|
DILATOR 19mm 57fr 70cm
|
Facility
|
OP
|
$3,171.00
|
|
| Hospital Charge Code |
2973327
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$923.40 |
| Max. Negotiated Rate |
$3,034.01 |
| Rate for Payer: Aetna Commercial |
$2,968.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,836.14
|
| Rate for Payer: Aetna Managed Medicare |
$923.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,143.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,648.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,582.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,747.86
|
| Rate for Payer: Cash Price |
$951.30
|
| Rate for Payer: Cigna Commercial |
$3,034.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,845.52
|
| Rate for Payer: Health EOS Commercial |
$2,935.08
|
| Rate for Payer: HFN Commercial |
$3,034.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,473.38
|
| Rate for Payer: Multiplan Commercial |
$2,638.27
|
| Rate for Payer: NAPHCARE Commercial |
$1,978.70
|
| Rate for Payer: Preferred Network Access Commercial |
$3,034.01
|
| Rate for Payer: Quartz Beloit One Network |
$1,615.94
|
| Rate for Payer: Quartz Commercial |
$2,143.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,978.70
|
| Rate for Payer: The Alliance Commercial |
$1,648.92
|
| Rate for Payer: WEA Trust Commercial |
$1,813.81
|
| Rate for Payer: WPS Commercial |
$2,442.62
|
|
|
DILATOR 4fr MERIT
|
Facility
|
IP
|
$121.00
|
|
| Hospital Charge Code |
2971699
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$61.66 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
DILATOR 4fr MERIT
|
Facility
|
OP
|
$121.00
|
|
| Hospital Charge Code |
2971699
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.24 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Aetna Managed Medicare |
$35.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.42
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.38
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: NAPHCARE Commercial |
$75.50
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$81.80
|
| Rate for Payer: Quartz Medicare Advantage |
$75.50
|
| Rate for Payer: The Alliance Commercial |
$62.92
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
DILATOR 5fr MERIT
|
Facility
|
OP
|
$121.00
|
|
| Hospital Charge Code |
2971700
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.24 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Aetna Managed Medicare |
$35.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.42
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.38
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: NAPHCARE Commercial |
$75.50
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$81.80
|
| Rate for Payer: Quartz Medicare Advantage |
$75.50
|
| Rate for Payer: The Alliance Commercial |
$62.92
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
DILATOR 5fr MERIT
|
Facility
|
IP
|
$121.00
|
|
| Hospital Charge Code |
2971700
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$61.66 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
DILATOR 6-12FR NOTTINGHAM 230-101
|
Facility
|
OP
|
$1,826.00
|
|
| Hospital Charge Code |
2964809
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$531.73 |
| Max. Negotiated Rate |
$1,747.12 |
| Rate for Payer: Aetna Commercial |
$1,709.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,633.17
|
| Rate for Payer: Aetna Managed Medicare |
$531.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,234.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$949.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$911.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,006.49
|
| Rate for Payer: Cash Price |
$547.80
|
| Rate for Payer: Cigna Commercial |
$1,747.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,062.73
|
| Rate for Payer: Health EOS Commercial |
$1,690.15
|
| Rate for Payer: HFN Commercial |
$1,747.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,424.28
|
| Rate for Payer: Multiplan Commercial |
$1,519.23
|
| Rate for Payer: NAPHCARE Commercial |
$1,139.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,747.12
|
| Rate for Payer: Quartz Beloit One Network |
$930.53
|
| Rate for Payer: Quartz Commercial |
$1,234.38
|
| Rate for Payer: Quartz Medicare Advantage |
$1,139.42
|
| Rate for Payer: The Alliance Commercial |
$949.52
|
| Rate for Payer: WEA Trust Commercial |
$1,044.47
|
| Rate for Payer: WPS Commercial |
$1,406.57
|
|
|
DILATOR 6-12FR NOTTINGHAM 230-101
|
Facility
|
IP
|
$1,826.00
|
|
| Hospital Charge Code |
2964809
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$930.53 |
| Max. Negotiated Rate |
$1,747.12 |
| Rate for Payer: Aetna Commercial |
$1,709.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,633.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,006.49
|
| Rate for Payer: Cash Price |
$547.80
|
| Rate for Payer: Cigna Commercial |
$1,747.12
|
| Rate for Payer: Health EOS Commercial |
$1,690.15
|
| Rate for Payer: HFN Commercial |
$1,747.12
|
| Rate for Payer: Multiplan Commercial |
$1,519.23
|
| Rate for Payer: Preferred Network Access Commercial |
$1,747.12
|
| Rate for Payer: Quartz Beloit One Network |
$930.53
|
| Rate for Payer: Quartz Commercial |
$1,139.42
|
| Rate for Payer: WEA Trust Commercial |
$1,044.47
|
