|
DEVICE EMBOLIC PROTECTION SPD2-US-050-320
|
Facility
|
OP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973739
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,999.08 |
| Max. Negotiated Rate |
$42,844.00 |
| Rate for Payer: Aetna Commercial |
$9,639.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,211.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,999.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,962.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,355.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,141.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,676.83
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$9,854.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,993.88
|
| Rate for Payer: Health EOS Commercial |
$9,532.79
|
| Rate for Payer: HFN Commercial |
$9,854.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,033.25
|
| Rate for Payer: Multiplan Commercial |
$8,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,426.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,854.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,248.39
|
| Rate for Payer: Quartz Commercial |
$6,962.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6,426.60
|
| Rate for Payer: The Alliance Commercial |
$42,844.00
|
| Rate for Payer: WEA Trust Commercial |
$5,891.05
|
| Rate for Payer: WPS Commercial |
$7,933.64
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-060-320
|
Facility
|
IP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,248.39 |
| Max. Negotiated Rate |
$9,854.12 |
| Rate for Payer: Aetna Commercial |
$9,639.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,211.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,676.83
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$9,854.12
|
| Rate for Payer: Health EOS Commercial |
$9,532.79
|
| Rate for Payer: HFN Commercial |
$9,854.12
|
| Rate for Payer: Multiplan Commercial |
$8,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,426.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,854.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,248.39
|
| Rate for Payer: Quartz Commercial |
$6,426.60
|
| Rate for Payer: WEA Trust Commercial |
$5,891.05
|
| Rate for Payer: WPS Commercial |
$7,933.64
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-060-320
|
Facility
|
OP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,999.08 |
| Max. Negotiated Rate |
$42,844.00 |
| Rate for Payer: Aetna Commercial |
$9,639.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,211.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,999.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,962.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,355.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,141.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,676.83
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$9,854.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,993.88
|
| Rate for Payer: Health EOS Commercial |
$9,532.79
|
| Rate for Payer: HFN Commercial |
$9,854.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,033.25
|
| Rate for Payer: Multiplan Commercial |
$8,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,426.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,854.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,248.39
|
| Rate for Payer: Quartz Commercial |
$6,962.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6,426.60
|
| Rate for Payer: The Alliance Commercial |
$42,844.00
|
| Rate for Payer: WEA Trust Commercial |
$5,891.05
|
| Rate for Payer: WPS Commercial |
$7,933.64
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-070-320
|
Facility
|
OP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
3107491
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,999.08 |
| Max. Negotiated Rate |
$42,844.00 |
| Rate for Payer: Aetna Commercial |
$9,639.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,211.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,999.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,962.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,355.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,141.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,676.83
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$9,854.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,993.88
|
| Rate for Payer: Health EOS Commercial |
$9,532.79
|
| Rate for Payer: HFN Commercial |
$9,854.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,033.25
|
| Rate for Payer: Multiplan Commercial |
$8,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,426.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,854.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,248.39
|
| Rate for Payer: Quartz Commercial |
$6,962.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6,426.60
|
| Rate for Payer: The Alliance Commercial |
$42,844.00
|
| Rate for Payer: WEA Trust Commercial |
$5,891.05
|
| Rate for Payer: WPS Commercial |
$7,933.64
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-070-320
|
Facility
|
IP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
3107491
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,248.39 |
| Max. Negotiated Rate |
$9,854.12 |
| Rate for Payer: Aetna Commercial |
$9,639.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,211.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,676.83
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$9,854.12
|
| Rate for Payer: Health EOS Commercial |
$9,532.79
|
| Rate for Payer: HFN Commercial |
$9,854.12
|
| Rate for Payer: Multiplan Commercial |
