|
Diamondback Atherectomy Device
|
Facility
IP
|
$12,634.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
5184610
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$6,190.66 |
| Max. Negotiated Rate |
$11,623.28 |
| Rate for Payer: Aetna Commercial |
$11,370.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,696.02
|
| Rate for Payer: Cash Price |
$3,790.20
|
| Rate for Payer: Cigna Commercial |
$11,623.28
|
| Rate for Payer: Health EOS Commercial |
$11,244.26
|
| Rate for Payer: HFN Commercial |
$11,623.28
|
| Rate for Payer: Multiplan Commercial |
$10,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,580.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,623.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,190.66
|
| Rate for Payer: Quartz Commercial |
$7,580.40
|
| Rate for Payer: WEA Trust Commercial |
$6,948.70
|
| Rate for Payer: WPS Commercial |
$9,358.00
|
|
|
Diamondback Atherectomy Device
|
Facility
OP
|
$12,634.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
5184610
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,537.52 |
| Max. Negotiated Rate |
$11,623.28 |
| Rate for Payer: Aetna Commercial |
$11,370.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,865.24
|
| Rate for Payer: Aetna Managed Medicare |
$3,537.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,212.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,317.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,064.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,696.02
|
| Rate for Payer: Cash Price |
$3,790.20
|
| Rate for Payer: Cigna Commercial |
$11,623.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,069.99
|
| Rate for Payer: Health EOS Commercial |
$11,244.26
|
| Rate for Payer: HFN Commercial |
$11,623.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,475.50
|
| Rate for Payer: Multiplan Commercial |
$10,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,580.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,623.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,190.66
|
| Rate for Payer: Quartz Commercial |
$8,212.10
|
| Rate for Payer: Quartz Medicare Advantage |
$7,580.40
|
| Rate for Payer: WEA Trust Commercial |
$6,948.70
|
| Rate for Payer: WPS Commercial |
$9,358.00
|
|
|
DIAMOND BUR 5MM
|
Facility
IP
|
$1,738.00
|
|
| Hospital Charge Code |
2964910
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$851.62 |
| Max. Negotiated Rate |
$1,598.96 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,042.80
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
DIAMOND BUR 5MM
|
Facility
OP
|
$1,738.00
|
|
| Hospital Charge Code |
2964910
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$486.64 |
| Max. Negotiated Rate |
$6,952.00 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,494.68
|
| Rate for Payer: Aetna Managed Medicare |
$486.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,129.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$869.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$834.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$972.58
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,303.50
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,129.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,042.80
|
| Rate for Payer: The Alliance Commercial |
$6,952.00
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
DIAMOND BUR 6MM
|
Facility
OP
|
$1,738.00
|
|
| Hospital Charge Code |
2974041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$486.64 |
| Max. Negotiated Rate |
$6,952.00 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,494.68
|
| Rate for Payer: Aetna Managed Medicare |
$486.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,129.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$869.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$834.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$972.58
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,303.50
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,129.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,042.80
|
| Rate for Payer: The Alliance Commercial |
$6,952.00
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
DIAMOND BUR 6MM
|
Facility
IP
|
$1,738.00
|
|
| Hospital Charge Code |
2974041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$851.62 |
| Max. Negotiated Rate |
$1,598.96 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,042.80
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
DIAMOND TOOL MIDAS REX 2MM BALL 75BA20D
|
Facility
OP
|
$2,024.00
|
|
| Hospital Charge Code |
3613497
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.72 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Aetna Managed Medicare |
$566.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,315.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,012.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.63
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,315.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,214.40
|
| Rate for Payer: The Alliance Commercial |
$8,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 2MM BALL 75BA20D
|
Facility
IP
|
$2,024.00
|
|
| Hospital Charge Code |
3613497
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$991.76 |
| Max. Negotiated Rate |
$1,862.08 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,214.40
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 2MM BALL 75BA20DL
|
Facility
IP
|
$2,024.00
|
|
| Hospital Charge Code |
3495516
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$991.76 |
| Max. Negotiated Rate |
$1,862.08 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,214.40
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 2MM BALL 75BA20DL
|
Facility
OP
|
$2,024.00
|
|
| Hospital Charge Code |
3495516
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.72 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Aetna Managed Medicare |
$566.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,315.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,012.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.63
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,315.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,214.40
|
| Rate for Payer: The Alliance Commercial |
