|
DISSECTOR ENDO PEANUT 5MM 173019
|
Facility
|
IP
|
$204.00
|
|
| Hospital Charge Code |
2963715
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$103.96 |
| Max. Negotiated Rate |
$195.19 |
| Rate for Payer: Aetna Commercial |
$190.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$182.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.44
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$195.19
|
| Rate for Payer: Health EOS Commercial |
$188.82
|
| Rate for Payer: HFN Commercial |
$195.19
|
| Rate for Payer: Multiplan Commercial |
$169.73
|
| Rate for Payer: Preferred Network Access Commercial |
$195.19
|
| Rate for Payer: Quartz Beloit One Network |
$103.96
|
| Rate for Payer: Quartz Commercial |
$127.30
|
| Rate for Payer: WEA Trust Commercial |
$116.69
|
| Rate for Payer: WPS Commercial |
$157.14
|
|
|
DISSECTOR ENDO PEANUT 5MM 173019
|
Facility
|
OP
|
$204.00
|
|
| Hospital Charge Code |
2963715
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.40 |
| Max. Negotiated Rate |
$195.19 |
| Rate for Payer: Aetna Commercial |
$190.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$182.46
|
| Rate for Payer: Aetna Managed Medicare |
$59.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$137.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$101.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.44
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$195.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$118.73
|
| Rate for Payer: Health EOS Commercial |
$188.82
|
| Rate for Payer: HFN Commercial |
$195.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$159.12
|
| Rate for Payer: Multiplan Commercial |
$169.73
|
| Rate for Payer: NAPHCARE Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$195.19
|
| Rate for Payer: Quartz Beloit One Network |
$103.96
|
| Rate for Payer: Quartz Commercial |
$137.90
|
| Rate for Payer: Quartz Medicare Advantage |
$127.30
|
| Rate for Payer: The Alliance Commercial |
$106.08
|
| Rate for Payer: WEA Trust Commercial |
$116.69
|
| Rate for Payer: WPS Commercial |
$157.14
|
|
|
DISSECTOR SEPS BALLOON
|
Facility
|
OP
|
$5,845.00
|
|
| Hospital Charge Code |
2967372
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,702.06 |
| Max. Negotiated Rate |
$5,592.50 |
| Rate for Payer: Aetna Commercial |
$5,470.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,227.77
|
| Rate for Payer: Aetna Managed Medicare |
$1,702.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,951.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,039.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,917.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,221.76
|
| Rate for Payer: Cash Price |
$1,753.50
|
| Rate for Payer: Cigna Commercial |
$5,592.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,401.79
|
| Rate for Payer: Health EOS Commercial |
$5,410.13
|
| Rate for Payer: HFN Commercial |
$5,592.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,559.10
|
| Rate for Payer: Multiplan Commercial |
$4,863.04
|
| Rate for Payer: NAPHCARE Commercial |
$3,647.28
|
| Rate for Payer: Preferred Network Access Commercial |
$5,592.50
|
| Rate for Payer: Quartz Beloit One Network |
$2,978.61
|
| Rate for Payer: Quartz Commercial |
$3,951.22
|
| Rate for Payer: Quartz Medicare Advantage |
$3,647.28
|
| Rate for Payer: The Alliance Commercial |
$3,039.40
|
| Rate for Payer: WEA Trust Commercial |
$3,343.34
|
| Rate for Payer: WPS Commercial |
$4,502.40
|
|
|
DISSECTOR SEPS BALLOON
|
Facility
|
IP
|
$5,845.00
|
|
| Hospital Charge Code |
2967372
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,978.61 |
| Max. Negotiated Rate |
$5,592.50 |
| Rate for Payer: Aetna Commercial |
$5,470.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,227.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,221.76
|
| Rate for Payer: Cash Price |
$1,753.50
|
| Rate for Payer: Cigna Commercial |
$5,592.50
|
| Rate for Payer: Health EOS Commercial |
$5,410.13
|
| Rate for Payer: HFN Commercial |
$5,592.50
|
| Rate for Payer: Multiplan Commercial |
$4,863.04
|
| Rate for Payer: Preferred Network Access Commercial |
$5,592.50
|
| Rate for Payer: Quartz Beloit One Network |
$2,978.61
|
| Rate for Payer: Quartz Commercial |
$3,647.28
|
| Rate for Payer: WEA Trust Commercial |
$3,343.34
|
| Rate for Payer: WPS Commercial |
$4,502.40
|
|
|
DISSECTOR SYSTEM SPACEMAKER PLUS OVAL BALLOON/TROCAR SMBTTOVLX
|
Facility
|
IP
|
$5,309.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4508954
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,705.47 |
| Max. Negotiated Rate |
$5,079.65 |
| Rate for Payer: Aetna Commercial |