$8,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,426.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,854.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,248.39
|
| Rate for Payer: Quartz Commercial |
$6,426.60
|
| Rate for Payer: WEA Trust Commercial |
$5,891.05
|
| Rate for Payer: WPS Commercial |
$7,933.64
|
|
|
DEVICE HEMIGARD ADHESIVE RETENTION SUTURE ARS HRD001
|
Facility
|
OP
|
$805.00
|
|
| Hospital Charge Code |
6153699
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$225.40 |
| Max. Negotiated Rate |
$3,220.00 |
| Rate for Payer: Aetna Commercial |
$724.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$692.30
|
| Rate for Payer: Aetna Managed Medicare |
$225.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$523.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$402.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$386.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$426.65
|
| Rate for Payer: Cash Price |
$241.50
|
| Rate for Payer: Cigna Commercial |
$740.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$450.48
|
| Rate for Payer: Health EOS Commercial |
$716.45
|
| Rate for Payer: HFN Commercial |
$740.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$603.75
|
| Rate for Payer: Multiplan Commercial |
$644.00
|
| Rate for Payer: NAPHCARE Commercial |
$483.00
|
| Rate for Payer: Preferred Network Access Commercial |
$740.60
|
| Rate for Payer: Quartz Beloit One Network |
$394.45
|
| Rate for Payer: Quartz Commercial |
$523.25
|
| Rate for Payer: Quartz Medicare Advantage |
$483.00
|
| Rate for Payer: The Alliance Commercial |
$3,220.00
|
| Rate for Payer: WEA Trust Commercial |
$442.75
|
| Rate for Payer: WPS Commercial |
$596.26
|
|
|
DEVICE HEMIGARD ADHESIVE RETENTION SUTURE ARS HRD001
|
Facility
|
IP
|
$805.00
|
|
| Hospital Charge Code |
6153699
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$394.45 |
| Max. Negotiated Rate |
$740.60 |
| Rate for Payer: Aetna Commercial |
$724.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$692.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$426.65
|
| Rate for Payer: Cash Price |
$241.50
|
| Rate for Payer: Cigna Commercial |
$740.60
|
| Rate for Payer: Health EOS Commercial |
$716.45
|
| Rate for Payer: HFN Commercial |
$740.60
|
| Rate for Payer: Multiplan Commercial |
$644.00
|
| Rate for Payer: NAPHCARE Commercial |
$483.00
|
| Rate for Payer: Preferred Network Access Commercial |
$740.60
|
| Rate for Payer: Quartz Beloit One Network |
$394.45
|
| Rate for Payer: Quartz Commercial |
$483.00
|
| Rate for Payer: WEA Trust Commercial |
$442.75
|
| Rate for Payer: WPS Commercial |
$596.26
|
|
|
Devices
|
Facility
|
IP
|
$19,632.00
|
|
| Hospital Charge Code |
5102624
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$9,619.68 |
| Max. Negotiated Rate |
$18,061.44 |
| Rate for Payer: Aetna Commercial |
$17,668.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,883.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,404.96
|
| Rate for Payer: Cash Price |
$5,889.60
|
| Rate for Payer: Cigna Commercial |
$18,061.44
|
| Rate for Payer: Health EOS Commercial |
$17,472.48
|
| Rate for Payer: HFN Commercial |
$18,061.44
|
| Rate for Payer: Multiplan Commercial |
$15,705.60
|
| Rate for Payer: NAPHCARE Commercial |
$11,779.20
|
| Rate for Payer: Preferred Network Access Commercial |
$18,061.44
|
| Rate for Payer: Quartz Beloit One Network |
$9,619.68
|
| Rate for Payer: Quartz Commercial |
$11,779.20
|
| Rate for Payer: WEA Trust Commercial |
$10,797.60
|
| Rate for Payer: WPS Commercial |
$14,541.42
|
|
|
Devices
|
Facility
|
OP
|
$19,632.00
|
|
| Hospital Charge Code |
5102624
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$5,496.96 |
| Max. Negotiated Rate |
$78,528.00 |
| Rate for Payer: Aetna Commercial |
$17,668.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,883.52
|
| Rate for Payer: Aetna Managed Medicare |
$5,496.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,760.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,816.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,423.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,404.96
|
| Rate for Payer: Cash Price |
$5,889.60
|
| Rate for Payer: Cigna Commercial |
$18,061.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,986.07
|
| Rate for Payer: Health EOS Commercial |
$17,472.48
|
| Rate for Payer: HFN Commercial |
$18,061.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,724.00
|
| Rate for Payer: Multiplan Commercial |
$15,705.60
|
| Rate for Payer: NAPHCARE Commercial |
$11,779.20
|
| Rate for Payer: Preferred Network Access Commercial |
$18,061.44
|
| Rate for Payer: Quartz Beloit One Network |
$9,619.68
|
| Rate for Payer: Quartz Commercial |
$12,760.80
|
| Rate for Payer: Quartz Medicare Advantage |
$11,779.20
|
| Rate for Payer: The Alliance Commercial |
$78,528.00
|
| Rate for Payer: WEA Trust Commercial |
$10,797.60
|
| Rate for Payer: WPS Commercial |
$14,541.42
|
|
|
DEVICE ULTRA MINI TRUCLEAR 72204064
|
Facility
|
IP
|
$6,680.00
|
|
| Hospital Charge Code |
5179377
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,273.20 |
| Max. Negotiated Rate |
$6,145.60 |
| Rate for Payer: Aetna Commercial |
$6,012.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,744.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,540.40
|
| Rate for Payer: Cash Price |
$2,004.00
|
| Rate for Payer: Cigna Commercial |
$6,145.60
|
| Rate for Payer: Health EOS Commercial |
$5,945.20
|
| Rate for Payer: HFN Commercial |
$6,145.60
|
| Rate for Payer: Multiplan Commercial |
$5,344.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,008.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,145.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,273.20
