|
STENT BANDER URETERAL DIVERSION 7.2FR X75CM G18070
|
Facility
|
IP
|
$4,290.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
2965894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,102.10 |
| Max. Negotiated Rate |
$3,946.80 |
| Rate for Payer: Aetna Commercial |
$3,861.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,689.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,273.70
|
| Rate for Payer: Cash Price |
$1,287.00
|
| Rate for Payer: Cigna Commercial |
$3,946.80
|
| Rate for Payer: Health EOS Commercial |
$3,818.10
|
| Rate for Payer: HFN Commercial |
$3,946.80
|
| Rate for Payer: Multiplan Commercial |
$3,432.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,574.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,946.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,102.10
|
| Rate for Payer: Quartz Commercial |
$2,574.00
|
| Rate for Payer: WEA Trust Commercial |
$2,359.50
|
| Rate for Payer: WPS Commercial |
$3,177.60
|
|
|
STENT BM VeriFLEX 3.0 x 12mm
|
Facility
|
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2973672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
STENT BM VeriFLEX 3.0 x 12mm
|
Facility
|
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2973672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$69,632.00 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: The Alliance Commercial |
$69,632.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
STENT BM VeriFLEX 3.0 x 16mm
|
Facility
|
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2973671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
STENT BM VeriFLEX 3.0 x 16mm
|
Facility
|
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2973671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$69,632.00 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: The Alliance Commercial |
$69,632.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
STENTBM VERIFLEX 3.0 X 20
|
Facility
|
IP
|
$6,204.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3521504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,039.96 |
| Max. Negotiated Rate |
$5,707.68 |
| Rate for Payer: Aetna Commercial |
$5,583.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,288.12
|
| Rate for Payer: Cash Price |
$1,861.20
|
| Rate for Payer: Cigna Commercial |
$5,707.68
|
| Rate for Payer: Health EOS Commercial |
$5,521.56
|
| Rate for Payer: HFN Commercial |
$5,707.68
|
| Rate for Payer: Multiplan Commercial |
$4,963.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,722.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.96
|
| Rate for Payer: Quartz Commercial |
$3,722.40
|
| Rate for Payer: WEA Trust Commercial |
$3,412.20
|
| Rate for Payer: WPS Commercial |
$4,595.30
|
|
|
STENTBM VERIFLEX 3.0 X 20
|
Facility
|
OP
|
$6,204.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3521504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,737.12 |
| Max. Negotiated Rate |
$24,816.00 |
| Rate for Payer: Aetna Commercial |
$5,583.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,737.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,032.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,102.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,977.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,288.12
|
| Rate for Payer: Cash Price |
$1,861.20
|
| Rate for Payer: Cigna Commercial |
$5,707.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,471.76
|
| Rate for Payer: Health EOS Commercial |
$5,521.56
|
| Rate for Payer: HFN Commercial |
$5,707.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,653.00
|
| Rate for Payer: Multiplan Commercial |
$4,963.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,722.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.96
|
| Rate for Payer: Quartz Commercial |
$4,032.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,722.40
|
| Rate for Payer: The Alliance Commercial |
$24,816.00
|
| Rate for Payer: WEA Trust Commercial |
$3,412.20
|
| Rate for Payer: WPS Commercial |
$4,595.30
|
|
|
STENTBM VERIFLEX 3.0 X 24
|
Facility
|
IP
|
$6,204.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3521506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,039.96 |
| Max. Negotiated Rate |
$5,707.68 |
| Rate for Payer: Aetna Commercial |
$5,583.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,288.12
|
| Rate for Payer: Cash Price |
$1,861.20
|
| Rate for Payer: Cigna Commercial |
$5,707.68
|
| Rate for Payer: Health EOS Commercial |
$5,521.56
|
| Rate for Payer: HFN Commercial |
$5,707.68
|
| Rate for Payer: Multiplan Commercial |
$4,963.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,722.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.96
|
| Rate for Payer: Quartz Commercial |
$3,722.40
|
| Rate for Payer: WEA Trust Commercial |
$3,412.20
|
| Rate for Payer: WPS Commercial |
$4,595.30
|
|
|
STENTBM VERIFLEX 3.0 X 24
|
Facility
|
OP
|
$6,204.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3521506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,737.12 |
| Max. Negotiated Rate |
$24,816.00 |
| Rate for Payer: Aetna Commercial |
$5,583.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,737.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,032.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,102.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,977.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,288.12
|
| Rate for Payer: Cash Price |
$1,861.20
|
| Rate for Payer: Cigna Commercial |
$5,707.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,471.76
|