$4,969.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,748.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,926.32
|
| Rate for Payer: Cash Price |
$1,592.70
|
| Rate for Payer: Cigna Commercial |
$5,079.65
|
| Rate for Payer: Health EOS Commercial |
$4,914.01
|
| Rate for Payer: HFN Commercial |
$5,079.65
|
| Rate for Payer: Multiplan Commercial |
$4,417.09
|
| Rate for Payer: Preferred Network Access Commercial |
$5,079.65
|
| Rate for Payer: Quartz Beloit One Network |
$2,705.47
|
| Rate for Payer: Quartz Commercial |
$3,312.82
|
| Rate for Payer: WEA Trust Commercial |
$3,036.75
|
| Rate for Payer: WPS Commercial |
$4,089.52
|
|
|
DISSECTOR SYSTEM SPACEMAKER PLUS OVAL BALLOON/TROCAR SMBTTOVLX
|
Facility
|
OP
|
$5,309.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4508954
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,545.98 |
| Max. Negotiated Rate |
$5,079.65 |
| Rate for Payer: Aetna Commercial |
$4,969.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,748.37
|
| Rate for Payer: Aetna Managed Medicare |
$1,545.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,588.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,760.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,650.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,926.32
|
| Rate for Payer: Cash Price |
$1,592.70
|
| Rate for Payer: Cigna Commercial |
$5,079.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,089.84
|
| Rate for Payer: Health EOS Commercial |
$4,914.01
|
| Rate for Payer: HFN Commercial |
$5,079.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,141.02
|
| Rate for Payer: Multiplan Commercial |
$4,417.09
|
| Rate for Payer: NAPHCARE Commercial |
$3,312.82
|
| Rate for Payer: Preferred Network Access Commercial |
$5,079.65
|
| Rate for Payer: Quartz Beloit One Network |
$2,705.47
|
| Rate for Payer: Quartz Commercial |
$3,588.88
|
| Rate for Payer: Quartz Medicare Advantage |
$3,312.82
|
| Rate for Payer: The Alliance Commercial |
$2,760.68
|
| Rate for Payer: WEA Trust Commercial |
$3,036.75
|
| Rate for Payer: WPS Commercial |
$4,089.52
|
|
|
DISTAL CEMENT SPACER OMNIFIT 10MM 1067-0010
|
Facility
|
OP
|
$860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3431505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$250.43 |
| Max. Negotiated Rate |
$822.85 |
| Rate for Payer: Aetna Commercial |
$804.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$769.18
|
| Rate for Payer: Aetna Managed Medicare |
$250.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$581.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$447.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$429.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.03
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$822.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$500.52
|
| Rate for Payer: Health EOS Commercial |
$796.02
|
| Rate for Payer: HFN Commercial |
$822.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$670.80
|
| Rate for Payer: Multiplan Commercial |
$715.52
|
| Rate for Payer: NAPHCARE Commercial |
$536.64
|
| Rate for Payer: Preferred Network Access Commercial |
$822.85
|
| Rate for Payer: Quartz Beloit One Network |
$438.26
|
| Rate for Payer: Quartz Commercial |
$581.36
|
| Rate for Payer: Quartz Medicare Advantage |
$536.64
|
| Rate for Payer: The Alliance Commercial |
$447.20
|
| Rate for Payer: WEA Trust Commercial |
$491.92
|
| Rate for Payer: WPS Commercial |
$662.46
|
|
|
DISTAL CEMENT SPACER OMNIFIT 10MM 1067-0010
|
Facility
|
IP
|
$860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3431505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$438.26 |
| Max. Negotiated Rate |
$822.85 |
| Rate for Payer: Aetna Commercial |
$804.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$769.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.03
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$822.85
|
| Rate for Payer: Health EOS Commercial |
$796.02
|
| Rate for Payer: HFN Commercial |
$822.85
|
| Rate for Payer: Multiplan Commercial |
$715.52
|
| Rate for Payer: Preferred Network Access Commercial |
$822.85
|
| Rate for Payer: Quartz Beloit One Network |
$438.26
|
| Rate for Payer: Quartz Commercial |
$536.64
|
| Rate for Payer: WEA Trust Commercial |
$491.92
|
| Rate for Payer: WPS Commercial |
$662.46
|
|
|
DISTAL CEMENT SPACER OMNIFIT 11MM 1067-0011
|
Facility
|
IP
|
$860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$438.26 |
| Max. Negotiated Rate |
$822.85 |
| Rate for Payer: Aetna Commercial |
$804.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$769.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.03
