|
STENT METALLIC 6X24 URETERAL G34110
|
Facility
|
OP
|
$8,574.00
|
|
| Hospital Charge Code |
2964979
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,400.72 |
| Max. Negotiated Rate |
$34,296.00 |
| Rate for Payer: Aetna Commercial |
$7,716.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,373.64
|
| Rate for Payer: Aetna Managed Medicare |
$2,400.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,573.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,115.52
|
| 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: Dean Health DHI/DHP/ASO |
$4,798.01
|
| Rate for Payer: Health EOS Commercial |
$7,630.86
|
| Rate for Payer: HFN Commercial |
$7,888.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,430.50
|
| 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 |
$5,573.10
|
| Rate for Payer: Quartz Medicare Advantage |
$5,144.40
|
| Rate for Payer: The Alliance Commercial |
$34,296.00
|
| Rate for Payer: WEA Trust Commercial |
$4,715.70
|
| Rate for Payer: WPS Commercial |
$6,350.76
|
|
|
STENT METALLIC 6X28 URETERAL G34112
|
Facility
|
IP
|
$8,256.00
|
|
| Hospital Charge Code |
2964980
|
|
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 6X28 URETERAL G34112
|
Facility
|
OP
|
$8,256.00
|
|
| Hospital Charge Code |
2964980
|
|
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 6 X 30 URETERAL G34176
|
Facility
|
OP
|
$8,256.00
|
|
| Hospital Charge Code |
2964981
|
|
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 6 X 30 URETERAL G34176
|
Facility
|
IP
|
$8,256.00
|
|
| Hospital Charge Code |
2964981
|
|
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-Palmaz Blue
|
Facility
|
IP
|
$11,473.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4139320
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$5,621.77 |
| Max. Negotiated Rate |
$10,555.16 |
| Rate for Payer: Aetna Commercial |
$10,325.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,866.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,080.69
|
| Rate for Payer: Cash Price |
$3,441.90
|
| Rate for Payer: Cigna Commercial |
$10,555.16
|
| Rate for Payer: Health EOS Commercial |
$10,210.97
|
| Rate for Payer: HFN Commercial |
$10,555.16
|
| Rate for Payer: Multiplan Commercial |
$9,178.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,883.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,555.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,621.77
|
| Rate for Payer: Quartz Commercial |
$6,883.80
|
| Rate for Payer: WEA Trust Commercial |
$6,310.15
|
| Rate for Payer: WPS Commercial |
$8,498.05
|
|
|
Stent-Palmaz Blue
|
Facility
|
OP
|
$11,473.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4139320
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,212.44 |
| Max. Negotiated Rate |
$45,892.00 |
| Rate for Payer: Aetna Commercial |
$10,325.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,866.78
|
| Rate for Payer: Aetna Managed Medicare |
$3,212.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,457.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,736.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,507.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,080.69
|
| Rate for Payer: Cash Price |
$3,441.90
|
| Rate for Payer: Cigna Commercial |
$10,555.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,420.29
|
| Rate for Payer: Health EOS Commercial |
$10,210.97
|
| Rate for Payer: HFN Commercial |
$10,555.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,604.75
|
| Rate for Payer: Multiplan Commercial |
$9,178.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,883.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,555.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,621.77
|
| Rate for Payer: Quartz Commercial |
$7,457.45
|
| Rate for Payer: Quartz Medicare Advantage |
$6,883.80
|
| Rate for Payer: The Alliance Commercial |
$45,892.00
|
| Rate for Payer: WEA Trust Commercial |
$6,310.15
|
| Rate for Payer: WPS Commercial |
$8,498.05
|
|
|
STENT PALMAZ BLUE 6MMX 18MM X 135CM
|
Facility
|
OP
|
$11,473.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3082053
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,212.44 |
| Max. Negotiated Rate |
$45,892.00 |
| Rate for Payer: Aetna Commercial |
$10,325.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,866.78
|
| Rate for Payer: Aetna Managed Medicare |
$3,212.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,457.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,736.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,507.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,080.69
