.00
|
|
| Hospital Charge Code |
4641061
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,707.16 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,090.40
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
CATH KIT GLIDEPATH 31CM 5393310
|
Facility
|
OP
|
$3,350.00
|
|
| Hospital Charge Code |
4641062
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$975.52 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Aetna Managed Medicare |
$975.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,264.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,742.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,672.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,949.70
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,613.00
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,090.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,264.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,090.40
|
| Rate for Payer: The Alliance Commercial |
$1,742.00
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
CATH KIT GLIDEPATH 31CM 5393310
|
Facility
|
IP
|
$3,350.00
|
|
| Hospital Charge Code |
4641062
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,707.16 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,090.40
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
CATH KIT GLIDEPATH 50CM 5393500
|
Facility
|
OP
|
$3,350.00
|
|
| Hospital Charge Code |
4641063
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$975.52 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Aetna Managed Medicare |
$975.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,264.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,742.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,672.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,949.70
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,613.00
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,090.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,264.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,090.40
|
| Rate for Payer: The Alliance Commercial |
$1,742.00
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
CATH KIT GLIDEPATH 50CM 5393500
|
Facility
|
IP
|
$3,350.00
|
|
| Hospital Charge Code |
4641063
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,707.16 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,090.40
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
CATH KIT PALINDROME 19CM 8888145057P
|
Facility
|
OP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
2962850
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,392.23 |
| Max. Negotiated Rate |
$4,574.46 |
| Rate for Payer: Aetna Commercial |
$4,475.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,276.13
|
| Rate for Payer: Aetna Managed Medicare |
$1,392.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,231.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,486.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,386.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,635.29
|
| Rate for Payer: Cash Price |
$1,434.30
|
| Rate for Payer: Cigna Commercial |
$4,574.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,782.54
|
| Rate for Payer: Health EOS Commercial |
$4,425.29
|
| Rate for Payer: HFN Commercial |
$4,574.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,729.18
|
| Rate for Payer: Multiplan Commercial |
$3,977.79
|
| Rate for Payer: NAPHCARE Commercial |
$2,983.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,574.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,436.40
|
| Rate for Payer: Quartz Commercial |
$3,231.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,983.34
|
| Rate for Payer: The Alliance Commercial |
$2,486.12
|
| Rate for Payer: WEA Trust Commercial |
$2,734.73
|
| Rate for Payer: WPS Commercial |
$3,682.80
|
|
|
CATH KIT PALINDROME 19CM 8888145057P
|
Facility
|
IP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
2962850
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,436.40 |
| Max. Negotiated Rate |
$4,574.46 |
| Rate for Payer: Aetna Commercial |
$4,475.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,276.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,635.29
|
| Rate for Payer: Cash Price |
$1,434.30
|
| Rate for Payer: Cigna Commercial |
$4,574.46
|
| Rate for Payer: Health EOS Commercial |
$4,425.29
|
| Rate for Payer: HFN Commercial |
$4,574.46
|
| Rate for Payer: Multiplan Commercial |
$3,977.79
|
| Rate for Payer: Preferred Network Access Commercial |
$4,574.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,436.40
|
| Rate for Payer: Quartz Commercial |
$2,983.34
|
| Rate for Payer: WEA Trust Commercial |
$2,734.73
|
| Rate for Payer: WPS Commercial |
$3,682.80
|
|
|
CATH KIT PALINDROME 23CM 8888145048P
|
Facility
|
OP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
2962852
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,392.23 |
| Max. Negotiated Rate |
$4,574.46 |
| Rate for Payer: Aetna Commercial |
$4,475.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,276.13
|