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$822.85
|
| Rate for Payer: Health EOS Commercial |
$796.02
|
| Rate for Payer: HFN Commercial |
$822.85
|
| Rate for Payer: Multiplan Commercial |
$715.52
|
| Rate for Payer: Preferred Network Access Commercial |
$822.85
|
| Rate for Payer: Quartz Beloit One Network |
$438.26
|
| Rate for Payer: Quartz Commercial |
$536.64
|
| Rate for Payer: WEA Trust Commercial |
$491.92
|
| Rate for Payer: WPS Commercial |
$662.46
|
|
|
DISTAL CEMENT SPACER OMNIFIT 11MM 1067-0011
|
Facility
|
OP
|
$860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$250.43 |
| Max. Negotiated Rate |
$822.85 |
| Rate for Payer: Aetna Commercial |
$804.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$769.18
|
| Rate for Payer: Aetna Managed Medicare |
$250.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$581.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$447.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$429.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.03
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$822.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$500.52
|
| Rate for Payer: Health EOS Commercial |
$796.02
|
| Rate for Payer: HFN Commercial |
$822.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$670.80
|
| Rate for Payer: Multiplan Commercial |
$715.52
|
| Rate for Payer: NAPHCARE Commercial |
$536.64
|
| Rate for Payer: Preferred Network Access Commercial |
$822.85
|
| Rate for Payer: Quartz Beloit One Network |
$438.26
|
| Rate for Payer: Quartz Commercial |
$581.36
|
| Rate for Payer: Quartz Medicare Advantage |
$536.64
|
| Rate for Payer: The Alliance Commercial |
$447.20
|
| Rate for Payer: WEA Trust Commercial |
$491.92
|
| Rate for Payer: WPS Commercial |
$662.46
|
|
|
DISTAL CENTRALIZER VERSYS SZ 10 7859-10
|
Facility
|
OP
|
$582.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967876
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$169.48 |
| Max. Negotiated Rate |
$556.86 |
| Rate for Payer: Aetna Commercial |
$544.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$520.54
|
| Rate for Payer: Aetna Managed Medicare |
$169.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$393.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$302.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$290.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$320.80
|
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$556.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$338.72
|
| Rate for Payer: Health EOS Commercial |
$538.70
|
| Rate for Payer: HFN Commercial |
$556.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$453.96
|
| Rate for Payer: Multiplan Commercial |
$484.22
|
| Rate for Payer: NAPHCARE Commercial |
$363.17
|
| Rate for Payer: Preferred Network Access Commercial |
$556.86
|
| Rate for Payer: Quartz Beloit One Network |
$296.59
|
| Rate for Payer: Quartz Commercial |
$393.43
|
| Rate for Payer: Quartz Medicare Advantage |
$363.17
|
| Rate for Payer: The Alliance Commercial |
$302.64
|
| Rate for Payer: WEA Trust Commercial |
$332.90
|
| Rate for Payer: WPS Commercial |
$448.31
|
|
|
DISTAL CENTRALIZER VERSYS SZ 10 7859-10
|
Facility
|
IP
|
$582.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967876
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$296.59 |
| Max. Negotiated Rate |
$556.86 |
| Rate for Payer: Aetna Commercial |
$544.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$520.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$320.80
|
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$556.86
|
| Rate for Payer: Health EOS Commercial |
$538.70
|
| Rate for Payer: HFN Commercial |
$556.86
|
| Rate for Payer: Multiplan Commercial |
$484.22
|
| Rate for Payer: Preferred Network Access Commercial |
$556.86
|
| Rate for Payer: Quartz Beloit One Network |
$296.59
|
| Rate for Payer: Quartz Commercial |
$363.17
|
| Rate for Payer: WEA Trust Commercial |
$332.90
|
| Rate for Payer: WPS Commercial |
$448.31
|
|
|
DISTAL CENTRALIZER VERSYS SZ 11 7859-11
|
Facility
|
IP
|
$582.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967877
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$296.59 |
| Max. Negotiated Rate |
$556.86 |
| Rate for Payer: Aetna Commercial |
$544.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$520.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$320.80
|
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$556.86
|
| Rate for Payer: Health EOS Commercial |
$538.70
|
| Rate for Payer: HFN Commercial |
$556.86
