|
STENT GRAFT 3.0 x 19mm JOS #12744-19
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973906
|
|
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 GRAFT 3.0 x 19mm JOS #12744-19
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973906
|
|
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 GRAFT 4.0 x 16mm ***DISCONTINUED
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973907
|
|
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 GRAFT 4.0 x 16mm ***DISCONTINUED
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973907
|
|
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 GRAFT 4.0 x 19mm JOS #12746-19
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973908
|
|
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 GRAFT 4.0 x 19mm JOS #12746-19
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973908
|
|
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 GRAFT FLUENCY 12MM X 60MM X 80CM FEM12060
|
Facility
|
OP
|
$11,348.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,177.44 |
| Max. Negotiated Rate |
$45,392.00 |
| Rate for Payer: Aetna Commercial |
$10,213.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,759.28
|
| Rate for Payer: Aetna Managed Medicare |
$3,177.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,376.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,674.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,447.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,014.44
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,440.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,350.34
|
| Rate for Payer: Health EOS Commercial |
$10,099.72
|
| Rate for Payer: HFN Commercial |
$10,440.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,511.00
|
| Rate for Payer: Multiplan Commercial |
$9,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,808.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,440.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,560.52
|
| Rate for Payer: Quartz Commercial |
$7,376.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,808.80
|
| Rate for Payer: The Alliance Commercial |
$45,392.00
|
| Rate for Payer: WEA Trust Commercial |
$6,241.40
|
| Rate for Payer: WPS Commercial |
$8,405.46
|
|
|
STENT GRAFT FLUENCY 12MM X 60MM X 80CM FEM12060
|
Facility
|
IP
|
$11,348.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,560.52 |
| Max. Negotiated Rate |
$10,440.16 |
| Rate for Payer: Aetna Commercial |
$10,213.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,759.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,014.44
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,440.16
|
| Rate for Payer: Health EOS Commercial |
$10,099.72
|
| Rate for Payer: HFN Commercial |
$10,440.16
|
| Rate for Payer: Multiplan Commercial |
$9,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,808.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,440.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,560.52
|
| Rate for Payer: Quartz Commercial |
$6,808.80
|
| Rate for Payer: WEA Trust Commercial |
$6,241.40
|
| Rate for Payer: WPS Commercial |
$8,405.46
|
|
|
STENT GRAFT FLUENCY 13.5MM X 60MM X 80CM FEM14060
|
Facility
|
OP
|
$11,348.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,177.44 |
| Max. Negotiated Rate |
$45,392.00 |
| Rate for Payer: Aetna Commercial |
$10,213.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,759.28
|
| Rate for Payer: Aetna Managed Medicare |
$3,177.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,376.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,674.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,447.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,014.44
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,440.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,350.34
|
| Rate for Payer: Health EOS Commercial |
$10,099.72
|
| Rate for Payer: HFN Commercial |
$10,440.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,511.00
|
| Rate for Payer: Multiplan Commercial |
$9,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,808.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,440.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,560.52
|
| Rate for Payer: Quartz Commercial |
$7,376.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,808.80
|
| Rate for Payer: The Alliance Commercial |
$45,392.00
|
| Rate for Payer: WEA Trust Commercial |
$6,241.40
|
| Rate for Payer: WPS Commercial |
$8,405.46
|
|
|
STENT GRAFT FLUENCY 13.5MM X 60MM X 80CM FEM14060
|
Facility
|
IP
|
$11,348.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,560.52 |
| Max. Negotiated Rate |
$10,440.16 |
| Rate for Payer: Aetna Commercial |
$10,213.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,759.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,014.44
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,440.16
|
| Rate for Payer: Health EOS Commercial |
$10,099.72
|
| Rate for Payer: HFN Commercial |
$10,440.16
|
| Rate for Payer: Multiplan Commercial |
$9,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,808.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,440.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,560.52
|
| Rate for Payer: Quartz Commercial |
$6,808.80
|
| Rate for Payer: WEA Trust Commercial |
$6,241.40
|
| Rate for Payer: WPS Commercial |
$8,405.46
|
|
|
STENT ICAST 10mm x 38mm X 120 85424
|
Facility
|
OP
|
$16,316.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973919
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,568.48 |