| Rate for Payer: Aetna Managed Medicare |
$1,392.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,231.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,486.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,386.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,635.29
|
| Rate for Payer: Cash Price |
$1,434.30
|
| Rate for Payer: Cigna Commercial |
$4,574.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,782.54
|
| Rate for Payer: Health EOS Commercial |
$4,425.29
|
| Rate for Payer: HFN Commercial |
$4,574.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,729.18
|
| Rate for Payer: Multiplan Commercial |
$3,977.79
|
| Rate for Payer: NAPHCARE Commercial |
$2,983.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,574.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,436.40
|
| Rate for Payer: Quartz Commercial |
$3,231.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,983.34
|
| Rate for Payer: The Alliance Commercial |
$2,486.12
|
| Rate for Payer: WEA Trust Commercial |
$2,734.73
|
| Rate for Payer: WPS Commercial |
$3,682.80
|
|
|
CATH KIT PALINDROME 23CM 8888145048P
|
Facility
|
IP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
2962852
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,436.40 |
| Max. Negotiated Rate |
$4,574.46 |
| Rate for Payer: Aetna Commercial |
$4,475.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,276.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,635.29
|
| Rate for Payer: Cash Price |
$1,434.30
|
| Rate for Payer: Cigna Commercial |
$4,574.46
|
| Rate for Payer: Health EOS Commercial |
$4,425.29
|
| Rate for Payer: HFN Commercial |
$4,574.46
|
| Rate for Payer: Multiplan Commercial |
$3,977.79
|
| Rate for Payer: Preferred Network Access Commercial |
$4,574.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,436.40
|
| Rate for Payer: Quartz Commercial |
$2,983.34
|
| Rate for Payer: WEA Trust Commercial |
$2,734.73
|
| Rate for Payer: WPS Commercial |
$3,682.80
|
|
|
CATH KIT PALINDROME 28CM 8888145049P
|
Facility
|
OP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
2962853
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,392.23 |
| Max. Negotiated Rate |
$4,574.46 |
| Rate for Payer: Aetna Commercial |
$4,475.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,276.13
|
| Rate for Payer: Aetna Managed Medicare |
$1,392.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,231.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,486.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,386.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,635.29
|
| Rate for Payer: Cash Price |
$1,434.30
|
| Rate for Payer: Cigna Commercial |
$4,574.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,782.54
|
| Rate for Payer: Health EOS Commercial |
$4,425.29
|
| Rate for Payer: HFN Commercial |
$4,574.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,729.18
|
| Rate for Payer: Multiplan Commercial |
$3,977.79
|
| Rate for Payer: NAPHCARE Commercial |
$2,983.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,574.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,436.40
|
| Rate for Payer: Quartz Commercial |
$3,231.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,983.34
|
| Rate for Payer: The Alliance Commercial |
$2,486.12
|
| Rate for Payer: WEA Trust Commercial |
$2,734.73
|
| Rate for Payer: WPS Commercial |
$3,682.80
|
|
|
CATH KIT PALINDROME 28CM 8888145049P
|
Facility
|
IP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
2962853
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,436.40 |
| Max. Negotiated Rate |
$4,574.46 |
| Rate for Payer: Aetna Commercial |
$4,475.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,276.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,635.29
|
| Rate for Payer: Cash Price |
$1,434.30
|
| Rate for Payer: Cigna Commercial |
$4,574.46
|
| Rate for Payer: Health EOS Commercial |
$4,425.29
|
| Rate for Payer: HFN Commercial |
$4,574.46
|
| Rate for Payer: Multiplan Commercial |
$3,977.79
|
| Rate for Payer: Preferred Network Access Commercial |
$4,574.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,436.40
|
| Rate for Payer: Quartz Commercial |
$2,983.34
|
| Rate for Payer: WEA Trust Commercial |
$2,734.73
|
| Rate for Payer: WPS Commercial |
$3,682.80
|
|
|
CATH KIT PALINDROME 33CM 8888145050P
|
Facility
|
OP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
2962851
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,392.23 |
| Max. Negotiated Rate |
$4,574.46 |
| Rate for Payer: Aetna Commercial |
$4,475.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,276.13
|
| Rate for Payer: Aetna Managed Medicare |
$1,392.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,231.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,486.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,386.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,635.29
|
| Rate for Payer: Cash Price |
$1,434.30
|
| Rate for Payer: Cigna Commercial |
$4,574.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,782.54
