|
GLIDE WIRE .035 260cm ANGLED STIFF 46-316B
|
Facility
|
OP
|
$915.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2971883
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.45 |
| Max. Negotiated Rate |
$875.47 |
| Rate for Payer: Aetna Commercial |
$856.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.38
|
| Rate for Payer: Aetna Managed Medicare |
$266.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$475.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.35
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$875.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.53
|
| Rate for Payer: Health EOS Commercial |
$846.92
|
| Rate for Payer: HFN Commercial |
$875.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$713.70
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: NAPHCARE Commercial |
$570.96
|
| Rate for Payer: Preferred Network Access Commercial |
$875.47
|
| Rate for Payer: Quartz Beloit One Network |
$466.28
|
| Rate for Payer: Quartz Commercial |
$618.54
|
| Rate for Payer: Quartz Medicare Advantage |
$570.96
|
| Rate for Payer: The Alliance Commercial |
$475.80
|
| Rate for Payer: WEA Trust Commercial |
$523.38
|
| Rate for Payer: WPS Commercial |
$704.82
|
|
|
GLIDE WIRE .035 260cm ANGLED STIFF 46-316B
|
Facility
|
IP
|
$915.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2971883
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$466.28 |
| Max. Negotiated Rate |
$875.47 |
| Rate for Payer: Aetna Commercial |
$856.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.35
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$875.47
|
| Rate for Payer: Health EOS Commercial |
$846.92
|
| Rate for Payer: HFN Commercial |
$875.47
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: Preferred Network Access Commercial |
$875.47
|
| Rate for Payer: Quartz Beloit One Network |
$466.28
|
| Rate for Payer: Quartz Commercial |
$570.96
|
| Rate for Payer: WEA Trust Commercial |
$523.38
|
| Rate for Payer: WPS Commercial |
$704.82
|
|
|
GLIDE WIRE .035 260cm STR 46-317B
|
Facility
|
OP
|
$881.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2971884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$256.55 |
| Max. Negotiated Rate |
$842.94 |
| Rate for Payer: Aetna Commercial |
$824.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$787.97
|
| Rate for Payer: Aetna Managed Medicare |
$256.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$595.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$458.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$439.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$485.61
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cigna Commercial |
$842.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.74
|
| Rate for Payer: Health EOS Commercial |
$815.45
|
| Rate for Payer: HFN Commercial |
$842.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$687.18
|
| Rate for Payer: Multiplan Commercial |
$732.99
|
| Rate for Payer: NAPHCARE Commercial |
$549.74
|
| Rate for Payer: Preferred Network Access Commercial |
$842.94
|
| Rate for Payer: Quartz Beloit One Network |
$448.96
|
| Rate for Payer: Quartz Commercial |
$595.56
|
| Rate for Payer: Quartz Medicare Advantage |
$549.74
|
| Rate for Payer: The Alliance Commercial |
$458.12
|
| Rate for Payer: WEA Trust Commercial |
$503.93
|
| Rate for Payer: WPS Commercial |
$678.63
|
|
|
GLIDE WIRE .035 260cm STR 46-317B
|
Facility
|
IP
|
$881.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2971884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.96 |
| Max. Negotiated Rate |
$842.94 |
| Rate for Payer: Aetna Commercial |
$824.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$787.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$485.61
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cigna Commercial |
$842.94
|
| Rate for Payer: Health EOS Commercial |
$815.45
|
| Rate for Payer: HFN Commercial |
$842.94
|
| Rate for Payer: Multiplan Commercial |
$732.99
|
| Rate for Payer: Preferred Network Access Commercial |
$842.94
|
| Rate for Payer: Quartz Beloit One Network |
$448.96
|
| Rate for Payer: Quartz Commercial |
$549.74
|
| Rate for Payer: WEA Trust Commercial |
$503.93
|
| Rate for Payer: WPS Commercial |
$678.63
|
|
|
GLIDEWIRE .035 NITINOL STIFF G30474
|
Facility
|
IP
|
$1,034.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2965535
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.93 |
| Max. Negotiated Rate |
$989.33 |
| Rate for Payer: Aetna Commercial |
$967.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$924.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$569.94
|
| Rate for Payer: Cash Price |
$310.20
|
| Rate for Payer: Cigna Commercial |
$989.33
|
| Rate for Payer: Health EOS Commercial |
$957.07
|
| Rate for Payer: HFN Commercial |
$989.33
|
| Rate for Payer: Multiplan Commercial |
$860.29
|
| Rate for Payer: Preferred Network Access Commercial |
$989.33
|
| Rate for Payer: Quartz Beloit One Network |