|
| Rate for Payer: Multiplan Commercial |
$484.22
|
| Rate for Payer: Preferred Network Access Commercial |
$556.86
|
| Rate for Payer: Quartz Beloit One Network |
$296.59
|
| Rate for Payer: Quartz Commercial |
$363.17
|
| Rate for Payer: WEA Trust Commercial |
$332.90
|
| Rate for Payer: WPS Commercial |
$448.31
|
|
|
DISTAL CENTRALIZER VERSYS SZ 11 7859-11
|
Facility
|
OP
|
$582.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967877
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$169.48 |
| Max. Negotiated Rate |
$556.86 |
| Rate for Payer: Aetna Commercial |
$544.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$520.54
|
| Rate for Payer: Aetna Managed Medicare |
$169.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$393.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$302.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$290.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$320.80
|
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$556.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$338.72
|
| Rate for Payer: Health EOS Commercial |
$538.70
|
| Rate for Payer: HFN Commercial |
$556.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$453.96
|
| Rate for Payer: Multiplan Commercial |
$484.22
|
| Rate for Payer: NAPHCARE Commercial |
$363.17
|
| Rate for Payer: Preferred Network Access Commercial |
$556.86
|
| Rate for Payer: Quartz Beloit One Network |
$296.59
|
| Rate for Payer: Quartz Commercial |
$393.43
|
| Rate for Payer: Quartz Medicare Advantage |
$363.17
|
| Rate for Payer: The Alliance Commercial |
$302.64
|
| Rate for Payer: WEA Trust Commercial |
$332.90
|
| Rate for Payer: WPS Commercial |
$448.31
|
|
|
DISTAL CENTRALIZER VERSYS SZ 12 7859-12
|
Facility
|
IP
|
$582.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967878
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$296.59 |
| Max. Negotiated Rate |
$556.86 |
| Rate for Payer: Aetna Commercial |
$544.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$520.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$320.80
|
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$556.86
|
| Rate for Payer: Health EOS Commercial |
$538.70
|
| Rate for Payer: HFN Commercial |
$556.86
|
| Rate for Payer: Multiplan Commercial |
$484.22
|
| Rate for Payer: Preferred Network Access Commercial |
$556.86
|
| Rate for Payer: Quartz Beloit One Network |
$296.59
|
| Rate for Payer: Quartz Commercial |
$363.17
|
| Rate for Payer: WEA Trust Commercial |
$332.90
|
| Rate for Payer: WPS Commercial |
$448.31
|
|
|
DISTAL CENTRALIZER VERSYS SZ 12 7859-12
|
Facility
|
OP
|
$582.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967878
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$169.48 |
| Max. Negotiated Rate |
$556.86 |
| Rate for Payer: Aetna Commercial |
$544.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$520.54
|
| Rate for Payer: Aetna Managed Medicare |
$169.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$393.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$302.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$290.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$320.80
|
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$556.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$338.72
|
| Rate for Payer: Health EOS Commercial |
$538.70
|
| Rate for Payer: HFN Commercial |
$556.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$453.96
|
| Rate for Payer: Multiplan Commercial |
$484.22
|
| Rate for Payer: NAPHCARE Commercial |
$363.17
|
| Rate for Payer: Preferred Network Access Commercial |
$556.86
|
| Rate for Payer: Quartz Beloit One Network |
$296.59
|
| Rate for Payer: Quartz Commercial |
$393.43
|
| Rate for Payer: Quartz Medicare Advantage |
$363.17
|
| Rate for Payer: The Alliance Commercial |
$302.64
|
| Rate for Payer: WEA Trust Commercial |
$332.90
|
| Rate for Payer: WPS Commercial |
$448.31
|
|
|
DISTAL CENTRALIZER VERSYS SZ 13 7859-13
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$163.36 |
| Max. Negotiated Rate |
$536.76 |
| Rate for Payer: Aetna Commercial |
$525.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$501.76
|
| Rate for Payer: Aetna Managed Medicare |
$163.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$379.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$291.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.22
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cigna Commercial |
$536.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$326.50
|
| Rate for Payer: Health EOS Commercial |
$519.26
|
| Rate for Payer: HFN Commercial |
