|
DISTAL CENTRALIZER VERSYS SZ 17 7859-17
|
Facility
|
IP
|
$562.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967883
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$286.40 |
| Max. Negotiated Rate |
$537.72 |
| Rate for Payer: Aetna Commercial |
$526.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.65
|
| 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: Health EOS Commercial |
$520.19
|
| Rate for Payer: HFN Commercial |
$537.72
|
| Rate for Payer: Multiplan Commercial |
$467.58
|
| Rate for Payer: Preferred Network Access Commercial |
$537.72
|
| Rate for Payer: Quartz Beloit One Network |
$286.40
|
| Rate for Payer: Quartz Commercial |
$350.69
|
| Rate for Payer: WEA Trust Commercial |
$321.46
|
| Rate for Payer: WPS Commercial |
$432.91
|
|
|
DISTAL CENTRALIZER VERSYS SZ 18 7895-18
|
Facility
|
OP
|
$562.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967884
|
|
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
|
|
|
DISTAL CENTRALIZER VERSYS SZ 18 7895-18
|
Facility
|
IP
|
$562.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$286.40 |
| Max. Negotiated Rate |
$537.72 |
| Rate for Payer: Aetna Commercial |
$526.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.65
|
| 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: Health EOS Commercial |
$520.19
|
| Rate for Payer: HFN Commercial |
$537.72
|
| Rate for Payer: Multiplan Commercial |
$467.58
|
| Rate for Payer: Preferred Network Access Commercial |
$537.72
|
| Rate for Payer: Quartz Beloit One Network |
$286.40
|
| Rate for Payer: Quartz Commercial |
$350.69
|
| Rate for Payer: WEA Trust Commercial |
$321.46
|
| Rate for Payer: WPS Commercial |
$432.91
|
|
|
DISTAL CENTRALIZER VERSYS SZ 19 7859-19
|
Facility
|
IP
|
$562.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967885
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$286.40 |
| Max. Negotiated Rate |
$537.72 |
| Rate for Payer: Aetna Commercial |
$526.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.65
|
| 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: Health EOS Commercial |
$520.19
|
| Rate for Payer: HFN Commercial |
$537.72
|
| Rate for Payer: Multiplan Commercial |
$467.58
|
| Rate for Payer: Preferred Network Access Commercial |
$537.72
|
| Rate for Payer: Quartz Beloit One Network |
$286.40
|
| Rate for Payer: Quartz Commercial |
$350.69
|
| Rate for Payer: WEA Trust Commercial |
$321.46
|
| Rate for Payer: WPS Commercial |
$432.91
|
|
|
DISTAL CENTRALIZER VERSYS SZ 19 7859-19
|
Facility
|
OP
|
$562.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967885
|
|
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
|
|
|
DISTAL CENTRALIZER VERSYS SZ 9 7859-09
|
Facility
|
OP
|
$582.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967460
|
|
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 9 7859-09
|
Facility
|
IP
|
$582.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967460
|
|
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 FIBULA PLATE LOCK 4HL RT TI AR-9943BR-04
|
Facility
|
OP
|
$4,296.61
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6244275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,251.17 |
| Max. Negotiated Rate |
$4,111.00 |
| Rate for Payer: Aetna Commercial |
$4,021.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,842.89
|
| Rate for Payer: Aetna Managed Medicare |
$1,251.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,904.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,234.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,144.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,368.29
|
| Rate for Payer: Cash Price |
$1,288.98
|
| Rate for Payer: Cigna Commercial |
$4,111.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,500.63
|
| Rate for Payer: Health EOS Commercial |
$3,976.94
|
| Rate for Payer: HFN Commercial |
$4,111.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,351.36
|
| Rate for Payer: Multiplan Commercial |
$3,574.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,681.08
|
| Rate for Payer: Preferred Network Access Commercial |
$4,111.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,189.55
|
| Rate for Payer: Quartz Commercial |
$2,904.51
|
| Rate for Payer: Quartz Medicare Advantage |
$2,681.08
|
| Rate for Payer: The Alliance Commercial |
$2,234.24
|
| Rate for Payer: WEA Trust Commercial |
$2,457.66
|
| Rate for Payer: WPS Commercial |
$3,309.68
|
|
|
DISTAL FIBULA PLATE LOCK 4HL RT TI AR-9943BR-04
|
Facility
|
IP
|
$4,296.61
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6244275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,189.55 |
| Max. Negotiated Rate |
$4,111.00 |
| Rate for Payer: Aetna Commercial |
$4,021.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,842.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,368.29
|
| Rate for Payer: Cash Price |
$1,288.98
|
| Rate for Payer: Cigna Commercial |
$4,111.00
|
| Rate for Payer: Health EOS Commercial |
$3,976.94
|
| Rate for Payer: HFN Commercial |
$4,111.00
|
| Rate for Payer: Multiplan Commercial |
$3,574.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,111.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,189.55
|
| Rate for Payer: Quartz Commercial |
$2,681.08
|
| Rate for Payer: WEA Trust Commercial |
$2,457.66
|
| Rate for Payer: WPS Commercial |
$3,309.68
|
|
|
Distal Protection Device 3mm
|
Facility
|
IP
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549106
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,457.82 |
| Max. Negotiated Rate |
$10,247.33 |
| Rate for Payer: Aetna Commercial |
$10,024.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.35
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,247.33
|
| Rate for Payer: Health EOS Commercial |
$9,913.18
|
| Rate for Payer: HFN Commercial |
$10,247.33
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: Preferred Network Access Commercial |
$10,247.33
|
| Rate for Payer: Quartz Beloit One Network |
$5,457.82
|
| Rate for Payer: Quartz Commercial |
$6,683.04
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 3mm
|
Professional
|
Both
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549106