| Rate for Payer: Health EOS Commercial |
$5,521.56
|
| Rate for Payer: HFN Commercial |
$5,707.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,653.00
|
| Rate for Payer: Multiplan Commercial |
$4,963.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,722.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.96
|
| Rate for Payer: Quartz Commercial |
$4,032.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,722.40
|
| Rate for Payer: The Alliance Commercial |
$24,816.00
|
| Rate for Payer: WEA Trust Commercial |
$3,412.20
|
| Rate for Payer: WPS Commercial |
$4,595.30
|
|
|
STENT CATHETER BALLOON GRAFT REL46
|
Facility
|
OP
|
$5,059.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3104708
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,416.52 |
| Max. Negotiated Rate |
$20,236.00 |
| Rate for Payer: Aetna Commercial |
$4,553.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,350.74
|
| Rate for Payer: Aetna Managed Medicare |
$1,416.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,288.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,529.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,428.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,681.27
|
| Rate for Payer: Cash Price |
$1,517.70
|
| Rate for Payer: Cigna Commercial |
$4,654.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,831.02
|
| Rate for Payer: Health EOS Commercial |
$4,502.51
|
| Rate for Payer: HFN Commercial |
$4,654.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,794.25
|
| Rate for Payer: Multiplan Commercial |
$4,047.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,035.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,654.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,478.91
|
| Rate for Payer: Quartz Commercial |
$3,288.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,035.40
|
| Rate for Payer: The Alliance Commercial |
$20,236.00
|
| Rate for Payer: WEA Trust Commercial |
$2,782.45
|
| Rate for Payer: WPS Commercial |
$3,747.20
|
|
|
STENT CATHETER BALLOON GRAFT REL46
|
Facility
|
IP
|
$5,059.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3104708
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,478.91 |
| Max. Negotiated Rate |
$4,654.28 |
| Rate for Payer: Aetna Commercial |
$4,553.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,350.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,681.27
|
| Rate for Payer: Cash Price |
$1,517.70
|
| Rate for Payer: Cigna Commercial |
$4,654.28
|
| Rate for Payer: Health EOS Commercial |
$4,502.51
|
| Rate for Payer: HFN Commercial |
$4,654.28
|
| Rate for Payer: Multiplan Commercial |
$4,047.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,035.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,654.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,478.91
|
| Rate for Payer: Quartz Commercial |
$3,035.40
|
| Rate for Payer: WEA Trust Commercial |
$2,782.45
|
| Rate for Payer: WPS Commercial |
$3,747.20
|
|
|
STENT/CATHETER NEPHROSTOMY PERCUTANEOUS COMBINATION 8FR X 25CM M0064101260
|
Facility
|
OP
|
$1,334.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
5459834
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$373.52 |
| Max. Negotiated Rate |
$5,336.00 |
| Rate for Payer: Aetna Commercial |
$1,200.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,147.24
|
| Rate for Payer: Aetna Managed Medicare |
$373.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$867.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$667.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$640.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$707.02
|
| Rate for Payer: Cash Price |
$400.20
|
| Rate for Payer: Cigna Commercial |
$1,227.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$746.51
|
| Rate for Payer: Health EOS Commercial |
$1,187.26
|
| Rate for Payer: HFN Commercial |
$1,227.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,000.50
|
| Rate for Payer: Multiplan Commercial |
$1,067.20
|
| Rate for Payer: NAPHCARE Commercial |
$800.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,227.28
|
| Rate for Payer: Quartz Beloit One Network |
$653.66
|
| Rate for Payer: Quartz Commercial |
$867.10
|
| Rate for Payer: Quartz Medicare Advantage |
$800.40
|
| Rate for Payer: The Alliance Commercial |
$5,336.00
|
| Rate for Payer: WEA Trust Commercial |
$733.70
|
| Rate for Payer: WPS Commercial |
$988.09
|
|
|
STENT/CATHETER NEPHROSTOMY PERCUTANEOUS COMBINATION 8FR X 25CM M0064101260
|
Facility
|
IP
|
$1,334.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
5459834
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$653.66 |
| Max. Negotiated Rate |
$1,227.28 |
| Rate for Payer: Aetna Commercial |
$1,200.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,147.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$707.02
|
| Rate for Payer: Cash Price |
$400.20
|
| Rate for Payer: Cigna Commercial |
$1,227.28
|
| Rate for Payer: Health EOS Commercial |
$1,187.26
|
| Rate for Payer: HFN Commercial |
$1,227.28
|
| Rate for Payer: Multiplan Commercial |
$1,067.20
|
| Rate for Payer: NAPHCARE Commercial |
$800.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,227.28
|
| Rate for Payer: Quartz Beloit One Network |
$653.66
|
| Rate for Payer: Quartz Commercial |
$800.40
|
| Rate for Payer: WEA Trust Commercial |
$733.70
|
| Rate for Payer: WPS Commercial |
$988.09
|
|
|
STENT C-FLEX 10x10 PIGTAIL
|
Facility
|
OP
|
$915.00
|
|
| Hospital Charge Code |
2971853
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$256.20 |
| Max. Negotiated Rate |