$526.93
|
| Rate for Payer: Quartz Commercial |
$645.22
|
| Rate for Payer: WEA Trust Commercial |
$591.45
|
| Rate for Payer: WPS Commercial |
$796.49
|
|
|
GLIDEWIRE .035 NITINOL STIFF G30474
|
Facility
|
OP
|
$1,034.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2965535
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$301.10 |
| Max. Negotiated Rate |
$989.33 |
| Rate for Payer: Aetna Commercial |
$967.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$924.81
|
| Rate for Payer: Aetna Managed Medicare |
$301.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$698.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$537.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$516.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$569.94
|
| Rate for Payer: Cash Price |
$310.20
|
| Rate for Payer: Cigna Commercial |
$989.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$601.79
|
| Rate for Payer: Health EOS Commercial |
$957.07
|
| Rate for Payer: HFN Commercial |
$989.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$806.52
|
| Rate for Payer: Multiplan Commercial |
$860.29
|
| Rate for Payer: NAPHCARE Commercial |
$645.22
|
| Rate for Payer: Preferred Network Access Commercial |
$989.33
|
| Rate for Payer: Quartz Beloit One Network |
$526.93
|
| Rate for Payer: Quartz Commercial |
$698.98
|
| Rate for Payer: Quartz Medicare Advantage |
$645.22
|
| Rate for Payer: The Alliance Commercial |
$537.68
|
| Rate for Payer: WEA Trust Commercial |
$591.45
|
| Rate for Payer: WPS Commercial |
$796.49
|
|
|
GLIDEWIRE .035 X 150CM 3CM TIP ANGLED STIFF SHAFT TERUMO GS3506
|
Facility
|
OP
|
$1,158.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5459716
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$337.21 |
| Max. Negotiated Rate |
$1,107.97 |
| Rate for Payer: Aetna Commercial |
$1,083.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,035.72
|
| Rate for Payer: Aetna Managed Medicare |
$337.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$782.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$602.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$578.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$638.29
|
| Rate for Payer: Cash Price |
$347.40
|
| Rate for Payer: Cigna Commercial |
$1,107.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$673.96
|
| Rate for Payer: Health EOS Commercial |
$1,071.84
|
| Rate for Payer: HFN Commercial |
$1,107.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$903.24
|
| Rate for Payer: Multiplan Commercial |
$963.46
|
| Rate for Payer: NAPHCARE Commercial |
$722.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,107.97
|
| Rate for Payer: Quartz Beloit One Network |
$590.12
|
| Rate for Payer: Quartz Commercial |
$782.81
|
| Rate for Payer: Quartz Medicare Advantage |
$722.59
|
| Rate for Payer: The Alliance Commercial |
$602.16
|
| Rate for Payer: WEA Trust Commercial |
$662.38
|
| Rate for Payer: WPS Commercial |
$892.01
|
|
|
GLIDEWIRE .035 X 150CM 3CM TIP ANGLED STIFF SHAFT TERUMO GS3506
|
Facility
|
IP
|
$1,158.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5459716
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$590.12 |
| Max. Negotiated Rate |
$1,107.97 |
| Rate for Payer: Aetna Commercial |
$1,083.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,035.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$638.29
|
| Rate for Payer: Cash Price |
$347.40
|
| Rate for Payer: Cigna Commercial |
$1,107.97
|
| Rate for Payer: Health EOS Commercial |
$1,071.84
|
| Rate for Payer: HFN Commercial |
$1,107.97
|
| Rate for Payer: Multiplan Commercial |
$963.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,107.97
|
| Rate for Payer: Quartz Beloit One Network |
$590.12
|
| Rate for Payer: Quartz Commercial |
$722.59
|
| Rate for Payer: WEA Trust Commercial |
$662.38
|
| Rate for Payer: WPS Commercial |
$892.01
|
|
|
GLIDEWIRE .035 X 80CM 3CM TIP ANGLED STIFF SHAFT TERUMO GS3505
|
Facility
|
IP
|
$1,158.00
|
|
| Hospital Charge Code |
5459403
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$590.12 |
| Max. Negotiated Rate |
$1,107.97 |
| Rate for Payer: Aetna Commercial |
$1,083.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,035.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$638.29
|
| Rate for Payer: Cash Price |
$347.40
|
| Rate for Payer: Cigna Commercial |
$1,107.97
|
| Rate for Payer: Health EOS Commercial |
$1,071.84
|
| Rate for Payer: HFN Commercial |
$1,107.97
|
| Rate for Payer: Multiplan Commercial |
$963.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,107.97
|
| Rate for Payer: Quartz Beloit One Network |
$590.12
|
| Rate for Payer: Quartz Commercial |
$722.59
|
| Rate for Payer: WEA Trust Commercial |
$662.38
|
| Rate for Payer: WPS Commercial |
$892.01
|
|
|
GLIDEWIRE .035 X 80CM 3CM TIP ANGLED STIFF SHAFT TERUMO GS3505
|
Facility
|
OP
|
$1,158.00
|
|
| Hospital Charge Code |
5459403
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$337.21 |