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,900.90 |
| Max. Negotiated Rate |
$10,581.48 |
| Rate for Payer: Aetna Commercial |
$10,581.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,581.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,569.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,683.04
|
| Rate for Payer: Health EOS Commercial |
$10,135.94
|
| Rate for Payer: HFN Commercial |
$10,581.48
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: Preferred Network Access Commercial |
$10,581.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,900.90
|
| Rate for Payer: Quartz Commercial |
$6,348.89
|
| Rate for Payer: The Alliance Commercial |
$5,569.20
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 3mm
|
Facility
|
OP
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549106
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,118.75 |
| Max. Negotiated Rate |
$10,247.33 |
| Rate for Payer: Aetna Commercial |
$10,024.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Aetna Managed Medicare |
$3,118.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,239.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.35
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,247.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.22
|
| Rate for Payer: Health EOS Commercial |
$9,913.18
|
| Rate for Payer: HFN Commercial |
$10,247.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,353.80
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.04
|
| Rate for Payer: Preferred Network Access Commercial |
$10,247.33
|
| Rate for Payer: Quartz Beloit One Network |
$5,457.82
|
| Rate for Payer: Quartz Commercial |
$7,239.96
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.04
|
| Rate for Payer: The Alliance Commercial |
$5,569.20
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 4mm
|
Professional
|
Both
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,900.90 |
| Max. Negotiated Rate |
$10,581.48 |
| Rate for Payer: Aetna Commercial |
$10,581.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,581.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,569.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,683.04
|
| Rate for Payer: Health EOS Commercial |
$10,135.94
|
| Rate for Payer: HFN Commercial |
$10,581.48
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: Preferred Network Access Commercial |
$10,581.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,900.90
|
| Rate for Payer: Quartz Commercial |
$6,348.89
|
| Rate for Payer: The Alliance Commercial |
$5,569.20
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 4mm
|
Facility
|
OP
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,118.75 |
| Max. Negotiated Rate |
$10,247.33 |
| Rate for Payer: Aetna Commercial |
$10,024.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Aetna Managed Medicare |
$3,118.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,239.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.35
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,247.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.22
|
| Rate for Payer: Health EOS Commercial |
$9,913.18
|
| Rate for Payer: HFN Commercial |
$10,247.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,353.80
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.04
|
| Rate for Payer: Preferred Network Access Commercial |
$10,247.33
|
| Rate for Payer: Quartz Beloit One Network |
$5,457.82
|
| Rate for Payer: Quartz Commercial |
$7,239.96
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.04
|
| Rate for Payer: The Alliance Commercial |
$5,569.20
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 4mm
|
Facility
|
IP
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,457.82 |
| Max. Negotiated Rate |
$10,247.33 |
| Rate for Payer: Aetna Commercial |
$10,024.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.35
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,247.33
|
| Rate for Payer: Health EOS Commercial |
$9,913.18
|
| Rate for Payer: HFN Commercial |
$10,247.33
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: Preferred Network Access Commercial |
$10,247.33
|
| Rate for Payer: Quartz Beloit One Network |
$5,457.82
|
| Rate for Payer: Quartz Commercial |
$6,683.04
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 5mm
|
Professional
|
Both
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,900.90 |
| Max. Negotiated Rate |
$10,581.48 |
| Rate for Payer: Aetna Commercial |
$10,581.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,581.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,569.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,683.04
|
| Rate for Payer: Health EOS Commercial |
$10,135.94
|
| Rate for Payer: HFN Commercial |
$10,581.48
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: Preferred Network Access Commercial |
$10,581.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,900.90
|
| Rate for Payer: Quartz Commercial |
$6,348.89
|
| Rate for Payer: The Alliance Commercial |
$5,569.20
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 5mm
|
Facility
|
IP
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,457.82 |
| Max. Negotiated Rate |
$10,247.33 |
| Rate for Payer: Aetna Commercial |
$10,024.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.35
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,247.33
|
| Rate for Payer: Health EOS Commercial |
$9,913.18
|
| Rate for Payer: HFN Commercial |
$10,247.33
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: Preferred Network Access Commercial |
$10,247.33
|
| Rate for Payer: Quartz Beloit One Network |
$5,457.82
|
| Rate for Payer: Quartz Commercial |
$6,683.04
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 5mm
|
Facility
|
OP
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,118.75 |
| Max. Negotiated Rate |
$10,247.33 |
| Rate for Payer: Aetna Commercial |
$10,024.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Aetna Managed Medicare |
$3,118.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,239.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.35
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,247.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.22