| Rate for Payer: WPS Commercial |
$1,406.57
|
|
|
DILATOR 6FR
|
Facility
|
OP
|
$163.00
|
|
| Hospital Charge Code |
2970585
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.47 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Aetna Managed Medicare |
$47.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$84.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.87
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.14
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: NAPHCARE Commercial |
$101.71
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$110.19
|
| Rate for Payer: Quartz Medicare Advantage |
$101.71
|
| Rate for Payer: The Alliance Commercial |
$84.76
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
DILATOR 6FR
|
Facility
|
IP
|
$163.00
|
|
| Hospital Charge Code |
2970585
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.06 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$101.71
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
DILATOR 6fr MERIT
|
Facility
|
IP
|
$121.00
|
|
| Hospital Charge Code |
2971701
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$61.66 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
DILATOR 6fr MERIT
|
Facility
|
OP
|
$121.00
|
|
| Hospital Charge Code |
2971701
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.24 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Aetna Managed Medicare |
$35.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.42
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.38
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: NAPHCARE Commercial |
$75.50
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$81.80
|
| Rate for Payer: Quartz Medicare Advantage |
$75.50
|
| Rate for Payer: The Alliance Commercial |
$62.92
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
DILATOR 7FR
|
Facility
|
IP
|
$260.00
|
|
| Hospital Charge Code |
2970842
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.50 |
| Max. Negotiated Rate |
$248.77 |
| Rate for Payer: Aetna Commercial |
$243.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.31
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$248.77
|
| Rate for Payer: Health EOS Commercial |
$240.66
|
| Rate for Payer: HFN Commercial |
$248.77
|
| Rate for Payer: Multiplan Commercial |
$216.32
|
| Rate for Payer: Preferred Network Access Commercial |
$248.77
|
| Rate for Payer: Quartz Beloit One Network |
$132.50
|
| Rate for Payer: Quartz Commercial |
$162.24
|
| Rate for Payer: WEA Trust Commercial |
$148.72
|
| Rate for Payer: WPS Commercial |
$200.28
|
|
|
DILATOR 7FR
|
Facility
|
OP
|
$260.00
|
|
| Hospital Charge Code |
2970842
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.71 |
| Max. Negotiated Rate |
$248.77 |
| Rate for Payer: Aetna Commercial |
$243.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.54
|
| Rate for Payer: Aetna Managed Medicare |
$75.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$175.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$129.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.31
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$248.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.32
|
| Rate for Payer: Health EOS Commercial |
$240.66
|
| Rate for Payer: HFN Commercial |
$248.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.80
|
| Rate for Payer: Multiplan Commercial |
$216.32
|
| Rate for Payer: NAPHCARE Commercial |
$162.24
|
| Rate for Payer: Preferred Network Access Commercial |
$248.77
|
| Rate for Payer: Quartz Beloit One Network |
$132.50
|
| Rate for Payer: Quartz Commercial |
$175.76
|
| Rate for Payer: Quartz Medicare Advantage |
$162.24
|
| Rate for Payer: The Alliance Commercial |
$135.20
|
| Rate for Payer: WEA Trust Commercial |
$148.72
|
| Rate for Payer: WPS Commercial |
$200.28
|
|
|
DILATOR 7fr #OBT-7FR-11
|
Facility
|
IP
|
$258.00
|
|
| Hospital Charge Code |
2969093
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$131.48 |
| Max. Negotiated Rate |
$246.85 |
| Rate for Payer: Aetna Commercial |
$241.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.21
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$246.85
|
| Rate for Payer: Health EOS Commercial |
$238.80
|
| Rate for Payer: HFN Commercial |
$246.85
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: Preferred Network Access Commercial |
$246.85
|
| Rate for Payer: Quartz Beloit One Network |
$131.48
|
| Rate for Payer: Quartz Commercial |
$160.99
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: WPS Commercial |
$198.74
|
|
|
DILATOR 7fr #OBT-7FR-11
|
Facility
|
OP
|
$258.00
|
|
| Hospital Charge Code |
2969093
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.13 |
| Max. Negotiated Rate |
$246.85 |
| Rate for Payer: Aetna Commercial |
$241.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Aetna Managed Medicare |
$75.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$174.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$134.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$128.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.21
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$246.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.16
|
| Rate for Payer: Health EOS Commercial |
$238.80
|
| Rate for Payer: HFN Commercial |