|
| Rate for Payer: Cash Price |
$3,441.90
|
| Rate for Payer: Cigna Commercial |
$10,555.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,420.29
|
| Rate for Payer: Health EOS Commercial |
$10,210.97
|
| Rate for Payer: HFN Commercial |
$10,555.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,604.75
|
| Rate for Payer: Multiplan Commercial |
$9,178.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,883.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,555.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,621.77
|
| Rate for Payer: Quartz Commercial |
$7,457.45
|
| Rate for Payer: Quartz Medicare Advantage |
$6,883.80
|
| Rate for Payer: The Alliance Commercial |
$45,892.00
|
| Rate for Payer: WEA Trust Commercial |
$6,310.15
|
| Rate for Payer: WPS Commercial |
$8,498.05
|
|
|
STENT PALMAZ BLUE 6MMX 18MM X 135CM
|
Facility
|
IP
|
$11,473.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3082053
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,621.77 |
| Max. Negotiated Rate |
$10,555.16 |
| Rate for Payer: Aetna Commercial |
$10,325.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,866.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,080.69
|
| Rate for Payer: Cash Price |
$3,441.90
|
| Rate for Payer: Cigna Commercial |
$10,555.16
|
| Rate for Payer: Health EOS Commercial |
$10,210.97
|
| Rate for Payer: HFN Commercial |
$10,555.16
|
| Rate for Payer: Multiplan Commercial |
$9,178.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,883.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,555.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,621.77
|
| Rate for Payer: Quartz Commercial |
$6,883.80
|
| Rate for Payer: WEA Trust Commercial |
$6,310.15
|
| Rate for Payer: WPS Commercial |
$8,498.05
|
|
|
STENT PALMAZ BLUE 7 X 15MM PB1570BSX
|
Facility
|
IP
|
$11,473.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3549514
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,621.77 |
| Max. Negotiated Rate |
$10,555.16 |
| Rate for Payer: Aetna Commercial |
$10,325.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,866.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,080.69
|
| Rate for Payer: Cash Price |
$3,441.90
|
| Rate for Payer: Cigna Commercial |
$10,555.16
|
| Rate for Payer: Health EOS Commercial |
$10,210.97
|
| Rate for Payer: HFN Commercial |
$10,555.16
|
| Rate for Payer: Multiplan Commercial |
$9,178.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,883.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,555.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,621.77
|
| Rate for Payer: Quartz Commercial |
$6,883.80
|
| Rate for Payer: WEA Trust Commercial |
$6,310.15
|
| Rate for Payer: WPS Commercial |
$8,498.05
|
|
|
STENT PALMAZ BLUE 7 X 15MM PB1570BSX
|
Facility
|
OP
|
$11,473.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3549514
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,212.44 |
| Max. Negotiated Rate |
$45,892.00 |
| Rate for Payer: Aetna Commercial |
$10,325.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,866.78
|
| Rate for Payer: Aetna Managed Medicare |
$3,212.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,457.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,736.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,507.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,080.69
|
| Rate for Payer: Cash Price |
$3,441.90
|
| Rate for Payer: Cigna Commercial |
$10,555.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,420.29
|
| Rate for Payer: Health EOS Commercial |
$10,210.97
|
| Rate for Payer: HFN Commercial |
$10,555.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,604.75
|
| Rate for Payer: Multiplan Commercial |
$9,178.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,883.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,555.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,621.77
|
| Rate for Payer: Quartz Commercial |
$7,457.45
|
| Rate for Payer: Quartz Medicare Advantage |
$6,883.80
|
| Rate for Payer: The Alliance Commercial |
$45,892.00
|
| Rate for Payer: WEA Trust Commercial |
$6,310.15
|
| Rate for Payer: WPS Commercial |
$8,498.05
|
|
|
STENT PALMAZ BLUE 7 X 18MM PB1870BSX
|
Facility
|
IP
|
$11,473.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3549515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,621.77 |
| Max. Negotiated Rate |
$10,555.16 |