| Max. Negotiated Rate |
$1,107.97 |
| Rate for Payer: Aetna Commercial |
$1,083.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,035.72
|
| Rate for Payer: Aetna Managed Medicare |
$337.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$782.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$602.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$578.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$638.29
|
| Rate for Payer: Cash Price |
$347.40
|
| Rate for Payer: Cigna Commercial |
$1,107.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$673.96
|
| Rate for Payer: Health EOS Commercial |
$1,071.84
|
| Rate for Payer: HFN Commercial |
$1,107.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$903.24
|
| Rate for Payer: Multiplan Commercial |
$963.46
|
| Rate for Payer: NAPHCARE Commercial |
$722.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,107.97
|
| Rate for Payer: Quartz Beloit One Network |
$590.12
|
| Rate for Payer: Quartz Commercial |
$782.81
|
| Rate for Payer: Quartz Medicare Advantage |
$722.59
|
| Rate for Payer: The Alliance Commercial |
$602.16
|
| Rate for Payer: WEA Trust Commercial |
$662.38
|
| Rate for Payer: WPS Commercial |
$892.01
|
|
|
GLIDEWIRE .038 NITINOL STIFF G30470
|
Facility
|
IP
|
$1,034.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2965536
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.93 |
| Max. Negotiated Rate |
$989.33 |
| Rate for Payer: Aetna Commercial |
$967.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$924.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$569.94
|
| Rate for Payer: Cash Price |
$310.20
|
| Rate for Payer: Cigna Commercial |
$989.33
|
| Rate for Payer: Health EOS Commercial |
$957.07
|
| Rate for Payer: HFN Commercial |
$989.33
|
| Rate for Payer: Multiplan Commercial |
$860.29
|
| Rate for Payer: Preferred Network Access Commercial |
$989.33
|
| Rate for Payer: Quartz Beloit One Network |
$526.93
|
| Rate for Payer: Quartz Commercial |
$645.22
|
| Rate for Payer: WEA Trust Commercial |
$591.45
|
| Rate for Payer: WPS Commercial |
$796.49
|
|
|
GLIDEWIRE .038 NITINOL STIFF G30470
|
Facility
|
OP
|
$1,034.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2965536
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$301.10 |
| Max. Negotiated Rate |
$989.33 |
| Rate for Payer: Aetna Commercial |
$967.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$924.81
|
| Rate for Payer: Aetna Managed Medicare |
$301.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$698.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$537.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$516.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$569.94
|
| Rate for Payer: Cash Price |
$310.20
|
| Rate for Payer: Cigna Commercial |
$989.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$601.79
|
| Rate for Payer: Health EOS Commercial |
$957.07
|
| Rate for Payer: HFN Commercial |
$989.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$806.52
|
| Rate for Payer: Multiplan Commercial |
$860.29
|
| Rate for Payer: NAPHCARE Commercial |
$645.22
|
| Rate for Payer: Preferred Network Access Commercial |
$989.33
|
| Rate for Payer: Quartz Beloit One Network |
$526.93
|
| Rate for Payer: Quartz Commercial |
$698.98
|
| Rate for Payer: Quartz Medicare Advantage |
$645.22
|
| Rate for Payer: The Alliance Commercial |
$537.68
|
| Rate for Payer: WEA Trust Commercial |
$591.45
|
| Rate for Payer: WPS Commercial |
$796.49
|
|
|
GLIDEWIRE GI .035 260cm 5191
|
Facility
|
IP
|
$1,827.00
|
|
| Hospital Charge Code |
2973626
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$931.04 |
| Max. Negotiated Rate |
$1,748.07 |
| Rate for Payer: Aetna Commercial |
$1,710.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,634.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,007.04
|
| Rate for Payer: Cash Price |
$548.10
|
| Rate for Payer: Cigna Commercial |
$1,748.07
|
| Rate for Payer: Health EOS Commercial |
$1,691.07
|
| Rate for Payer: HFN Commercial |
$1,748.07
|
| Rate for Payer: Multiplan Commercial |
$1,520.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,748.07
|
| Rate for Payer: Quartz Beloit One Network |
$931.04
|
| Rate for Payer: Quartz Commercial |
$1,140.05
|
| Rate for Payer: WEA Trust Commercial |
$1,045.04
|
| Rate for Payer: WPS Commercial |
$1,407.34
|
|
|
GLIDEWIRE GI .035 260cm 5191
|
Facility
|
OP
|
$1,827.00
|
|
| Hospital Charge Code |
2973626
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$532.02 |
| Max. Negotiated Rate |
$1,748.07 |
| Rate for Payer: Aetna Commercial |
$1,710.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,634.07
|
| Rate for Payer: Aetna Managed Medicare |
$532.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,235.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$950.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$912.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,007.04
|
| Rate for Payer: Cash Price |
$548.10
|