$246.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$201.24
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: NAPHCARE Commercial |
$160.99
|
| Rate for Payer: Preferred Network Access Commercial |
$246.85
|
| Rate for Payer: Quartz Beloit One Network |
$131.48
|
| Rate for Payer: Quartz Commercial |
$174.41
|
| Rate for Payer: Quartz Medicare Advantage |
$160.99
|
| Rate for Payer: The Alliance Commercial |
$134.16
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: WPS Commercial |
$198.74
|
|
|
DILATOR 9fr
|
Facility
|
IP
|
$260.00
|
|
| Hospital Charge Code |
2970838
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.50 |
| Max. Negotiated Rate |
$248.77 |
| Rate for Payer: Aetna Commercial |
$243.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.31
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$248.77
|
| Rate for Payer: Health EOS Commercial |
$240.66
|
| Rate for Payer: HFN Commercial |
$248.77
|
| Rate for Payer: Multiplan Commercial |
$216.32
|
| Rate for Payer: Preferred Network Access Commercial |
$248.77
|
| Rate for Payer: Quartz Beloit One Network |
$132.50
|
| Rate for Payer: Quartz Commercial |
$162.24
|
| Rate for Payer: WEA Trust Commercial |
$148.72
|
| Rate for Payer: WPS Commercial |
$200.28
|
|
|
DILATOR 9fr
|
Facility
|
OP
|
$260.00
|
|
| Hospital Charge Code |
2970838
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.71 |
| Max. Negotiated Rate |
$248.77 |
| Rate for Payer: Aetna Commercial |
$243.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.54
|
| Rate for Payer: Aetna Managed Medicare |
$75.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$175.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$129.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.31
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$248.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.32
|
| Rate for Payer: Health EOS Commercial |
$240.66
|
| Rate for Payer: HFN Commercial |
$248.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.80
|
| Rate for Payer: Multiplan Commercial |
$216.32
|
| Rate for Payer: NAPHCARE Commercial |
$162.24
|
| Rate for Payer: Preferred Network Access Commercial |
$248.77
|
| Rate for Payer: Quartz Beloit One Network |
$132.50
|
| Rate for Payer: Quartz Commercial |
$175.76
|
| Rate for Payer: Quartz Medicare Advantage |
$162.24
|
| Rate for Payer: The Alliance Commercial |
$135.20
|
| Rate for Payer: WEA Trust Commercial |
$148.72
|
| Rate for Payer: WPS Commercial |
$200.28
|
|
|
DILATOR AAA
|
Facility
|
OP
|
$1,464.00
|
|
| Hospital Charge Code |
2972290
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$426.32 |
| Max. Negotiated Rate |
$1,400.76 |
| Rate for Payer: Aetna Commercial |
$1,370.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,309.40
|
| Rate for Payer: Aetna Managed Medicare |
$426.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$989.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$761.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$730.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$806.96
|
| Rate for Payer: Cash Price |
$439.20
|
| Rate for Payer: Cigna Commercial |
$1,400.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$852.05
|
| Rate for Payer: Health EOS Commercial |
$1,355.08
|
| Rate for Payer: HFN Commercial |
$1,400.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,141.92
|
| Rate for Payer: Multiplan Commercial |
$1,218.05
|
| Rate for Payer: NAPHCARE Commercial |
$913.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,400.76
|
| Rate for Payer: Quartz Beloit One Network |
$746.05
|
| Rate for Payer: Quartz Commercial |
$989.66
|
| Rate for Payer: Quartz Medicare Advantage |
$913.54
|
| Rate for Payer: The Alliance Commercial |
$761.28
|
| Rate for Payer: WEA Trust Commercial |
$837.41
|
| Rate for Payer: WPS Commercial |
$1,127.72
|
|
|
DILATOR AAA
|
Facility
|
IP
|
$1,464.00
|
|
| Hospital Charge Code |
2972290
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$746.05 |
| Max. Negotiated Rate |
$1,400.76 |
| Rate for Payer: Aetna Commercial |
$1,370.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,309.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$806.96
|
| Rate for Payer: Cash Price |
$439.20
|
| Rate for Payer: Cigna Commercial |
$1,400.76
|
| Rate for Payer: Health EOS Commercial |
$1,355.08
|
| Rate for Payer: HFN Commercial |
$1,400.76
|
| Rate for Payer: Multiplan Commercial |
$1,218.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,400.76
|
| Rate for Payer: Quartz Beloit One Network |
$746.05
|
| Rate for Payer: Quartz Commercial |
$913.54
|
| Rate for Payer: WEA Trust Commercial |
$837.41
|
| Rate for Payer: WPS Commercial |
$1,127.72
|
|
|
DILATORS 14FR
|
Facility
|
IP
|
$260.00
|
|
| Hospital Charge Code |
2970841
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.50 |
| Max. Negotiated Rate |
$248.77 |
| Rate for Payer: Aetna Commercial |
$243.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.31
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$248.77
|
| Rate for Payer: Health EOS Commercial |
$240.66
|
| Rate for Payer: HFN Commercial |
$248.77
|
| Rate for Payer: Multiplan Commercial |
$216.32
|
| Rate for Payer: Preferred Network Access Commercial |
$248.77
|
| Rate for Payer: Quartz Beloit One Network |