| Rate for Payer: Aetna Commercial |
$10,325.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,866.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,080.69
|
| Rate for Payer: Cash Price |
$3,441.90
|
| Rate for Payer: Cigna Commercial |
$10,555.16
|
| Rate for Payer: Health EOS Commercial |
$10,210.97
|
| Rate for Payer: HFN Commercial |
$10,555.16
|
| Rate for Payer: Multiplan Commercial |
$9,178.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,883.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,555.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,621.77
|
| Rate for Payer: Quartz Commercial |
$6,883.80
|
| Rate for Payer: WEA Trust Commercial |
$6,310.15
|
| Rate for Payer: WPS Commercial |
$8,498.05
|
|
|
STENT PALMAZ BLUE 7 X 18MM PB1870BSX
|
Facility
|
OP
|
$11,473.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3549515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,212.44 |
| Max. Negotiated Rate |
$45,892.00 |
| Rate for Payer: Aetna Commercial |
$10,325.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,866.78
|
| Rate for Payer: Aetna Managed Medicare |
$3,212.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,457.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,736.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,507.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,080.69
|
| Rate for Payer: Cash Price |
$3,441.90
|
| Rate for Payer: Cigna Commercial |
$10,555.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,420.29
|
| Rate for Payer: Health EOS Commercial |
$10,210.97
|
| Rate for Payer: HFN Commercial |
$10,555.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,604.75
|
| Rate for Payer: Multiplan Commercial |
$9,178.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,883.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,555.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,621.77
|
| Rate for Payer: Quartz Commercial |
$7,457.45
|
| Rate for Payer: Quartz Medicare Advantage |
$6,883.80
|
| Rate for Payer: The Alliance Commercial |
$45,892.00
|
| Rate for Payer: WEA Trust Commercial |
$6,310.15
|
| Rate for Payer: WPS Commercial |
$8,498.05
|
|
|
STENT PERCUFLEX INTRODUCER 10FR M00533920
|
Facility
|
IP
|
$855.00
|
|
| Hospital Charge Code |
2972181
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$418.95 |
| Max. Negotiated Rate |
$786.60 |
| Rate for Payer: Aetna Commercial |
$769.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$735.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$453.15
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Cigna Commercial |
$786.60
|
| Rate for Payer: Health EOS Commercial |
$760.95
|
| Rate for Payer: HFN Commercial |
$786.60
|
| Rate for Payer: Multiplan Commercial |
$684.00
|
| Rate for Payer: NAPHCARE Commercial |
$513.00
|
| Rate for Payer: Preferred Network Access Commercial |
$786.60
|
| Rate for Payer: Quartz Beloit One Network |
$418.95
|
| Rate for Payer: Quartz Commercial |
$513.00
|
| Rate for Payer: WEA Trust Commercial |
$470.25
|
| Rate for Payer: WPS Commercial |
$633.30
|
|
|
STENT PERCUFLEX INTRODUCER 10FR M00533920
|
Facility
|
OP
|
$855.00
|
|
| Hospital Charge Code |
2972181
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$239.40 |
| Max. Negotiated Rate |
$3,420.00 |
| Rate for Payer: Aetna Commercial |
$769.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$735.30
|
| Rate for Payer: Aetna Managed Medicare |
$239.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$555.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$427.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$410.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$453.15
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Cigna Commercial |
$786.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$478.46
|
| Rate for Payer: Health EOS Commercial |
$760.95
|
| Rate for Payer: HFN Commercial |
$786.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$641.25
|
| Rate for Payer: Multiplan Commercial |
$684.00
|
| Rate for Payer: NAPHCARE Commercial |
$513.00
|
| Rate for Payer: Preferred Network Access Commercial |
$786.60
|
| Rate for Payer: Quartz Beloit One Network |
$418.95
|
| Rate for Payer: Quartz Commercial |
$555.75
|
| Rate for Payer: Quartz Medicare Advantage |
$513.00
|
| Rate for Payer: The Alliance Commercial |
$3,420.00
|
| Rate for Payer: WEA Trust Commercial |
$470.25
|
| Rate for Payer: WPS Commercial |
$633.30
|
|
|
STENT PERCUFLEX NEPHROURETERAL 8FR X 24CM NON-COATED M001221370