|
| Rate for Payer: Quartz Commercial |
$4,008.00
|
| Rate for Payer: WEA Trust Commercial |
$3,674.00
|
| Rate for Payer: WPS Commercial |
$4,947.88
|
|
|
DEVICE ULTRA MINI TRUCLEAR 72204064
|
Facility
|
OP
|
$6,680.00
|
|
| Hospital Charge Code |
5179377
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,870.40 |
| Max. Negotiated Rate |
$26,720.00 |
| Rate for Payer: Aetna Commercial |
$6,012.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,744.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,870.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,342.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,340.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,206.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,540.40
|
| Rate for Payer: Cash Price |
$2,004.00
|
| Rate for Payer: Cigna Commercial |
$6,145.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,738.13
|
| Rate for Payer: Health EOS Commercial |
$5,945.20
|
| Rate for Payer: HFN Commercial |
$6,145.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,010.00
|
| Rate for Payer: Multiplan Commercial |
$5,344.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,008.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,145.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,273.20
|
| Rate for Payer: Quartz Commercial |
$4,342.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,008.00
|
| Rate for Payer: The Alliance Commercial |
$26,720.00
|
| Rate for Payer: WEA Trust Commercial |
$3,674.00
|
| Rate for Payer: WPS Commercial |
$4,947.88
|
|
|
DEVICE ULTRA PLUS TRUCLEAR 72203012
|
Facility
|
OP
|
$8,212.00
|
|
| Hospital Charge Code |
5106993
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,299.36 |
| Max. Negotiated Rate |
$32,848.00 |
| Rate for Payer: Aetna Commercial |
$7,390.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,062.32
|
| Rate for Payer: Aetna Managed Medicare |
$2,299.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,337.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,106.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,941.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,352.36
|
| Rate for Payer: Cash Price |
$2,463.60
|
| Rate for Payer: Cigna Commercial |
$7,555.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,595.44
|
| Rate for Payer: Health EOS Commercial |
$7,308.68
|
| Rate for Payer: HFN Commercial |
$7,555.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,159.00
|
| Rate for Payer: Multiplan Commercial |
$6,569.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,927.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,555.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,023.88
|
| Rate for Payer: Quartz Commercial |
$5,337.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,927.20
|
| Rate for Payer: The Alliance Commercial |
$32,848.00
|
| Rate for Payer: WEA Trust Commercial |
$4,516.60
|
| Rate for Payer: WPS Commercial |
$6,082.63
|
|
|
DEVICE ULTRA PLUS TRUCLEAR 72203012
|
Facility
|
IP
|
$8,212.00
|
|
| Hospital Charge Code |
5106993
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,023.88 |
| Max. Negotiated Rate |
$7,555.04 |
| Rate for Payer: Aetna Commercial |
$7,390.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,062.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,352.36
|
| Rate for Payer: Cash Price |
$2,463.60
|
| Rate for Payer: Cigna Commercial |
$7,555.04
|
| Rate for Payer: Health EOS Commercial |
$7,308.68
|
| Rate for Payer: HFN Commercial |
$7,555.04
|
| Rate for Payer: Multiplan Commercial |
$6,569.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,927.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,555.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,023.88
|
| Rate for Payer: Quartz Commercial |
$4,927.20
|
| Rate for Payer: WEA Trust Commercial |
$4,516.60
|
| Rate for Payer: WPS Commercial |
$6,082.63
|
|
|
DEVICE VOYANT 5MM FUSION (BLUNT) 37CM EB210
|
Facility
|
IP
|
$3,197.00
|
|
| Hospital Charge Code |
6153654
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,566.53 |
| Max. Negotiated Rate |
$2,941.24 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$1,918.20
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
DEVICE VOYANT 5MM FUSION (BLUNT) 37CM EB210
|
Facility
|
OP
|
$3,197.00
|
|
| Hospital Charge Code |
6153654
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$895.16 |
| Max. Negotiated Rate |
$12,788.00 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Aetna Managed Medicare |
$895.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,078.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,598.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,534.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,789.04
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,397.75
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$2,078.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,918.20
|
| Rate for Payer: The Alliance Commercial |
$12,788.00
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
DEVICE VOYANT 5MM MARYLAND FUSION EB215
|
Facility
|
IP
|
$3,197.00
|
|
| Hospital Charge Code |
6153653
|
|
Hospital Revenue Code
|
372
|
| Min. Negotiated Rate |
$1,566.53 |
| Max. Negotiated Rate |
$2,941.24 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$1,918.20
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
DEVICE VOYANT 5MM MARYLAND FUSION EB215
|
Facility
|
OP
|
$3,197.00
|
|
| Hospital Charge Code |
6153653
|
|
Hospital Revenue Code
|
372
|
| Min. Negotiated Rate |
$895.16 |
| Max. Negotiated Rate |