$132.50
|
| Rate for Payer: Quartz Commercial |
$162.24
|
| Rate for Payer: WEA Trust Commercial |
$148.72
|
| Rate for Payer: WPS Commercial |
$200.28
|
|
|
DILATORS 14FR
|
Facility
|
OP
|
$260.00
|
|
| Hospital Charge Code |
2970841
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.71 |
| Max. Negotiated Rate |
$248.77 |
| Rate for Payer: Aetna Commercial |
$243.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.54
|
| Rate for Payer: Aetna Managed Medicare |
$75.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$175.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$129.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.31
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$248.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.32
|
| Rate for Payer: Health EOS Commercial |
$240.66
|
| Rate for Payer: HFN Commercial |
$248.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.80
|
| Rate for Payer: Multiplan Commercial |
$216.32
|
| Rate for Payer: NAPHCARE Commercial |
$162.24
|
| Rate for Payer: Preferred Network Access Commercial |
$248.77
|
| Rate for Payer: Quartz Beloit One Network |
$132.50
|
| Rate for Payer: Quartz Commercial |
$175.76
|
| Rate for Payer: Quartz Medicare Advantage |
$162.24
|
| Rate for Payer: The Alliance Commercial |
$135.20
|
| Rate for Payer: WEA Trust Commercial |
$148.72
|
| Rate for Payer: WPS Commercial |
$200.28
|
|
|
DILATOR/SHEATH SET 8/10 M0062601200
|
Facility
|
OP
|
$992.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5415301
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$288.87 |
| Max. Negotiated Rate |
$949.15 |
| Rate for Payer: Aetna Commercial |
$928.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$887.24
|
| Rate for Payer: Aetna Managed Medicare |
$288.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$670.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$515.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$495.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.79
|
| Rate for Payer: Cash Price |
$297.60
|
| Rate for Payer: Cigna Commercial |
$949.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$577.34
|
| Rate for Payer: Health EOS Commercial |
$918.20
|
| Rate for Payer: HFN Commercial |
$949.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$773.76
|
| Rate for Payer: Multiplan Commercial |
$825.34
|
| Rate for Payer: NAPHCARE Commercial |
$619.01
|
| Rate for Payer: Preferred Network Access Commercial |
$949.15
|
| Rate for Payer: Quartz Beloit One Network |
$505.52
|
| Rate for Payer: Quartz Commercial |
$670.59
|
| Rate for Payer: Quartz Medicare Advantage |
$619.01
|
| Rate for Payer: The Alliance Commercial |
$515.84
|
| Rate for Payer: WEA Trust Commercial |
$567.42
|
| Rate for Payer: WPS Commercial |
$764.14
|
|
|
DILATOR/SHEATH SET 8/10 M0062601200
|
Facility
|
IP
|
$992.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5415301
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$505.52 |
| Max. Negotiated Rate |
$949.15 |
| Rate for Payer: Aetna Commercial |
$928.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$887.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.79
|
| Rate for Payer: Cash Price |
$297.60
|
| Rate for Payer: Cigna Commercial |
$949.15
|
| Rate for Payer: Health EOS Commercial |
$918.20
|
| Rate for Payer: HFN Commercial |
$949.15
|
| Rate for Payer: Multiplan Commercial |
$825.34
|
| Rate for Payer: Preferred Network Access Commercial |
$949.15
|
| Rate for Payer: Quartz Beloit One Network |
$505.52
|
| Rate for Payer: Quartz Commercial |
$619.01
|
| Rate for Payer: WEA Trust Commercial |
$567.42
|
| Rate for Payer: WPS Commercial |
$764.14
|
|
|
diphenhydrAMINE 50 mg/mL Inj Vial [Med]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2983105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$18.18 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.99
|
| Rate for Payer: Aetna Managed Medicare |
$5.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.47
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$18.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.13
|
| Rate for Payer: Health EOS Commercial |
$17.59
|
| Rate for Payer: HFN Commercial |
$18.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.82
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: NAPHCARE Commercial |
$11.86
|
| Rate for Payer: Preferred Network Access Commercial |
$18.18
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.84
|
| Rate for Payer: Quartz Medicare Advantage |
$11.86
|
| Rate for Payer: The Alliance Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$10.87
|
| Rate for Payer: WPS Commercial |
$2.14
|
|
|
diphenhydrAMINE 50 mg/mL Inj Vial [Med]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2983105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$18.18 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.47
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$18.18
|
| Rate for Payer: Health EOS Commercial |
$17.59
|
| Rate for Payer: HFN Commercial |
$18.18
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: Preferred Network Access Commercial |
$18.18
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$11.86
|
| Rate for Payer: WEA Trust Commercial |
$10.87
|
| Rate for Payer: WPS Commercial |
$14.64
|
|