|
Facility
|
IP
|
$1,208.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5307025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$591.92 |
| Max. Negotiated Rate |
$1,111.36 |
| Rate for Payer: Aetna Commercial |
$1,087.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,038.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$640.24
|
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Cigna Commercial |
$1,111.36
|
| Rate for Payer: Health EOS Commercial |
$1,075.12
|
| Rate for Payer: HFN Commercial |
$1,111.36
|
| Rate for Payer: Multiplan Commercial |
$966.40
|
| Rate for Payer: NAPHCARE Commercial |
$724.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,111.36
|
| Rate for Payer: Quartz Beloit One Network |
$591.92
|
| Rate for Payer: Quartz Commercial |
$724.80
|
| Rate for Payer: WEA Trust Commercial |
$664.40
|
| Rate for Payer: WPS Commercial |
$894.77
|
|
|
STENT PERCUFLEX NEPHROURETERAL 8FR X 24CM NON-COATED M001221370
|
Facility
|
OP
|
$1,208.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5307025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$338.24 |
| Max. Negotiated Rate |
$4,832.00 |
| Rate for Payer: Aetna Commercial |
$1,087.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,038.88
|
| Rate for Payer: Aetna Managed Medicare |
$338.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$785.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$604.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$579.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$640.24
|
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Cigna Commercial |
$1,111.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$676.00
|
| Rate for Payer: Health EOS Commercial |
$1,075.12
|
| Rate for Payer: HFN Commercial |
$1,111.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$906.00
|
| Rate for Payer: Multiplan Commercial |
$966.40
|
| Rate for Payer: NAPHCARE Commercial |
$724.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,111.36
|
| Rate for Payer: Quartz Beloit One Network |
$591.92
|
| Rate for Payer: Quartz Commercial |
$785.20
|
| Rate for Payer: Quartz Medicare Advantage |
$724.80
|
| Rate for Payer: The Alliance Commercial |
$4,832.00
|
| Rate for Payer: WEA Trust Commercial |
$664.40
|
| Rate for Payer: WPS Commercial |
$894.77
|
|
|
STENT PERCUFLEX NEPHROURETERAL 8FR X 28CM NON-COATED M001221390
|
Facility
|
IP
|
$1,208.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5307026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$591.92 |
| Max. Negotiated Rate |
$1,111.36 |
| Rate for Payer: Aetna Commercial |
$1,087.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,038.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$640.24
|
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Cigna Commercial |
$1,111.36
|
| Rate for Payer: Health EOS Commercial |
$1,075.12
|
| Rate for Payer: HFN Commercial |
$1,111.36
|
| Rate for Payer: Multiplan Commercial |
$966.40
|
| Rate for Payer: NAPHCARE Commercial |
$724.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,111.36
|
| Rate for Payer: Quartz Beloit One Network |
$591.92
|
| Rate for Payer: Quartz Commercial |
$724.80
|
| Rate for Payer: WEA Trust Commercial |
$664.40
|
| Rate for Payer: WPS Commercial |
$894.77
|
|
|
STENT PERCUFLEX NEPHROURETERAL 8FR X 28CM NON-COATED M001221390
|
Facility
|
OP
|
$1,208.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5307026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$338.24 |
| Max. Negotiated Rate |
$4,832.00 |
| Rate for Payer: Aetna Commercial |
$1,087.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,038.88
|
| Rate for Payer: Aetna Managed Medicare |
$338.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$785.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$604.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$579.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$640.24
|
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Cigna Commercial |
$1,111.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$676.00
|
| Rate for Payer: Health EOS Commercial |
$1,075.12
|
| Rate for Payer: HFN Commercial |
$1,111.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$906.00
|
| Rate for Payer: Multiplan Commercial |
$966.40
|
| Rate for Payer: NAPHCARE Commercial |
$724.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,111.36
|
| Rate for Payer: Quartz Beloit One Network |
$591.92
|
| Rate for Payer: Quartz Commercial |
$785.20
|
