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BlueCross.BlueShield of Illinois vitals <br /> Betook Surgery-Laparoscop c Gash B1plass(Stapling) $500 <br /> $150 $0 <br /> Bariatric Surgery(Lap Band) $500 $150 $0 <br /> Bladder Repair For Incontinence($fang) $250 $75 $50 <br /> Bladder Scope with Lithotripsy,(K;dney Stone fragmentation; $250 $75 $50 <br /> Bladder Scope with Stent $250 S75 $50 <br /> Bone and Joint Scan of Whole Body $150 $75 $Q <br /> Baur Density study of Spine or PeNls $Sp $25 $o <br /> Breast biopsy,wJ imagung $150 $75 $50 <br /> Breast Lumpecamy $150 S75 $50 <br /> Bronchoscopy $150 $75 $50 <br /> Bunionectomy, $150 S75 $50 <br /> Carpa(Tunnel $ISO S75 S50 <br /> Cataract Removal $150 $75 $50 <br /> Colonoscopy Sx250 $75 $50 <br /> CT Scan $150 $75 $50 <br /> Hammertoe Correction $160 S75 $60 <br /> Harrier)ngtanal Repan(Age 5+.Non-Laparoscopic) $150 $75 $50 <br /> Hip Replacement $600 $260 $o <br /> Hysterectomy $150 S75 $50 <br /> Hysteroscopy VSO S75 SSO <br /> Knee Arthroscopy with Cartilage Repair $250 $75 $g0 <br /> Knee Replacement $500 $250 $o <br /> Larrnmomy-Inpatient $500 $26O yo <br /> Laparoscopic Gall Bladder Removal $250 $76 $50 <br /> LelaroscopkRemoval ofOvaries andiorFallopian Tubes $250 S75 $50 <br /> Laparoscopic Tuba)Block orTubalLgaUon $250 S75 $50 <br /> Lithotripsy-Fragmenting of Kidney Stones $250 $75 $50 <br /> Mammogram $50 $25 $0 <br /> MR Angiography Head w/o Dye $150 S75 $50 <br /> MRI $ISO $75 $50 <br /> MRI Abdomen w/contrast $150 $75 $50 <br /> NasaVSinus-Corrective Surgery-Septoplasty, $150 S75 $50 <br /> a NasaUSinus-Endoscopy-Sinus Surgery $150 $75 SSO <br /> NesaYSlnus-Submtwous Resection InferiorTurbmate $150 S75 $50 <br /> ` Partial OrTbt&I Rainoval of Thyroid Gland <br /> � a $150 $76 $50 <br /> PET Scan $ISO S75 $50 <br /> Repair of Laparoscopic Inguinal Hernia $150 S75 $50 <br /> Repair of Umbilical Hernia Age 5+) $250 $100 $50 <br /> Revision ofTatal Hid or Total Knee Replacement $500 $250 $o <br /> ROtamf Cuff Repair(Srugical.Non-Arthroscop c) $250 S75 <br /> $50 <br /> Shoukler Arthroscopy $260 $700 $50 <br /> Shoulder Artthroscopy,with Rotator Cuff Repair $250 $100 S50 <br /> 51 � $150 S75 $50 <br /> Spinal Fusion(Anterior) 5500 $250 $0 <br /> Spinal Fusion(Posteriori $600 $250 $0 <br /> Tonsillectomy and Adenoidectomy, $150 S75 S50 <br /> Total Thyroid Rerrwval $250 $75 $50 <br /> Tympanoplasty(ear drum repaid $ISO S75 S50 <br /> Tympanostomy and Myringwomy $150 S7S $50 <br /> Ultrasound Exam $50 S25 $o <br /> Upper GI Endoscgdy $250 $75 $50 <br /> Urethra and Bladder Scope $150 $75 $60 <br /> Please MAe that wdl be(resented porn avai(adle eptim EXCE T When the 8atand oproo is 25 P"c"ho"than the ams t 411ist dve option in die area. <br /> %Okili 311104611111,0011 dw toiaincentivewillbeoNared.for certain inpatient procedmss."one option isprWiled. <br /> Blue Cross and Blue Shield of Ilinom,a Division of Health Care Service Corporation, <br /> a Mutual Legal Reserve Company.an Independent Licensee of the Blue Cross and Blue Shield Association 2307270716 <br />