|
STENT COVERED COVERA 10MM X 60MM AVSM10060
|
Facility
|
OP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204965
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,309.88 |
| Max. Negotiated Rate |
$47,284.00 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Aetna Managed Medicare |
$3,309.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,683.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,910.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,674.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,615.03
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,865.75
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,683.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,092.60
|
| Rate for Payer: The Alliance Commercial |
$47,284.00
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 10MM X 60MM AVSM10060
|
Facility
|
IP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204965
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,792.29 |
| Max. Negotiated Rate |
$10,875.32 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,092.60
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 10MM X 80MM AVSM10080
|
Facility
|
IP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,792.29 |
| Max. Negotiated Rate |
$10,875.32 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,092.60
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 10MM X 80MM AVSM10080
|
Facility
|
OP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,309.88 |
| Max. Negotiated Rate |
$47,284.00 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Aetna Managed Medicare |
$3,309.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,683.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,910.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,674.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,615.03
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,865.75
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,683.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,092.60
|
| Rate for Payer: The Alliance Commercial |
$47,284.00
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 7MM X 60MM AVSM07060
|
Facility
|
OP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204966
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,309.88 |
| Max. Negotiated Rate |
$47,284.00 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Aetna Managed Medicare |
$3,309.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,683.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,910.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,674.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,615.03
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,865.75
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,683.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,092.60
|
| Rate for Payer: The Alliance Commercial |
$47,284.00
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 7MM X 60MM AVSM07060
|
Facility
|
IP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204966
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,792.29 |
| Max. Negotiated Rate |
$10,875.32 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,092.60
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 7MM X 80MM AVSM07080
|
Facility
|
IP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,792.29 |
| Max. Negotiated Rate |
$10,875.32 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,092.60
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 7MM X 80MM AVSM07080
|
Facility
|
OP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,309.88 |
| Max. Negotiated Rate |
$47,284.00 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Aetna Managed Medicare |
$3,309.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,683.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,910.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,674.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,615.03
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,865.75
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,683.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,092.60
|
| Rate for Payer: The Alliance Commercial |
$47,284.00
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 8MM X 60MM AVSM08060
|
Facility
|
OP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204963
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,309.88 |
| Max. Negotiated Rate |
$47,284.00 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Aetna Managed Medicare |
$3,309.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,683.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,910.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,674.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,615.03
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,865.75
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,683.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,092.60
|
| Rate for Payer: The Alliance Commercial |
$47,284.00
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 8MM X 60MM AVSM08060
|
Facility
|
IP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204963
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,792.29 |
| Max. Negotiated Rate |
$10,875.32 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,092.60
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 8MM X 80MM AVSM08080
|
Facility
|
OP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204968
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,309.88 |
| Max. Negotiated Rate |
$47,284.00 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Aetna Managed Medicare |
$3,309.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,683.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,910.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,674.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,615.03
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,865.75
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,683.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,092.60
|
| Rate for Payer: The Alliance Commercial |
$47,284.00
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 8MM X 80MM AVSM08080
|
Facility
|
IP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204968
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,792.29 |
| Max. Negotiated Rate |
$10,875.32 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,092.60
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 9MM X 60MM AVSM09060
|
Facility
|
IP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,792.29 |
| Max. Negotiated Rate |
$10,875.32 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,092.60
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 9MM X 60MM AVSM09060
|
Facility
|
OP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,309.88 |
| Max. Negotiated Rate |
$47,284.00 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Aetna Managed Medicare |
$3,309.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,683.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,910.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,674.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,615.03
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,865.75
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,683.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,092.60
|
| Rate for Payer: The Alliance Commercial |
$47,284.00
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 9MM X 80MM AVSM09080
|
Facility
|
OP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,309.88 |
| Max. Negotiated Rate |
$47,284.00 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Aetna Managed Medicare |
$3,309.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,683.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,910.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,674.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,615.03
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,865.75
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,683.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,092.60
|
| Rate for Payer: The Alliance Commercial |
$47,284.00
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT COVERED COVERA 9MM X 80MM AVSM09080
|
Facility
|
IP
|
$11,821.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,792.29 |
| Max. Negotiated Rate |
$10,875.32 |
| Rate for Payer: Aetna Commercial |
$10,638.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,166.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,265.13
|
| Rate for Payer: Cash Price |
$3,546.30
|
| Rate for Payer: Cigna Commercial |
$10,875.32
|
| Rate for Payer: Health EOS Commercial |
$10,520.69
|
| Rate for Payer: HFN Commercial |
$10,875.32
|
| Rate for Payer: Multiplan Commercial |
$9,456.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,092.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,875.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,792.29
|
| Rate for Payer: Quartz Commercial |
$7,092.60
|
| Rate for Payer: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
|
STENT DE ELEMENT PROMUS 2.5mm x 32mm
|
Facility
|
OP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
3595491
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.04 |
| Max. Negotiated Rate |
$29,272.00 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,049.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,756.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,659.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,512.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,095.15
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,488.50
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,756.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,390.80
|
| Rate for Payer: The Alliance Commercial |
$29,272.00
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE ELEMENT PROMUS 2.5mm x 32mm
|
Facility
|
IP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
3595491
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.82 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE ELEMENT PROMUS 2.75 X 32
|
Facility
|
IP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
3525522
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.82 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE ELEMENT PROMUS 2.75 X 32
|
Facility
|
OP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
3525522
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.04 |
| Max. Negotiated Rate |
$29,272.00 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,049.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,756.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,659.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,512.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,095.15
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,488.50
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,756.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,390.80
|
| Rate for Payer: The Alliance Commercial |
$29,272.00
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE ION MONO 2.25 X 12
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.88 |
| Max. Negotiated Rate |
$83,584.00 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,582.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,448.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,030.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,693.40
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,672.00
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$13,582.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.60
|
| Rate for Payer: The Alliance Commercial |
$83,584.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
STENT DE ION MONO 2.25 X 12
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,239.04 |
| Max. Negotiated Rate |
$19,224.32 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$12,537.60
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
STENT DE ION MONO 2.25 X 16
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973813
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.88 |
| Max. Negotiated Rate |
$83,584.00 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,582.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,448.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,030.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,693.40
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,672.00
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$13,582.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.60
|
| Rate for Payer: The Alliance Commercial |
$83,584.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
STENT DE ION MONO 2.25 X 16
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973813
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,239.04 |
| Max. Negotiated Rate |
$19,224.32 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$12,537.60
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
STENT DE ION MONO 2.25 X 20
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973819
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,239.04 |
| Max. Negotiated Rate |
$19,224.32 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$12,537.60
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