|
| Rate for Payer: Health EOS Commercial |
$4,425.29
|
| Rate for Payer: HFN Commercial |
$4,574.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,729.18
|
| Rate for Payer: Multiplan Commercial |
$3,977.79
|
| Rate for Payer: NAPHCARE Commercial |
$2,983.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,574.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,436.40
|
| Rate for Payer: Quartz Commercial |
$3,231.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,983.34
|
| Rate for Payer: The Alliance Commercial |
$2,486.12
|
| Rate for Payer: WEA Trust Commercial |
$2,734.73
|
| Rate for Payer: WPS Commercial |
$3,682.80
|
|
|
CATH KIT PALINDROME 33CM 8888145050P
|
Facility
|
IP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
2962851
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,436.40 |
| Max. Negotiated Rate |
$4,574.46 |
| Rate for Payer: Aetna Commercial |
$4,475.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,276.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,635.29
|
| Rate for Payer: Cash Price |
$1,434.30
|
| Rate for Payer: Cigna Commercial |
$4,574.46
|
| Rate for Payer: Health EOS Commercial |
$4,425.29
|
| Rate for Payer: HFN Commercial |
$4,574.46
|
| Rate for Payer: Multiplan Commercial |
$3,977.79
|
| Rate for Payer: Preferred Network Access Commercial |
$4,574.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,436.40
|
| Rate for Payer: Quartz Commercial |
$2,983.34
|
| Rate for Payer: WEA Trust Commercial |
$2,734.73
|
| Rate for Payer: WPS Commercial |
$3,682.80
|
|
|
CATH KIT PALINDROME 55CM 8888145066P
|
Facility
|
IP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
2962854
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,436.40 |
| Max. Negotiated Rate |
$4,574.46 |
| Rate for Payer: Aetna Commercial |
$4,475.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,276.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,635.29
|
| Rate for Payer: Cash Price |
$1,434.30
|
| Rate for Payer: Cigna Commercial |
$4,574.46
|
| Rate for Payer: Health EOS Commercial |
$4,425.29
|
| Rate for Payer: HFN Commercial |
$4,574.46
|
| Rate for Payer: Multiplan Commercial |
$3,977.79
|
| Rate for Payer: Preferred Network Access Commercial |
$4,574.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,436.40
|
| Rate for Payer: Quartz Commercial |
$2,983.34
|
| Rate for Payer: WEA Trust Commercial |
$2,734.73
|
| Rate for Payer: WPS Commercial |
$3,682.80
|
|
|
CATH KIT PALINDROME 55CM 8888145066P
|
Facility
|
OP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
2962854
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,392.23 |
| Max. Negotiated Rate |
$4,574.46 |
| Rate for Payer: Aetna Commercial |
$4,475.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,276.13
|
| Rate for Payer: Aetna Managed Medicare |
$1,392.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,231.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,486.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,386.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,635.29
|
| Rate for Payer: Cash Price |
$1,434.30
|
| Rate for Payer: Cigna Commercial |
$4,574.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,782.54
|
| Rate for Payer: Health EOS Commercial |
$4,425.29
|
| Rate for Payer: HFN Commercial |
$4,574.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,729.18
|
| Rate for Payer: Multiplan Commercial |
$3,977.79
|
| Rate for Payer: NAPHCARE Commercial |
$2,983.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,574.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,436.40
|
| Rate for Payer: Quartz Commercial |
$3,231.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,983.34
|
| Rate for Payer: The Alliance Commercial |
$2,486.12
|
| Rate for Payer: WEA Trust Commercial |
$2,734.73
|
| Rate for Payer: WPS Commercial |
$3,682.80
|
|
|
CATH.MENTOR SELF-CATH
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2963446
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.35 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$55.54
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
CATH.MENTOR SELF-CATH
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2963446
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$25.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.80
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.42
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$55.54
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$60.16
|
| Rate for Payer: Quartz Medicare Advantage |
$55.54
|
| Rate for Payer: The Alliance Commercial |
$10.73
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
CATH PLCMT COR ART, ANGIO, INC INTRA INJ 93454
|
Professional
|
Both
|
$4,807.00
|
|
|
Service Code
|
CPT 93454
|
| Hospital Charge Code |
3015389
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$650.78 |
| Max. Negotiated Rate |
$4,749.32 |
| Rate for Payer: Aetna Commercial |
$4,749.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,299.38
|
| Rate for Payer: Aetna Managed Medicare |