| Rate for Payer: Cigna Commercial |
$1,748.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,063.31
|
| Rate for Payer: Health EOS Commercial |
$1,691.07
|
| Rate for Payer: HFN Commercial |
$1,748.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,425.06
|
| Rate for Payer: Multiplan Commercial |
$1,520.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,140.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,748.07
|
| Rate for Payer: Quartz Beloit One Network |
$931.04
|
| Rate for Payer: Quartz Commercial |
$1,235.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,140.05
|
| Rate for Payer: The Alliance Commercial |
$950.04
|
| Rate for Payer: WEA Trust Commercial |
$1,045.04
|
| Rate for Payer: WPS Commercial |
$1,407.34
|
|
|
GLIDING SURFACE VEGA PS T2/2+ 12MM NX121
|
Facility
|
IP
|
$4,918.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659641
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,506.21 |
| Max. Negotiated Rate |
$4,705.54 |
| Rate for Payer: Aetna Commercial |
$4,603.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,398.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,710.80
|
| Rate for Payer: Cash Price |
$1,475.40
|
| Rate for Payer: Cigna Commercial |
$4,705.54
|
| Rate for Payer: Health EOS Commercial |
$4,552.10
|
| Rate for Payer: HFN Commercial |
$4,705.54
|
| Rate for Payer: Multiplan Commercial |
$4,091.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,705.54
|
| Rate for Payer: Quartz Beloit One Network |
$2,506.21
|
| Rate for Payer: Quartz Commercial |
$3,068.83
|
| Rate for Payer: WEA Trust Commercial |
$2,813.10
|
| Rate for Payer: WPS Commercial |
$3,788.34
|
|
|
GLIDING SURFACE VEGA PS T2/2+ 12MM NX121
|
Facility
|
OP
|
$4,918.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659641
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,432.12 |
| Max. Negotiated Rate |
$4,705.54 |
| Rate for Payer: Aetna Commercial |
$4,603.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,398.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,432.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,324.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,557.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,455.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,710.80
|
| Rate for Payer: Cash Price |
$1,475.40
|
| Rate for Payer: Cigna Commercial |
$4,705.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,862.28
|
| Rate for Payer: Health EOS Commercial |
$4,552.10
|
| Rate for Payer: HFN Commercial |
$4,705.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,836.04
|
| Rate for Payer: Multiplan Commercial |
$4,091.78
|
| Rate for Payer: NAPHCARE Commercial |
$3,068.83
|
| Rate for Payer: Preferred Network Access Commercial |
$4,705.54
|
| Rate for Payer: Quartz Beloit One Network |
$2,506.21
|
| Rate for Payer: Quartz Commercial |
$3,324.57
|
| Rate for Payer: Quartz Medicare Advantage |
$3,068.83
|
| Rate for Payer: The Alliance Commercial |
$2,557.36
|
| Rate for Payer: WEA Trust Commercial |
$2,813.10
|
| Rate for Payer: WPS Commercial |
$3,788.34
|
|
|
GLIDING SURFACE VEGA PS T3/3+ 12MM NX131
|
Facility
|
IP
|
$4,918.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6049672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,506.21 |
| Max. Negotiated Rate |
$4,705.54 |
| Rate for Payer: Aetna Commercial |
$4,603.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,398.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,710.80
|
| Rate for Payer: Cash Price |
$1,475.40
|
| Rate for Payer: Cigna Commercial |
$4,705.54
|
| Rate for Payer: Health EOS Commercial |
$4,552.10
|
| Rate for Payer: HFN Commercial |
$4,705.54
|
| Rate for Payer: Multiplan Commercial |
$4,091.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,705.54
|
| Rate for Payer: Quartz Beloit One Network |
$2,506.21
|
| Rate for Payer: Quartz Commercial |
$3,068.83
|
| Rate for Payer: WEA Trust Commercial |
$2,813.10
|
| Rate for Payer: WPS Commercial |
$3,788.34
|
|
|
GLIDING SURFACE VEGA PS T3/3+ 12MM NX131
|
Facility
|
OP
|
$4,918.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6049672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,432.12 |
| Max. Negotiated Rate |
$4,705.54 |
| Rate for Payer: Aetna Commercial |
$4,603.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,398.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,432.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,324.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,557.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,455.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,710.80
|
| Rate for Payer: Cash Price |
$1,475.40
|
| Rate for Payer: Cigna Commercial |
$4,705.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,862.28
|
| Rate for Payer: Health EOS Commercial |
$4,552.10
|
| Rate for Payer: HFN Commercial |
$4,705.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,836.04
|
| Rate for Payer: Multiplan Commercial |
$4,091.78
|