| Max. Negotiated Rate |
$65,264.00 |
| Rate for Payer: Aetna Commercial |
$14,684.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,031.76
|
| Rate for Payer: Aetna Managed Medicare |
$4,568.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,605.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,158.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,831.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,647.48
|
| Rate for Payer: Cash Price |
$4,894.80
|
| Rate for Payer: Cigna Commercial |
$15,010.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,130.43
|
| Rate for Payer: Health EOS Commercial |
$14,521.24
|
| Rate for Payer: HFN Commercial |
$15,010.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,237.00
|
| Rate for Payer: Multiplan Commercial |
$13,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,789.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,010.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,994.84
|
| Rate for Payer: Quartz Commercial |
$10,605.40
|
| Rate for Payer: Quartz Medicare Advantage |
$9,789.60
|
| Rate for Payer: The Alliance Commercial |
$65,264.00
|
| Rate for Payer: WEA Trust Commercial |
$8,973.80
|
| Rate for Payer: WPS Commercial |
$12,085.26
|
|
|
STENT ICAST 10mm x 38mm X 120 85424
|
Facility
|
IP
|
$16,316.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973919
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,994.84 |
| Max. Negotiated Rate |
$15,010.72 |
| Rate for Payer: Aetna Commercial |
$14,684.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,031.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,647.48
|
| Rate for Payer: Cash Price |
$4,894.80
|
| Rate for Payer: Cigna Commercial |
$15,010.72
|
| Rate for Payer: Health EOS Commercial |
$14,521.24
|
| Rate for Payer: HFN Commercial |
$15,010.72
|
| Rate for Payer: Multiplan Commercial |
$13,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,789.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,010.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,994.84
|
| Rate for Payer: Quartz Commercial |
$9,789.60
|
| Rate for Payer: WEA Trust Commercial |
$8,973.80
|
| Rate for Payer: WPS Commercial |
$12,085.26
|
|
|
STENT INFRAVISION LIGHTED 0220-180-517
|
Facility
|
IP
|
$3,078.00
|
|
| Hospital Charge Code |
2966089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,508.22 |
| Max. Negotiated Rate |
$2,831.76 |
| Rate for Payer: Aetna Commercial |
$2,770.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,647.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,631.34
|
| Rate for Payer: Cash Price |
$923.40
|
| Rate for Payer: Cigna Commercial |
$2,831.76
|
| Rate for Payer: Health EOS Commercial |
$2,739.42
|
| Rate for Payer: HFN Commercial |
$2,831.76
|
| Rate for Payer: Multiplan Commercial |
$2,462.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,846.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,831.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,508.22
|
| Rate for Payer: Quartz Commercial |
$1,846.80
|
| Rate for Payer: WEA Trust Commercial |
$1,692.90
|
| Rate for Payer: WPS Commercial |
$2,279.87
|
|
|
STENT INFRAVISION LIGHTED 0220-180-517
|
Facility
|
OP
|
$3,078.00
|
|
| Hospital Charge Code |
2966089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$861.84 |
| Max. Negotiated Rate |
$12,312.00 |
| Rate for Payer: Aetna Commercial |
$2,770.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,647.08
|
| Rate for Payer: Aetna Managed Medicare |
$861.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,000.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,539.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,477.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,631.34
|
| Rate for Payer: Cash Price |
$923.40
|
| Rate for Payer: Cigna Commercial |
$2,831.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,722.45
|
| Rate for Payer: Health EOS Commercial |
$2,739.42
|
| Rate for Payer: HFN Commercial |
$2,831.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,308.50
|
| Rate for Payer: Multiplan Commercial |
$2,462.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,846.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,831.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,508.22
|
| Rate for Payer: Quartz Commercial |
$2,000.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,846.80
|
| Rate for Payer: The Alliance Commercial |
$12,312.00
|
| Rate for Payer: WEA Trust Commercial |
$1,692.90
|
| Rate for Payer: WPS Commercial |
$2,279.87
|
|
|
STENT IRIS LIGHTED URETERAL 0220-180-518
|
Facility
|
OP
|
$2,537.00
|
|
| Hospital Charge Code |
5306838
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$710.36 |
| Max. Negotiated Rate |
$10,148.00 |
| Rate for Payer: Aetna Commercial |
$2,283.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,181.82
|
| Rate for Payer: Aetna Managed Medicare |
$710.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,649.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,268.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,217.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,344.61
|
| Rate for Payer: Cash Price |
$761.10
|
| Rate for Payer: Cigna Commercial |
$2,334.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,419.71
|
| Rate for Payer: Health EOS Commercial |
$2,257.93
|
| Rate for Payer: HFN Commercial |
$2,334.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,902.75
|
| Rate for Payer: Multiplan Commercial |
