|
Promus 2.5mm x 20mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162818
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.5mm x 20mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162818
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.5mm x 24mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.5mm x 24mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.5mm x 24mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.5mm x 28mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162822
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.5mm x 28mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162822
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.5mm x 28mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162822
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.5mm x 8mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162812
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.5mm x 8mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162812
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.5mm x 8mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162812
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 3.0mm x 12mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
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 |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