$3,660.00 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Aetna Managed Medicare |
$256.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$594.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$457.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$439.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.03
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.25
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$594.75
|
| Rate for Payer: Quartz Medicare Advantage |
$549.00
|
| Rate for Payer: The Alliance Commercial |
$3,660.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
STENT C-FLEX 10x10 PIGTAIL
|
Facility
|
IP
|
$915.00
|
|
| Hospital Charge Code |
2971853
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.35 |
| Max. Negotiated Rate |
$841.80 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$549.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
STENT C-FLEX 10x5 PIGTAIL
|
Facility
|
IP
|
$915.00
|
|
| Hospital Charge Code |
2971852
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.35 |
| Max. Negotiated Rate |
$841.80 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$549.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
STENT C-FLEX 10x5 PIGTAIL
|
Facility
|
OP
|
$915.00
|
|
| Hospital Charge Code |
2971852
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$256.20 |
| Max. Negotiated Rate |
$3,660.00 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Aetna Managed Medicare |
$256.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$594.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$457.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$439.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.03
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.25
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$594.75
|
| Rate for Payer: Quartz Medicare Advantage |
$549.00
|
| Rate for Payer: The Alliance Commercial |
$3,660.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
STENT CONTOUR SOFT 6 X 22-33 W/O GUIDEWIRE M0061801560
|
Facility
|
IP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520090
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$794.78 |
| Max. Negotiated Rate |
$1,492.24 |
| Rate for Payer: Aetna Commercial |
$1,459.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,394.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.66
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,492.24
|
| Rate for Payer: Health EOS Commercial |
$1,443.58
|
| Rate for Payer: HFN Commercial |
$1,492.24
|
| Rate for Payer: Multiplan Commercial |
$1,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$973.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.24
|
| Rate for Payer: Quartz Beloit One Network |
$794.78
|
| Rate for Payer: Quartz Commercial |
$973.20
|
| Rate for Payer: WEA Trust Commercial |
$892.10
|
| Rate for Payer: WPS Commercial |
$1,201.42
|
|
|
STENT CONTOUR SOFT 6 X 22-33 W/O GUIDEWIRE M0061801560
|
Facility
|
OP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520090
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$454.16 |
| Max. Negotiated Rate |
$6,488.00 |
| Rate for Payer: Aetna Commercial |
$1,459.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,394.92
|
| Rate for Payer: Aetna Managed Medicare |
$454.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,054.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$811.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$778.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.66
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,492.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$907.67
|
| Rate for Payer: Health EOS Commercial |
$1,443.58
|
| Rate for Payer: HFN Commercial |
$1,492.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,216.50
|
| Rate for Payer: Multiplan Commercial |
$1,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$973.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.24
|
| Rate for Payer: Quartz Beloit One Network |
$794.78
|
| Rate for Payer: Quartz Commercial |
$1,054.30
|
| Rate for Payer: Quartz Medicare Advantage |
$973.20
|
| Rate for Payer: The Alliance Commercial |
$6,488.00
|
| Rate for Payer: WEA Trust Commercial |
$892.10
|
| Rate for Payer: WPS Commercial |
$1,201.42
|
|
|
STENT CONTOUR SOFT 7 X 22-30 W/O GUIDEWIRE M0061801570
|
Facility
|
IP
|
$1,685.00
|
|
| Hospital Charge Code |
4520089
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.65 |
| Max. Negotiated Rate |
$1,550.20 |
| Rate for Payer: Aetna Commercial |
$1,516.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,449.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$893.05
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,550.20
|
| Rate for Payer: Health EOS Commercial |
$1,499.65
|
| Rate for Payer: HFN Commercial |
$1,550.20
|
| Rate for Payer: Multiplan Commercial |
$1,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,011.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.20
|
| Rate for Payer: Quartz Beloit One Network |
$825.65
|
| Rate for Payer: Quartz Commercial |
$1,011.00
|
| Rate for Payer: WEA Trust Commercial |
$926.75
|
| Rate for Payer: WPS Commercial |
$1,248.08
|
|
|
STENT CONTOUR SOFT 7 X 22-30 W/O GUIDEWIRE M0061801570
|
Facility
|
OP
|
$1,685.00
|
|
| Hospital Charge Code |
4520089
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$471.80 |
| Max. Negotiated Rate |
$6,740.00 |
| Rate for Payer: Aetna Commercial |
$1,516.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,449.10
|
| Rate for Payer: Aetna Managed Medicare |