$2,029.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,522.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,334.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,243.13
|
| Rate for Payer: Quartz Commercial |
$1,649.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,522.20
|
| Rate for Payer: The Alliance Commercial |
$10,148.00
|
| Rate for Payer: WEA Trust Commercial |
$1,395.35
|
| Rate for Payer: WPS Commercial |
$1,879.16
|
|
|
STENT IRIS LIGHTED URETERAL 0220-180-518
|
Facility
|
IP
|
$2,537.00
|
|
| Hospital Charge Code |
5306838
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,243.13 |
| Max. Negotiated Rate |
$2,334.04 |
| Rate for Payer: Aetna Commercial |
$2,283.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,181.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,344.61
|
| Rate for Payer: Cash Price |
$761.10
|
| Rate for Payer: Cigna Commercial |
$2,334.04
|
| Rate for Payer: Health EOS Commercial |
$2,257.93
|
| Rate for Payer: HFN Commercial |
$2,334.04
|
| Rate for Payer: Multiplan Commercial |
$2,029.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,522.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,334.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,243.13
|
| Rate for Payer: Quartz Commercial |
$1,522.20
|
| Rate for Payer: WEA Trust Commercial |
$1,395.35
|
| Rate for Payer: WPS Commercial |
$1,879.16
|
|
|
STENT LOOP 8 X 28 POLARIS 155-254
|
Facility
|
OP
|
$1,805.00
|
|
| Hospital Charge Code |
2964819
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.40 |
| Max. Negotiated Rate |
$7,220.00 |
| Rate for Payer: Aetna Commercial |
$1,624.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,552.30
|
| Rate for Payer: Aetna Managed Medicare |
$505.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,173.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$902.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$866.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$956.65
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,660.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,010.08
|
| Rate for Payer: Health EOS Commercial |
$1,606.45
|
| Rate for Payer: HFN Commercial |
$1,660.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,353.75
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,083.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,660.60
|
| Rate for Payer: Quartz Beloit One Network |
$884.45
|
| Rate for Payer: Quartz Commercial |
$1,173.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,083.00
|
| Rate for Payer: The Alliance Commercial |
$7,220.00
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$1,336.96
|
|
|
STENT LOOP 8 X 28 POLARIS 155-254
|
Facility
|
IP
|
$1,805.00
|
|
| Hospital Charge Code |
2964819
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.45 |
| Max. Negotiated Rate |
$1,660.60 |
| Rate for Payer: Aetna Commercial |
$1,624.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,552.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$956.65
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,660.60
|
| Rate for Payer: Health EOS Commercial |
$1,606.45
|
| Rate for Payer: HFN Commercial |
$1,660.60
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,083.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,660.60
|
| Rate for Payer: Quartz Beloit One Network |
$884.45
|
| Rate for Payer: Quartz Commercial |
$1,083.00
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$1,336.96
|
|
|
STENT LOOP 8 X 30 POLARIS 155-255
|
Facility
|
OP
|
$1,805.00
|
|
| Hospital Charge Code |
2964820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.40 |
| Max. Negotiated Rate |
$7,220.00 |
| Rate for Payer: Aetna Commercial |
$1,624.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,552.30
|
| Rate for Payer: Aetna Managed Medicare |
$505.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,173.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$902.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$866.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$956.65
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,660.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,010.08
|
| Rate for Payer: Health EOS Commercial |
$1,606.45
|
| Rate for Payer: HFN Commercial |
$1,660.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,353.75
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,083.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,660.60
|
| Rate for Payer: Quartz Beloit One Network |
$884.45
|
| Rate for Payer: Quartz Commercial |
$1,173.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,083.00
|
| Rate for Payer: The Alliance Commercial |
$7,220.00
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$1,336.96
|
|
|
STENT LOOP 8 X 30 POLARIS 155-255
|
Facility
|
IP
|
$1,805.00
|
|
| Hospital Charge Code |
2964820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.45 |
| Max. Negotiated Rate |
$1,660.60 |
| Rate for Payer: Aetna Commercial |
$1,624.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,552.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$956.65
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,660.60
|
| Rate for Payer: Health EOS Commercial |
$1,606.45
|
| Rate for Payer: HFN Commercial |
$1,660.60
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,083.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,660.60
|
| Rate for Payer: Quartz Beloit One Network |
$884.45
|
| Rate for Payer: Quartz Commercial |
$1,083.00
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$1,336.96
|
|
|
STENT METAL COLON 25x30mm 9cm #M00565050