$8,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 3MM BALL D 75BA30DL
|
Facility
OP
|
$2,024.00
|
|
| Hospital Charge Code |
4519596
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.72 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Aetna Managed Medicare |
$566.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,315.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,012.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.63
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,315.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,214.40
|
| Rate for Payer: The Alliance Commercial |
$8,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 3MM BALL D 75BA30DL
|
Facility
IP
|
$2,024.00
|
|
| Hospital Charge Code |
4519596
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$991.76 |
| Max. Negotiated Rate |
$1,862.08 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,214.40
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 4MM BALL 75BA40D
|
Facility
IP
|
$2,024.00
|
|
| Hospital Charge Code |
3495514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$991.76 |
| Max. Negotiated Rate |
$1,862.08 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,214.40
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 4MM BALL 75BA40D
|
Facility
OP
|
$2,024.00
|
|
| Hospital Charge Code |
3495514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.72 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Aetna Managed Medicare |
$566.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,315.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,012.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.63
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,315.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,214.40
|
| Rate for Payer: The Alliance Commercial |
$8,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 4MM BALL D 75BA40DL
|
Facility
IP
|
$2,024.00
|
|
| Hospital Charge Code |
3495515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$991.76 |
| Max. Negotiated Rate |
$1,862.08 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,214.40
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 4MM BALL D 75BA40DL
|
Facility
OP
|
$2,024.00
|
|
| Hospital Charge Code |
3495515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.72 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Aetna Managed Medicare |
$566.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,315.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,012.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.63
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,315.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,214.40
|
| Rate for Payer: The Alliance Commercial |
$8,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 5MM BALL 75BA50D
|
Facility
OP
|
$2,024.00
|
|
| Hospital Charge Code |
3495513
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.72 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Aetna Managed Medicare |
$566.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,315.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,012.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.63
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,315.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,214.40
|
| Rate for Payer: The Alliance Commercial |
$8,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 5MM BALL 75BA50D
|
Facility
IP
|
$2,024.00
|
|
| Hospital Charge Code |
3495513
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$991.76 |
| Max. Negotiated Rate |
$1,862.08 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,214.40
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIANEAL 1.5% 2L LOW CALCIUM #5B9766
|
Facility
IP
|
$184.00
|
|
| Hospital Charge Code |
2971653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
DIANEAL 1.5% 2L LOW CALCIUM #5B9766
|
Facility
OP
|
$184.00
|
|
| Hospital Charge Code |
2971653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.52 |
| Max. Negotiated Rate |
$736.00 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$51.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$119.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.97
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$119.60
|
| Rate for Payer: Quartz Medicare Advantage |
$110.40
|
| Rate for Payer: The Alliance Commercial |
$736.00
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
Dianeal 2L 1.5% Ultrabag, Low
|
Facility
IP
|
$184.00
|
|
|
Service Code
|
HCPCS A4722
|
| Hospital Charge Code |
3603556
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
Dianeal 2L 1.5% Ultrabag, Low
|
Facility
OP
|
$184.00
|
|
|
Service Code
|
HCPCS A4722
|
| Hospital Charge Code |
3603556
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.52 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$51.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$119.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.97
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$119.60
|
| Rate for Payer: Quartz Medicare Advantage |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
Dianeal 2L 2.5% Ultrabag, Low
|
Facility
IP
|
$184.00
|
|
|
Service Code
|
HCPCS A4722
|
| Hospital Charge Code |
3603555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
Dianeal 2L 2.5% Ultrabag, Low
|
Facility
OP
|
$184.00
|
|
|
Service Code
|
HCPCS A4722
|
| Hospital Charge Code |
3603555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.52 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$51.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$119.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.97
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$119.60
|
| Rate for Payer: Quartz Medicare Advantage |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
Dianeal 2L 4.25% Ultrabag, Low
|
Facility
OP
|
$184.00
|
|
|
Service Code
|
HCPCS A4722
|
| Hospital Charge Code |
3603557
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.52 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$51.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$119.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.97
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$119.60
|
| Rate for Payer: Quartz Medicare Advantage |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
