|
Prolong Outpt/Office each add 15min 99417
|
Professional
|
Both
|
$77.00
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
5673635
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.24 |
| Max. Negotiated Rate |
$112.63 |
| Rate for Payer: Aetna Commercial |
$76.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$76.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.05
|
| Rate for Payer: Health EOS Commercial |
$72.87
|
| Rate for Payer: HFN Commercial |
$76.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.63
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: Preferred Network Access Commercial |
$76.08
|
| Rate for Payer: Quartz Beloit One Network |
$35.24
|
| Rate for Payer: Quartz Commercial |
$45.65
|
| Rate for Payer: The Alliance Commercial |
$40.04
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Prolong Outpt/Office Vis Mdcre E add 15min G2212
|
Professional
|
Both
|
$77.00
|
|
|
Service Code
|
HCPCS G2212
|
| Hospital Charge Code |
5683627
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$112.63 |
| Rate for Payer: Aetna Commercial |
$76.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Aetna Managed Medicare |
$27.05
|
| Rate for Payer: Anthem Medicare Advantage |
$27.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.05
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$76.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.05
|
| Rate for Payer: Health EOS Commercial |
$72.87
|
| Rate for Payer: HFN Commercial |
$76.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.05
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: NAPHCARE Commercial |
$40.58
|
| Rate for Payer: Preferred Network Access Commercial |
$76.08
|
| Rate for Payer: Quartz Beloit One Network |
$35.24
|
| Rate for Payer: Quartz Commercial |
$45.65
|
| Rate for Payer: Quartz Medicare Advantage |
$27.05
|
| Rate for Payer: The Alliance Commercial |
$74.39
|
| Rate for Payer: United Healthcare Medicaid |
$25.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.05
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$47.34
|
|
|
Promethazine hcl inj 50 MG J2550
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3407525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$15.14 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.26
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$15.14
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$8.06
|
|
|
Promethazine hcl inj 50 MG J2550
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3407525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Promethazine hcl inj 50 MG J2550
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3407525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$10.41 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$3.79
|
| Rate for Payer: Anthem Medicare Advantage |
$3.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.79
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.22
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.79
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$5.68
|
| Rate for Payer: Preferred Network Access Commercial |
$6.92
|
| Rate for Payer: Quartz Beloit One Network |
$3.20
|
| Rate for Payer: Quartz Commercial |
$4.15
|
| Rate for Payer: Quartz Medicare Advantage |
$3.79
|
| Rate for Payer: The Alliance Commercial |
$10.41
|
| Rate for Payer: United Healthcare Medicaid |
$4.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.79
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$8.06
|
|
|
Promote Rth 1000 mL
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
3031449
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Aetna Managed Medicare |
$14.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.22
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: NAPHCARE Commercial |
$30.58
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$33.12
|
| Rate for Payer: Quartz Medicare Advantage |
$30.58
|
| Rate for Payer: The Alliance Commercial |
$25.48
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Promote Rth 1000 mL
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
3031449
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$30.58
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Promote w/Fiber Rth 1000 mL
|
Facility
|
OP
|
$66.00
|
|
| Hospital Charge Code |
3031450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.22 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Aetna Managed Medicare |
$19.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.41
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.48
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: NAPHCARE Commercial |
$41.18
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$44.62
|
| Rate for Payer: Quartz Medicare Advantage |
$41.18
|
| Rate for Payer: The Alliance Commercial |
$34.32
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$50.84
|
|
|
Promote w/Fiber Rth 1000 mL
|
Facility
|
IP
|
$66.00
|
|
| Hospital Charge Code |
3031450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.63 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$41.18
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$50.84
|
|
|
Promus 2.25mm x 12mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162802
|
|
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 2.25mm x 12mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162802
|
|
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 2.25mm x 12mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162802
|
|
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 2.25mm x 16mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162804
|
|
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 2.25mm x 16mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162804
|
|
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 2.25mm x 16mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162804
|
|
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 2.25mm x 20mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162806
|
|
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 2.25mm x 20mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162806
|
|
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 2.25mm x 20mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162806
|
|
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 2.25mm x 24mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162808
|
|
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 2.25mm x 24mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162808
|
|
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 2.25mm x 24mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162808
|
|
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 2.25mm x 28mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162810
|
|
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 2.25mm x 28mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162810
|
|
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 2.25mm x 28mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162810
|
|
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 2.25mm x 8mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162800
|
|
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
|
|