|
Facility
|
IP
|
$14,613.00
|
|
| Hospital Charge Code |
3072501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,160.37 |
| Max. Negotiated Rate |
$13,443.96 |
| Rate for Payer: Aetna Commercial |
$13,151.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,567.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,744.89
|
| Rate for Payer: Cash Price |
$4,383.90
|
| Rate for Payer: Cigna Commercial |
$13,443.96
|
| Rate for Payer: Health EOS Commercial |
$13,005.57
|
| Rate for Payer: HFN Commercial |
$13,443.96
|
| Rate for Payer: Multiplan Commercial |
$11,690.40
|
| Rate for Payer: NAPHCARE Commercial |
$8,767.80
|
| Rate for Payer: Preferred Network Access Commercial |
$13,443.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,160.37
|
| Rate for Payer: Quartz Commercial |
$8,767.80
|
| Rate for Payer: WEA Trust Commercial |
$8,037.15
|
| Rate for Payer: WPS Commercial |
$10,823.85
|
|
|
STENT METAL COLON 25x30mm 9cm #M00565050
|
Facility
|
OP
|
$14,613.00
|
|
| Hospital Charge Code |
3072501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,091.64 |
| Max. Negotiated Rate |
$58,452.00 |
| Rate for Payer: Aetna Commercial |
$13,151.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,567.18
|
| Rate for Payer: Aetna Managed Medicare |
$4,091.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,498.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,306.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,014.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,744.89
|
| Rate for Payer: Cash Price |
$4,383.90
|
| Rate for Payer: Cigna Commercial |
$13,443.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,177.43
|
| Rate for Payer: Health EOS Commercial |
$13,005.57
|
| Rate for Payer: HFN Commercial |
$13,443.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,959.75
|
| Rate for Payer: Multiplan Commercial |
$11,690.40
|
| Rate for Payer: NAPHCARE Commercial |
$8,767.80
|
| Rate for Payer: Preferred Network Access Commercial |
$13,443.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,160.37
|
| Rate for Payer: Quartz Commercial |
$9,498.45
|
| Rate for Payer: Quartz Medicare Advantage |
$8,767.80
|
| Rate for Payer: The Alliance Commercial |
$58,452.00
|
| Rate for Payer: WEA Trust Commercial |
$8,037.15
|
| Rate for Payer: WPS Commercial |
$10,823.85
|
|
|
STENT METALLIC 6X22 URETERAL G34109
|
Facility
|
IP
|
$8,256.00
|
|
| Hospital Charge Code |
2964978
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,045.44 |
| Max. Negotiated Rate |
$7,595.52 |
| Rate for Payer: Aetna Commercial |
$7,430.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,100.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,375.68
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$7,595.52
|
| Rate for Payer: Health EOS Commercial |
$7,347.84
|
| Rate for Payer: HFN Commercial |
$7,595.52
|
| Rate for Payer: Multiplan Commercial |
$6,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,953.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,595.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,045.44
|
| Rate for Payer: Quartz Commercial |
$4,953.60
|
| Rate for Payer: WEA Trust Commercial |
$4,540.80
|
| Rate for Payer: WPS Commercial |
$6,115.22
|
|
|
STENT METALLIC 6X22 URETERAL G34109
|
Facility
|
OP
|
$8,256.00
|
|
| Hospital Charge Code |
2964978
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,311.68 |
| Max. Negotiated Rate |
$33,024.00 |
| Rate for Payer: Aetna Commercial |
$7,430.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,100.16
|
| Rate for Payer: Aetna Managed Medicare |
$2,311.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,366.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,128.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,962.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,375.68
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$7,595.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,620.06
|
| Rate for Payer: Health EOS Commercial |
$7,347.84
|
| Rate for Payer: HFN Commercial |
$7,595.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,192.00
|
| Rate for Payer: Multiplan Commercial |
$6,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,953.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,595.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,045.44
|
| Rate for Payer: Quartz Commercial |
$5,366.40
|
| Rate for Payer: Quartz Medicare Advantage |
$4,953.60
|
| Rate for Payer: The Alliance Commercial |
$33,024.00
|
| Rate for Payer: WEA Trust Commercial |
$4,540.80
|
| Rate for Payer: WPS Commercial |
$6,115.22
|
|
|
STENT METALLIC 6X24 URETERAL G34110
|
Facility
|
IP
|
$8,574.00
|
|
| Hospital Charge Code |
2964979
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,201.26 |
| Max. Negotiated Rate |
$7,888.08 |
| Rate for Payer: Aetna Commercial |
$7,716.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,373.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,544.22
|
| Rate for Payer: Cash Price |
$2,572.20
|
| Rate for Payer: Cigna Commercial |
$7,888.08
|
| Rate for Payer: Health EOS Commercial |
$7,630.86
|
| Rate for Payer: HFN Commercial |
$7,888.08
|
| Rate for Payer: Multiplan Commercial |
$6,859.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,144.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,888.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,201.26
|
| Rate for Payer: Quartz Commercial |
$5,144.40
|
| Rate for Payer: WEA Trust Commercial |
$4,715.70
|
| Rate for Payer: WPS Commercial |
$6,350.76
|
|