|
| Rate for Payer: Health EOS Commercial |
$9,913.18
|
| Rate for Payer: HFN Commercial |
$10,247.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,353.80
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.04
|
| Rate for Payer: Preferred Network Access Commercial |
$10,247.33
|
| Rate for Payer: Quartz Beloit One Network |
$5,457.82
|
| Rate for Payer: Quartz Commercial |
$7,239.96
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.04
|
| Rate for Payer: The Alliance Commercial |
$5,569.20
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 6mm
|
Facility
|
IP
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549112
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,457.82 |
| Max. Negotiated Rate |
$10,247.33 |
| Rate for Payer: Aetna Commercial |
$10,024.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.35
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,247.33
|
| Rate for Payer: Health EOS Commercial |
$9,913.18
|
| Rate for Payer: HFN Commercial |
$10,247.33
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: Preferred Network Access Commercial |
$10,247.33
|
| Rate for Payer: Quartz Beloit One Network |
$5,457.82
|
| Rate for Payer: Quartz Commercial |
$6,683.04
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 6mm
|
Professional
|
Both
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549112
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,900.90 |
| Max. Negotiated Rate |
$10,581.48 |
| Rate for Payer: Aetna Commercial |
$10,581.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,581.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,569.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,683.04
|
| Rate for Payer: Health EOS Commercial |
$10,135.94
|
| Rate for Payer: HFN Commercial |
$10,581.48
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: Preferred Network Access Commercial |
$10,581.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,900.90
|
| Rate for Payer: Quartz Commercial |
$6,348.89
|
| Rate for Payer: The Alliance Commercial |
$5,569.20
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 6mm
|
Facility
|
OP
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549112
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,118.75 |
| Max. Negotiated Rate |
$10,247.33 |
| Rate for Payer: Aetna Commercial |
$10,024.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Aetna Managed Medicare |
$3,118.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,239.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.35
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,247.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.22
|
| Rate for Payer: Health EOS Commercial |
$9,913.18
|
| Rate for Payer: HFN Commercial |
$10,247.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,353.80
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.04
|
| Rate for Payer: Preferred Network Access Commercial |
$10,247.33
|
| Rate for Payer: Quartz Beloit One Network |
$5,457.82
|
| Rate for Payer: Quartz Commercial |
$7,239.96
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.04
|
| Rate for Payer: The Alliance Commercial |
$5,569.20
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 7mm
|
Facility
|
IP
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,457.82 |
| Max. Negotiated Rate |
$10,247.33 |
| Rate for Payer: Aetna Commercial |
$10,024.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.35
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,247.33
|
| Rate for Payer: Health EOS Commercial |
$9,913.18
|
| Rate for Payer: HFN Commercial |
$10,247.33
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: Preferred Network Access Commercial |
$10,247.33
|
| Rate for Payer: Quartz Beloit One Network |
$5,457.82
|
| Rate for Payer: Quartz Commercial |
$6,683.04
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 7mm
|
Professional
|
Both
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,900.90 |
| Max. Negotiated Rate |
$10,581.48 |
| Rate for Payer: Aetna Commercial |
$10,581.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,581.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,569.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,683.04
|
| Rate for Payer: Health EOS Commercial |
$10,135.94
|
| Rate for Payer: HFN Commercial |
$10,581.48
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: Preferred Network Access Commercial |
$10,581.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,900.90
|
| Rate for Payer: Quartz Commercial |
$6,348.89
|
| Rate for Payer: The Alliance Commercial |
$5,569.20
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
Distal Protection Device 7mm
|
Facility
|
OP
|
$10,710.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2549114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,118.75 |
| Max. Negotiated Rate |
$10,247.33 |
| Rate for Payer: Aetna Commercial |
$10,024.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.02
|
| Rate for Payer: Aetna Managed Medicare |
$3,118.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,239.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.35
|
| Rate for Payer: Cash Price |
$3,213.00
|
| Rate for Payer: Cigna Commercial |
$10,247.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.22
|
| Rate for Payer: Health EOS Commercial |
$9,913.18
|
| Rate for Payer: HFN Commercial |
$10,247.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,353.80
|
| Rate for Payer: Multiplan Commercial |
$8,910.72
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.04
|
| Rate for Payer: Preferred Network Access Commercial |
$10,247.33
|
| Rate for Payer: Quartz Beloit One Network |
$5,457.82
|
| Rate for Payer: Quartz Commercial |
$7,239.96
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.04
|
| Rate for Payer: The Alliance Commercial |
$5,569.20
|
| Rate for Payer: WEA Trust Commercial |
$6,126.12
|
| Rate for Payer: WPS Commercial |
$8,249.91
|
|
|
DISTAL SPACER ACCOLADE LG 13MM 1059-6713
|
Facility
|
OP
|
$860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5813623
|
|
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
|
|