| Rate for Payer: NAPHCARE Commercial |
$3,068.83
|
| Rate for Payer: Preferred Network Access Commercial |
$4,705.54
|
| Rate for Payer: Quartz Beloit One Network |
$2,506.21
|
| Rate for Payer: Quartz Commercial |
$3,324.57
|
| Rate for Payer: Quartz Medicare Advantage |
$3,068.83
|
| Rate for Payer: The Alliance Commercial |
$2,557.36
|
| Rate for Payer: WEA Trust Commercial |
$2,813.10
|
| Rate for Payer: WPS Commercial |
$3,788.34
|
|
|
Glidin Peptide IgA
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2808799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.06 |
| Max. Negotiated Rate |
$105.25 |
| Rate for Payer: Aetna Commercial |
$102.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.63
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$105.25
|
| Rate for Payer: Health EOS Commercial |
$101.82
|
| Rate for Payer: HFN Commercial |
$105.25
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: Preferred Network Access Commercial |
$105.25
|
| Rate for Payer: Quartz Beloit One Network |
$56.06
|
| Rate for Payer: Quartz Commercial |
$68.64
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: WPS Commercial |
$84.73
|
|
|
Glidin Peptide IgA
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2808799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$105.25 |
| Rate for Payer: Aetna Commercial |
$102.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$105.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$101.82
|
| Rate for Payer: HFN Commercial |
$105.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$105.25
|
| Rate for Payer: Quartz Beloit One Network |
$56.06
|
| Rate for Payer: Quartz Commercial |
$74.36
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$85.80
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$84.73
|
|
|
Glidin Peptide IgA
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2808799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$108.68 |
| Rate for Payer: Aetna Commercial |
$108.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$108.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$104.10
|
| Rate for Payer: HFN Commercial |
$108.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$108.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.34
|
| Rate for Payer: Quartz Commercial |
$65.21
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
Glidin Peptide IgA & IgG
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2808810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$105.25 |
| Rate for Payer: Aetna Commercial |
$102.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$105.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$101.82
|
| Rate for Payer: HFN Commercial |
$105.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$105.25
|
| Rate for Payer: Quartz Beloit One Network |
$56.06
|
| Rate for Payer: Quartz Commercial |
$74.36
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$85.80
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$84.73
|
|
|
Glidin Peptide IgA & IgG
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2808810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.06 |
| Max. Negotiated Rate |
$105.25 |
| Rate for Payer: Aetna Commercial |
$102.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.63
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$105.25
|
| Rate for Payer: Health EOS Commercial |
$101.82
|
| Rate for Payer: HFN Commercial |
$105.25
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: Preferred Network Access Commercial |
$105.25
|
| Rate for Payer: Quartz Beloit One Network |
$56.06
|
| Rate for Payer: Quartz Commercial |
$68.64
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: WPS Commercial |
$84.73
|
|
|
Glidin Peptide IgA & IgG
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2808810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$108.68 |
| Rate for Payer: Aetna Commercial |
$108.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$108.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$104.10
|
| Rate for Payer: HFN Commercial |
$108.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$108.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.34
|
| Rate for Payer: Quartz Commercial |
$65.21
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
Glidin Peptide IgG
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2808801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.06 |
| Max. Negotiated Rate |
$105.25 |
| Rate for Payer: Aetna Commercial |
$102.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.63
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$105.25
|
| Rate for Payer: Health EOS Commercial |
$101.82
|
| Rate for Payer: HFN Commercial |
$105.25
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: Preferred Network Access Commercial |
$105.25
|
| Rate for Payer: Quartz Beloit One Network |
$56.06
|
| Rate for Payer: Quartz Commercial |
$68.64
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: WPS Commercial |
$84.73
|
|