$860.24
|
| Rate for Payer: Anthem Medicare Advantage |
$860.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$860.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$860.24
|
| Rate for Payer: Cash Price |
$1,442.10
|
| Rate for Payer: Cash Price |
$1,442.10
|
| Rate for Payer: Cash Price |
$1,442.10
|
| Rate for Payer: Cigna Commercial |
$4,749.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$650.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$860.24
|
| Rate for Payer: Health EOS Commercial |
$4,549.34
|
| Rate for Payer: HFN Commercial |
$4,749.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,362.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,362.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$860.24
|
| Rate for Payer: Multiplan Commercial |
$3,999.42
|
| Rate for Payer: NAPHCARE Commercial |
$1,290.35
|
| Rate for Payer: Preferred Network Access Commercial |
$4,749.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,199.68
|
| Rate for Payer: Quartz Commercial |
$2,849.59
|
| Rate for Payer: Quartz Medicare Advantage |
$860.24
|
| Rate for Payer: The Alliance Commercial |
$3,268.90
|
| Rate for Payer: United Healthcare Medicaid |
$650.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$860.24
|
| Rate for Payer: WEA Trust Commercial |
$2,749.60
|
| Rate for Payer: WPS Commercial |
$3,440.94
|
|
|
CATH PLCMT COR ART, ANGIO, INC INTRA INJ 9345422
|
Professional
|
Both
|
$5,768.00
|
|
|
Service Code
|
CPT 93454 22
|
| Hospital Charge Code |
5278617
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$650.78 |
| Max. Negotiated Rate |
$5,698.78 |
| Rate for Payer: Aetna Commercial |
$5,698.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,158.90
|
| Rate for Payer: Cash Price |
$1,730.40
|
| Rate for Payer: Cash Price |
$1,730.40
|
| Rate for Payer: Cash Price |
$1,730.40
|
| Rate for Payer: Cigna Commercial |
$5,698.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$650.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,599.23
|
| Rate for Payer: Health EOS Commercial |
$5,458.84
|
| Rate for Payer: HFN Commercial |
$5,698.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,362.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,362.60
|
| Rate for Payer: Multiplan Commercial |
$4,798.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,698.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,639.44
|
| Rate for Payer: Quartz Commercial |
$3,419.27
|
| Rate for Payer: The Alliance Commercial |
$2,999.36
|
| Rate for Payer: United Healthcare Medicaid |
$650.78
|
| Rate for Payer: WEA Trust Commercial |
$3,299.30
|
| Rate for Payer: WPS Commercial |
$4,443.09
|
|
|
CATH PLCMT COR ART, ANGIO, INC INTRA INJ 9345426
|
Professional
|
Both
|
$4,807.00
|
|
|
Service Code
|
CPT 93454 26
|
| Hospital Charge Code |
3015390
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$187.21 |
| Max. Negotiated Rate |
$4,749.32 |
| Rate for Payer: Aetna Commercial |
$4,749.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,299.38
|
| Rate for Payer: Aetna Managed Medicare |
$219.10
|
| Rate for Payer: Anthem Medicare Advantage |
$219.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$219.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$219.10
|
| Rate for Payer: Cash Price |
$1,442.10
|
| Rate for Payer: Cash Price |
$1,442.10
|
| Rate for Payer: Cash Price |
$1,442.10
|
| Rate for Payer: Cigna Commercial |
$4,749.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$187.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$219.10
|
| Rate for Payer: Health EOS Commercial |
$4,549.34
|
| Rate for Payer: HFN Commercial |
$4,749.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$805.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$805.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$219.10
|
| Rate for Payer: Multiplan Commercial |
$3,999.42
|
| Rate for Payer: NAPHCARE Commercial |
$328.65
|
| Rate for Payer: Preferred Network Access Commercial |
$4,749.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,199.68
|
| Rate for Payer: Quartz Commercial |
$2,849.59
|
| Rate for Payer: Quartz Medicare Advantage |
$219.10
|
| Rate for Payer: The Alliance Commercial |
$832.57
|
| Rate for Payer: United Healthcare Medicaid |
$187.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$219.10
|
| Rate for Payer: WEA Trust Commercial |
$2,749.60
|
| Rate for Payer: WPS Commercial |
$876.39
|
|
|
CATH STRAIGHT SELF CATH 12FR 12 28612"
|
Facility
|
OP
|
$89.00
|
|
| Hospital Charge Code |
4493864
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.92 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$25.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.80
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.42
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$55.54
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$60.16
|
| Rate for Payer: Quartz Medicare Advantage |
$55.54
|
| Rate for Payer: The Alliance Commercial |
$46.28
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