| Rate for Payer: Quartz Medicare Advantage |
$724.80
|
| Rate for Payer: The Alliance Commercial |
$4,832.00
|
| Rate for Payer: WEA Trust Commercial |
$664.40
|
| Rate for Payer: WPS Commercial |
$894.77
|
|
|
STENT PERCUFLEX PLUS 4.8 X 18 M0061751990
|
Facility
|
IP
|
$1,620.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5348712
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$793.80 |
| Max. Negotiated Rate |
$1,490.40 |
| Rate for Payer: Aetna Commercial |
$1,458.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,393.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$858.60
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cigna Commercial |
$1,490.40
|
| Rate for Payer: Health EOS Commercial |
$1,441.80
|
| Rate for Payer: HFN Commercial |
$1,490.40
|
| Rate for Payer: Multiplan Commercial |
$1,296.00
|
| Rate for Payer: NAPHCARE Commercial |
$972.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,490.40
|
| Rate for Payer: Quartz Beloit One Network |
$793.80
|
| Rate for Payer: Quartz Commercial |
$972.00
|
| Rate for Payer: WEA Trust Commercial |
$891.00
|
| Rate for Payer: WPS Commercial |
$1,199.93
|
|
|
STENT PERCUFLEX PLUS 4.8 X 18 M0061751990
|
Facility
|
OP
|
$1,620.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5348712
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$453.60 |
| Max. Negotiated Rate |
$6,480.00 |
| Rate for Payer: Aetna Commercial |
$1,458.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,393.20
|
| Rate for Payer: Aetna Managed Medicare |
$453.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,053.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$810.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$777.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$858.60
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cigna Commercial |
$1,490.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$906.55
|
| Rate for Payer: Health EOS Commercial |
$1,441.80
|
| Rate for Payer: HFN Commercial |
$1,490.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,215.00
|
| Rate for Payer: Multiplan Commercial |
$1,296.00
|
| Rate for Payer: NAPHCARE Commercial |
$972.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,490.40
|
| Rate for Payer: Quartz Beloit One Network |
$793.80
|
| Rate for Payer: Quartz Commercial |
$1,053.00
|
| Rate for Payer: Quartz Medicare Advantage |
$972.00
|
| Rate for Payer: The Alliance Commercial |
$6,480.00
|
| Rate for Payer: WEA Trust Commercial |
$891.00
|
| Rate for Payer: WPS Commercial |
$1,199.93
|
|
|
STENT PERCUFLEX PLUS 4.8 X 20 M0061752500
|
Facility
|
IP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.08 |
| Max. Negotiated Rate |
$1,096.64 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$715.20
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 20 M0061752500
|
Facility
|
OP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.76 |
| Max. Negotiated Rate |
$4,768.00 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Aetna Managed Medicare |
$333.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$774.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$596.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$572.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$667.04
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$894.00
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$774.80
|
| Rate for Payer: Quartz Medicare Advantage |
$715.20
|
| Rate for Payer: The Alliance Commercial |
$4,768.00
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 22 M0061752510
|
Facility
|
OP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.76 |
| Max. Negotiated Rate |
$4,768.00 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Aetna Managed Medicare |
$333.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$774.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$596.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$572.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$667.04
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$894.00
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$774.80
|
| Rate for Payer: Quartz Medicare Advantage |
$715.20
|
| Rate for Payer: The Alliance Commercial |
$4,768.00
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 22 M0061752510
|
Facility
|
IP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.08 |
| Max. Negotiated Rate |
$1,096.64 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$715.20
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