$536.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$437.58
|
| Rate for Payer: Multiplan Commercial |
$466.75
|
| Rate for Payer: NAPHCARE Commercial |
$350.06
|
| Rate for Payer: Preferred Network Access Commercial |
$536.76
|
| Rate for Payer: Quartz Beloit One Network |
$285.89
|
| Rate for Payer: Quartz Commercial |
$379.24
|
| Rate for Payer: Quartz Medicare Advantage |
$350.06
|
| Rate for Payer: The Alliance Commercial |
$291.72
|
| Rate for Payer: WEA Trust Commercial |
$320.89
|
| Rate for Payer: WPS Commercial |
$432.14
|
|
|
DISTAL CENTRALIZER VERSYS SZ 13 7859-13
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$285.89 |
| Max. Negotiated Rate |
$536.76 |
| Rate for Payer: Aetna Commercial |
$525.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$501.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.22
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cigna Commercial |
$536.76
|
| Rate for Payer: Health EOS Commercial |
$519.26
|
| Rate for Payer: HFN Commercial |
$536.76
|
| Rate for Payer: Multiplan Commercial |
$466.75
|
| Rate for Payer: Preferred Network Access Commercial |
$536.76
|
| Rate for Payer: Quartz Beloit One Network |
$285.89
|
| Rate for Payer: Quartz Commercial |
$350.06
|
| Rate for Payer: WEA Trust Commercial |
$320.89
|
| Rate for Payer: WPS Commercial |
$432.14
|
|
|
DISTAL CENTRALIZER VERSYS SZ 14 7859-14
|
Facility
|
IP
|
$583.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967880
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$297.10 |
| Max. Negotiated Rate |
$557.81 |
| Rate for Payer: Aetna Commercial |
$545.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$521.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$321.35
|
| Rate for Payer: Cash Price |
$174.90
|
| Rate for Payer: Cigna Commercial |
$557.81
|
| Rate for Payer: Health EOS Commercial |
$539.62
|
| Rate for Payer: HFN Commercial |
$557.81
|
| Rate for Payer: Multiplan Commercial |
$485.06
|
| Rate for Payer: Preferred Network Access Commercial |
$557.81
|
| Rate for Payer: Quartz Beloit One Network |
$297.10
|
| Rate for Payer: Quartz Commercial |
$363.79
|
| Rate for Payer: WEA Trust Commercial |
$333.48
|
| Rate for Payer: WPS Commercial |
$449.08
|
|
|
DISTAL CENTRALIZER VERSYS SZ 14 7859-14
|
Facility
|
OP
|
$583.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967880
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$169.77 |
| Max. Negotiated Rate |
$557.81 |
| Rate for Payer: Aetna Commercial |
$545.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$521.44
|
| Rate for Payer: Aetna Managed Medicare |
$169.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$394.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$303.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$291.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$321.35
|
| Rate for Payer: Cash Price |
$174.90
|
| Rate for Payer: Cigna Commercial |
$557.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$339.31
|
| Rate for Payer: Health EOS Commercial |
$539.62
|
| Rate for Payer: HFN Commercial |
$557.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$454.74
|
| Rate for Payer: Multiplan Commercial |
$485.06
|
| Rate for Payer: NAPHCARE Commercial |
$363.79
|
| Rate for Payer: Preferred Network Access Commercial |
$557.81
|
| Rate for Payer: Quartz Beloit One Network |
$297.10
|
| Rate for Payer: Quartz Commercial |
$394.11
|
| Rate for Payer: Quartz Medicare Advantage |
$363.79
|
| Rate for Payer: The Alliance Commercial |
$303.16
|
| Rate for Payer: WEA Trust Commercial |
$333.48
|
| Rate for Payer: WPS Commercial |
$449.08
|
|
|
DISTAL CENTRALIZER VERSYS SZ 15 7859-15
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967881
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$285.89 |
| Max. Negotiated Rate |
$536.76 |
| Rate for Payer: Aetna Commercial |
$525.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$501.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.22
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cigna Commercial |
$536.76
|
| Rate for Payer: Health EOS Commercial |
$519.26
|
| Rate for Payer: HFN Commercial |
$536.76
|
| Rate for Payer: Multiplan Commercial |
$466.75
|
| Rate for Payer: Preferred Network Access Commercial |
$536.76
|
| Rate for Payer: Quartz Beloit One Network |
$285.89
|
| Rate for Payer: Quartz Commercial |
$350.06
|
| Rate for Payer: WEA Trust Commercial |
$320.89
|
| Rate for Payer: WPS Commercial |
$432.14
|
|
|
DISTAL CENTRALIZER VERSYS SZ 15 7859-15
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967881
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$163.36 |
