|
Promus 3.0mm x 12mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 12mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 16mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162828
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 16mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162828
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 16mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162828
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 20mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162830
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 20mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162830
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 20mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162830
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 24mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 24mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 24mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 28mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162834
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 28mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162834
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 28mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162834
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 8mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 8mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.0mm x 8mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.5mm x 12mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162838
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.5mm x 12mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162838
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.5mm x 12mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162838
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.5mm x 16mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162840
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.5mm x 16mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162840
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.5mm x 16mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162840
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.5mm x 20mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162842
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Promus 3.5mm x 20mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162842
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