$12,788.00 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Aetna Managed Medicare |
$895.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,078.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,598.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,534.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,789.04
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,397.75
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$2,078.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,918.20
|
| Rate for Payer: The Alliance Commercial |
$12,788.00
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
DEVICE VOYANT 5MM MARYLAND SINGLE-STEP EB212
|
Facility
|
IP
|
$3,074.00
|
|
| Hospital Charge Code |
6178283
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,506.26 |
| Max. Negotiated Rate |
$2,828.08 |
| Rate for Payer: Aetna Commercial |
$2,766.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,643.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,629.22
|
| Rate for Payer: Cash Price |
$922.20
|
| Rate for Payer: Cigna Commercial |
$2,828.08
|
| Rate for Payer: Health EOS Commercial |
$2,735.86
|
| Rate for Payer: HFN Commercial |
$2,828.08
|
| Rate for Payer: Multiplan Commercial |
$2,459.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,844.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,828.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,506.26
|
| Rate for Payer: Quartz Commercial |
$1,844.40
|
| Rate for Payer: WEA Trust Commercial |
$1,690.70
|
| Rate for Payer: WPS Commercial |
$2,276.91
|
|
|
DEVICE VOYANT 5MM MARYLAND SINGLE-STEP EB212
|
Facility
|
OP
|
$3,074.00
|
|
| Hospital Charge Code |
6178283
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$860.72 |
| Max. Negotiated Rate |
$12,296.00 |
| Rate for Payer: Aetna Commercial |
$2,766.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,643.64
|
| Rate for Payer: Aetna Managed Medicare |
$860.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,998.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,537.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,475.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,629.22
|
| Rate for Payer: Cash Price |
$922.20
|
| Rate for Payer: Cigna Commercial |
$2,828.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,720.21
|
| Rate for Payer: Health EOS Commercial |
$2,735.86
|
| Rate for Payer: HFN Commercial |
$2,828.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,305.50
|
| Rate for Payer: Multiplan Commercial |
$2,459.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,844.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,828.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,506.26
|
| Rate for Payer: Quartz Commercial |
$1,998.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,844.40
|
| Rate for Payer: The Alliance Commercial |
$12,296.00
|
| Rate for Payer: WEA Trust Commercial |
$1,690.70
|
| Rate for Payer: WPS Commercial |
$2,276.91
|
|
|
DEVICE VOYANT FINE FUSION EB230
|
Facility
|
OP
|
$3,197.00
|
|
| Hospital Charge Code |
6153655
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$895.16 |
| Max. Negotiated Rate |
$12,788.00 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Aetna Managed Medicare |
$895.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,078.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,598.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,534.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,789.04
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,397.75
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$2,078.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,918.20
|
| Rate for Payer: The Alliance Commercial |
$12,788.00
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
DEVICE VOYANT FINE FUSION EB230
|
Facility
|
IP
|
$3,197.00
|
|
| Hospital Charge Code |
6153655
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,566.53 |
| Max. Negotiated Rate |
$2,941.24 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$1,918.20
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
DEVICE VOYANT OPEN FUSION EB240
|
Facility
|
OP
|
$3,197.00
|
|
| Hospital Charge Code |
6153656
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$895.16 |
| Max. Negotiated Rate |
$12,788.00 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Aetna Managed Medicare |
$895.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,078.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,598.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,534.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,789.04
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,397.75
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$2,078.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,918.20
|
| Rate for Payer: The Alliance Commercial |
$12,788.00
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
DEVICE VOYANT OPEN FUSION EB240
|
Facility
|
IP
|
$3,197.00
|
|
| Hospital Charge Code |
6153656
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,566.53 |
| Max. Negotiated Rate |
$2,941.24 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$1,918.20
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
Dexamethasone 10mg/1ml (1ml VIA) [MED]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
3031080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
Dexamethasone 10mg/1ml (1ml VIA) [MED]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
3031080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.15
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.60
|
| Rate for Payer: The Alliance Commercial |
$104.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$0.29
|
|