| Max. Negotiated Rate |
$536.76 |
| Rate for Payer: Aetna Commercial |
$525.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$501.76
|
| Rate for Payer: Aetna Managed Medicare |
$163.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$379.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$291.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.22
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cigna Commercial |
$536.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$326.50
|
| Rate for Payer: Health EOS Commercial |
$519.26
|
| Rate for Payer: HFN Commercial |
$536.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$437.58
|
| Rate for Payer: Multiplan Commercial |
$466.75
|
| Rate for Payer: NAPHCARE Commercial |
$350.06
|
| Rate for Payer: Preferred Network Access Commercial |
$536.76
|
| Rate for Payer: Quartz Beloit One Network |
$285.89
|
| Rate for Payer: Quartz Commercial |
$379.24
|
| Rate for Payer: Quartz Medicare Advantage |
$350.06
|
| Rate for Payer: The Alliance Commercial |
$291.72
|
| Rate for Payer: WEA Trust Commercial |
$320.89
|
| Rate for Payer: WPS Commercial |
$432.14
|
|
|
DISTAL CENTRALIZER VERSYS SZ 16 7859-16
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967882
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$163.36 |
| Max. Negotiated Rate |
$536.76 |
| Rate for Payer: Aetna Commercial |
$525.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$501.76
|
| Rate for Payer: Aetna Managed Medicare |
$163.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$379.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$291.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.22
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cigna Commercial |
$536.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$326.50
|
| Rate for Payer: Health EOS Commercial |
$519.26
|
| Rate for Payer: HFN Commercial |
$536.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$437.58
|
| Rate for Payer: Multiplan Commercial |
$466.75
|
| Rate for Payer: NAPHCARE Commercial |
$350.06
|
| Rate for Payer: Preferred Network Access Commercial |
$536.76
|
| Rate for Payer: Quartz Beloit One Network |
$285.89
|
| Rate for Payer: Quartz Commercial |
$379.24
|
| Rate for Payer: Quartz Medicare Advantage |
$350.06
|
| Rate for Payer: The Alliance Commercial |
$291.72
|
| Rate for Payer: WEA Trust Commercial |
$320.89
|
| Rate for Payer: WPS Commercial |
$432.14
|
|
|
DISTAL CENTRALIZER VERSYS SZ 16 7859-16
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967882
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$285.89 |
| Max. Negotiated Rate |
$536.76 |
| Rate for Payer: Aetna Commercial |
$525.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$501.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.22
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cigna Commercial |
$536.76
|
| Rate for Payer: Health EOS Commercial |
$519.26
|
| Rate for Payer: HFN Commercial |
$536.76
|
| Rate for Payer: Multiplan Commercial |
$466.75
|
| Rate for Payer: Preferred Network Access Commercial |
$536.76
|
| Rate for Payer: Quartz Beloit One Network |
$285.89
|
| Rate for Payer: Quartz Commercial |
$350.06
|
| Rate for Payer: WEA Trust Commercial |
$320.89
|
| Rate for Payer: WPS Commercial |
$432.14
|
|
|
DISTAL CENTRALIZER VERSYS SZ 17 7859-17
|
Facility
|
OP
|
$562.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967883
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$163.65 |
| Max. Negotiated Rate |
$537.72 |
| Rate for Payer: Aetna Commercial |
$526.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.65
|
| Rate for Payer: Aetna Managed Medicare |
$163.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$379.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$292.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.77
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$537.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$327.08
|
| Rate for Payer: Health EOS Commercial |
$520.19
|
| Rate for Payer: HFN Commercial |
$537.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$438.36
|
| Rate for Payer: Multiplan Commercial |
$467.58
|
| Rate for Payer: NAPHCARE Commercial |
$350.69
|
| Rate for Payer: Preferred Network Access Commercial |
$537.72
|
| Rate for Payer: Quartz Beloit One Network |
$286.40
|
| Rate for Payer: Quartz Commercial |
$379.91
|
| Rate for Payer: Quartz Medicare Advantage |
$350.69
|
| Rate for Payer: The Alliance Commercial |
$292.24
|
| Rate for Payer: WEA Trust Commercial |
$321.46
|
| Rate for Payer: WPS Commercial |
$432.91
|
|