$471.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,095.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$842.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$808.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$893.05
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,550.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$942.93
|
| Rate for Payer: Health EOS Commercial |
$1,499.65
|
| Rate for Payer: HFN Commercial |
$1,550.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,263.75
|
| Rate for Payer: Multiplan Commercial |
$1,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,011.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.20
|
| Rate for Payer: Quartz Beloit One Network |
$825.65
|
| Rate for Payer: Quartz Commercial |
$1,095.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,011.00
|
| Rate for Payer: The Alliance Commercial |
$6,740.00
|
| Rate for Payer: WEA Trust Commercial |
$926.75
|
| Rate for Payer: WPS Commercial |
$1,248.08
|
|
|
Stent-Coronary Bare Metal
|
Facility
|
IP
|
$5,153.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,524.97 |
| Max. Negotiated Rate |
$4,740.76 |
| Rate for Payer: Aetna Commercial |
$4,637.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,431.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,731.09
|
| Rate for Payer: Cash Price |
$1,545.90
|
| Rate for Payer: Cigna Commercial |
$4,740.76
|
| Rate for Payer: Health EOS Commercial |
$4,586.17
|
| Rate for Payer: HFN Commercial |
$4,740.76
|
| Rate for Payer: Multiplan Commercial |
$4,122.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,091.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,740.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,524.97
|
| Rate for Payer: Quartz Commercial |
$3,091.80
|
| Rate for Payer: WEA Trust Commercial |
$2,834.15
|
| Rate for Payer: WPS Commercial |
$3,816.83
|
|
|
Stent-Coronary Bare Metal
|
Facility
|
OP
|
$5,153.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,442.84 |
| Max. Negotiated Rate |
$20,612.00 |
| Rate for Payer: Aetna Commercial |
$4,637.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,431.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,442.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,349.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,576.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,473.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,731.09
|
| Rate for Payer: Cash Price |
$1,545.90
|
| Rate for Payer: Cigna Commercial |
$4,740.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,883.62
|
| Rate for Payer: Health EOS Commercial |
$4,586.17
|
| Rate for Payer: HFN Commercial |
$4,740.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,864.75
|
| Rate for Payer: Multiplan Commercial |
$4,122.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,091.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,740.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,524.97
|
| Rate for Payer: Quartz Commercial |
$3,349.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,091.80
|
| Rate for Payer: The Alliance Commercial |
$20,612.00
|
| Rate for Payer: WEA Trust Commercial |
$2,834.15
|
| Rate for Payer: WPS Commercial |
$3,816.83
|
|
|
Stent-Coronary DES
|
Facility
|
OP
|
$7,595.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
4001126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,126.60 |
| Max. Negotiated Rate |
$30,380.00 |
| Rate for Payer: Aetna Commercial |
$6,835.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,531.70
|
| Rate for Payer: Aetna Managed Medicare |
$2,126.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,936.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,797.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,645.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,025.35
|
| Rate for Payer: Cash Price |
$2,278.50
|
| Rate for Payer: Cigna Commercial |
$6,987.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,250.16
|
| Rate for Payer: Health EOS Commercial |
$6,759.55
|
| Rate for Payer: HFN Commercial |
$6,987.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,696.25
|
| Rate for Payer: Multiplan Commercial |
$6,076.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,557.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,987.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,721.55
|
| Rate for Payer: Quartz Commercial |
$4,936.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,557.00
|
| Rate for Payer: The Alliance Commercial |
$30,380.00
|
| Rate for Payer: WEA Trust Commercial |
$4,177.25
|
| Rate for Payer: WPS Commercial |
$5,625.62
|
|
|
Stent-Coronary DES
|
Facility
|
IP
|
$7,595.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
4001126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,721.55 |
| Max. Negotiated Rate |
$6,987.40 |
| Rate for Payer: Aetna Commercial |
$6,835.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,531.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,025.35
|
| Rate for Payer: Cash Price |
$2,278.50
|
| Rate for Payer: Cigna Commercial |
$6,987.40
|
| Rate for Payer: Health EOS Commercial |
$6,759.55
|
| Rate for Payer: HFN Commercial |
$6,987.40
|
| Rate for Payer: Multiplan Commercial |
$6,076.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,557.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,987.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,721.55
|
| Rate for Payer: Quartz Commercial |
$4,557.00
|
| Rate for Payer: WEA Trust Commercial |
$4,177.25
|
| Rate for Payer: WPS Commercial |
$5,625.62
|
|
