|
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 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 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 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 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
|
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
|
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: WEA Trust Commercial |
$6,126.12
|
| 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: 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
|
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 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 SPACER ACCOLADE LG 13MM 1059-6713
|
Facility
|
IP
|
$860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5813623
|
|
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 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
|
|
|
DISTRACTOR UC HIP SUPINE 72202207
|
Facility
|
OP
|
$5,533.00
|
|
| Hospital Charge Code |
5286795
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,611.21 |
| Max. Negotiated Rate |
$5,293.97 |
| Rate for Payer: Aetna Commercial |
$5,178.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,948.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,611.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,740.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,877.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,762.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.79
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,293.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,220.21
|
| Rate for Payer: Health EOS Commercial |
$5,121.34
|
| Rate for Payer: HFN Commercial |
$5,293.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,315.74
|
| Rate for Payer: Multiplan Commercial |
$4,603.46
|
| Rate for Payer: NAPHCARE Commercial |
$3,452.59
|
| Rate for Payer: Preferred Network Access Commercial |
$5,293.97
|
| Rate for Payer: Quartz Beloit One Network |
$2,819.62
|
| Rate for Payer: Quartz Commercial |
$3,740.31
|
| Rate for Payer: Quartz Medicare Advantage |
$3,452.59
|
| Rate for Payer: The Alliance Commercial |
$2,877.16
|
| Rate for Payer: WEA Trust Commercial |
$3,164.88
|
| Rate for Payer: WPS Commercial |
$4,262.07
|
|
|
DISTRACTOR UC HIP SUPINE 72202207
|
Facility
|
IP
|
$5,533.00
|
|
| Hospital Charge Code |
5286795
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2,819.62 |
| Max. Negotiated Rate |
$5,293.97 |
| Rate for Payer: Aetna Commercial |
$5,178.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,948.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.79
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,293.97
|
| Rate for Payer: Health EOS Commercial |
$5,121.34
|
| Rate for Payer: HFN Commercial |
$5,293.97
|
| Rate for Payer: Multiplan Commercial |
$4,603.46
|
| Rate for Payer: Preferred Network Access Commercial |
$5,293.97
|
| Rate for Payer: Quartz Beloit One Network |
$2,819.62
|
| Rate for Payer: Quartz Commercial |
$3,452.59
|
| Rate for Payer: WEA Trust Commercial |
$3,164.88
|
| Rate for Payer: WPS Commercial |
$4,262.07
|
|
|
Disulfiram Level
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4010555
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$122.81 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$150.38
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
Disulfiram Level
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4010555
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$238.11 |
| Rate for Payer: Aetna Commercial |
$238.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$238.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$125.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$228.08
|
| Rate for Payer: HFN Commercial |
$238.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$238.11
|
| Rate for Payer: Quartz Beloit One Network |
$110.28
|
| Rate for Payer: Quartz Commercial |
$142.86
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$76.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$85.30
|
|
|
Disulfiram Level
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4010555
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.18
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$162.92
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$77.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: United Healthcare PPO |
$187.98
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: Wellcare Medicare |
$19.39
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
DIVERTICULITIS AND DIVERTICULOSIS
|
Facility
|
IP
|
$18,325.77
|
|
|
Service Code
|
APR-DRG 2444
|
| Min. Negotiated Rate |
$16,278.09 |
| Max. Negotiated Rate |
$18,325.77 |
| Rate for Payer: Anthem Medicaid |
$17,547.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$17,547.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17,547.93
|
| Rate for Payer: Dean Health Medicaid |
$17,547.93
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16,278.09
|
| Rate for Payer: Managed Health Services Medicaid |
$18,325.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$17,547.93
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17,547.93
|
| Rate for Payer: United Healthcare Medicaid |
$17,547.93
|
|
|
DIVERTICULITIS AND DIVERTICULOSIS
|
Facility
|
IP
|
$6,400.87
|
|
|
Service Code
|
APR-DRG 2442
|
| Min. Negotiated Rate |
$5,685.65 |
| Max. Negotiated Rate |
$6,400.87 |
| Rate for Payer: Anthem Medicaid |
$6,129.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,129.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,129.18
|
| Rate for Payer: Dean Health Medicaid |
$6,129.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,685.65
|
| Rate for Payer: Managed Health Services Medicaid |
$6,400.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,129.18
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,129.18
|
| Rate for Payer: United Healthcare Medicaid |
$6,129.18
|
|
|
DIVERTICULITIS AND DIVERTICULOSIS
|
Facility
|
IP
|
$9,995.87
|
|
|
Service Code
|
APR-DRG 2443
|
| Min. Negotiated Rate |
$8,878.96 |
| Max. Negotiated Rate |
$9,995.87 |
| Rate for Payer: Anthem Medicaid |
$9,571.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,571.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,571.60
|
| Rate for Payer: Dean Health Medicaid |
$9,571.60
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,878.96
|
| Rate for Payer: Managed Health Services Medicaid |
$9,995.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,571.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,571.60
|
| Rate for Payer: United Healthcare Medicaid |
$9,571.60
|
|
