|
STENT C-FLEX 10x5 PIGTAIL
|
Facility
IP
|
$915.00
|
|
| Hospital Charge Code |
2971852
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.35 |
| Max. Negotiated Rate |
$841.80 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$549.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
STENT CONTOUR SOFT 6 X 22-33 W/O GUIDEWIRE M0061801560
|
Facility
IP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520090
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$794.78 |
| Max. Negotiated Rate |
$1,492.24 |
| Rate for Payer: Aetna Commercial |
$1,459.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.66
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,492.24
|
| Rate for Payer: Health EOS Commercial |
$1,443.58
|
| Rate for Payer: HFN Commercial |
$1,492.24
|
| Rate for Payer: Multiplan Commercial |
$1,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$973.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.24
|
| Rate for Payer: Quartz Beloit One Network |
$794.78
|
| Rate for Payer: Quartz Commercial |
$973.20
|
| Rate for Payer: WEA Trust Commercial |
$892.10
|
| Rate for Payer: WPS Commercial |
$1,201.42
|
|
|
STENT CONTOUR SOFT 6 X 22-33 W/O GUIDEWIRE M0061801560
|
Facility
OP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520090
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$454.16 |
| Max. Negotiated Rate |
$1,492.24 |
| Rate for Payer: Aetna Commercial |
$1,459.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,394.92
|
| Rate for Payer: Aetna Managed Medicare |
$454.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,054.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$811.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$778.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.66
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,492.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$907.67
|
| Rate for Payer: Health EOS Commercial |
$1,443.58
|
| Rate for Payer: HFN Commercial |
$1,492.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,216.50
|
| Rate for Payer: Multiplan Commercial |
$1,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$973.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.24
|
| Rate for Payer: Quartz Beloit One Network |
$794.78
|
| Rate for Payer: Quartz Commercial |
$1,054.30
|
| Rate for Payer: Quartz Medicare Advantage |
$973.20
|
| Rate for Payer: WEA Trust Commercial |
$892.10
|
| Rate for Payer: WPS Commercial |
$1,201.42
|
|
|
STENT CONTOUR SOFT 7 X 22-30 W/O GUIDEWIRE M0061801570
|
Facility
OP
|
$1,685.00
|
|
| Hospital Charge Code |
4520089
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$471.80 |
| Max. Negotiated Rate |
$6,740.00 |
| Rate for Payer: Aetna Commercial |
$1,516.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,449.10
|
| Rate for Payer: Aetna Managed Medicare |
$471.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,095.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$842.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$808.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$893.05
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,550.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$942.93
|
| Rate for Payer: Health EOS Commercial |
$1,499.65
|
| Rate for Payer: HFN Commercial |
$1,550.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,263.75
|
| Rate for Payer: Multiplan Commercial |
$1,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,011.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.20
|
| Rate for Payer: Quartz Beloit One Network |
$825.65
|
| Rate for Payer: Quartz Commercial |
$1,095.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,011.00
|
| Rate for Payer: The Alliance Commercial |
$6,740.00
|
| Rate for Payer: WEA Trust Commercial |
$926.75
|
| Rate for Payer: WPS Commercial |
$1,248.08
|
|
|
STENT CONTOUR SOFT 7 X 22-30 W/O GUIDEWIRE M0061801570
|
Facility
IP
|
$1,685.00
|
|
| Hospital Charge Code |
4520089
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.65 |
| Max. Negotiated Rate |
$1,550.20 |
| Rate for Payer: Aetna Commercial |
$1,516.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$893.05
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,550.20
|
| Rate for Payer: Health EOS Commercial |
$1,499.65
|
| Rate for Payer: HFN Commercial |
$1,550.20
|
| Rate for Payer: Multiplan Commercial |
$1,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,011.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.20
|
| Rate for Payer: Quartz Beloit One Network |
$825.65
|
| Rate for Payer: Quartz Commercial |
$1,011.00
|
| Rate for Payer: WEA Trust Commercial |
$926.75
|
| Rate for Payer: WPS Commercial |
$1,248.08
|
|
|
Stent-Coronary Bare Metal
|
Facility
OP
|
$5,153.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,442.84 |
| Max. Negotiated Rate |
$4,740.76 |
| Rate for Payer: Aetna Commercial |
$4,637.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,431.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,442.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,349.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,576.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,473.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,731.09
|
| Rate for Payer: Cash Price |
$1,545.90
|
| Rate for Payer: Cigna Commercial |
$4,740.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,883.62
|
| Rate for Payer: Health EOS Commercial |
$4,586.17
|
| Rate for Payer: HFN Commercial |
$4,740.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,864.75
|
| Rate for Payer: Multiplan Commercial |
$4,122.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,091.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,740.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,524.97
|
| Rate for Payer: Quartz Commercial |
$3,349.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,091.80
|
| Rate for Payer: WEA Trust Commercial |
$2,834.15
|
| Rate for Payer: WPS Commercial |
$3,816.83
|
|
|
Stent-Coronary Bare Metal
|
Facility
IP
|
$5,153.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,524.97 |
| Max. Negotiated Rate |
$4,740.76 |
| Rate for Payer: Aetna Commercial |
$4,637.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,731.09
|
| Rate for Payer: Cash Price |
$1,545.90
|
| Rate for Payer: Cigna Commercial |
$4,740.76
|
| Rate for Payer: Health EOS Commercial |
$4,586.17
|
| Rate for Payer: HFN Commercial |
$4,740.76
|
| Rate for Payer: Multiplan Commercial |
$4,122.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,091.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,740.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,524.97
|
| Rate for Payer: Quartz Commercial |
$3,091.80
|
| Rate for Payer: WEA Trust Commercial |
$2,834.15
|
| Rate for Payer: WPS Commercial |
$3,816.83
|
|
|
Stent-Coronary DES
|
Facility
OP
|
$7,595.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
4001126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,126.60 |
| Max. Negotiated Rate |
$6,987.40 |
| Rate for Payer: Aetna Commercial |
$6,835.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,531.70
|
| Rate for Payer: Aetna Managed Medicare |
$2,126.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,936.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,797.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,645.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,025.35
|
| Rate for Payer: Cash Price |
$2,278.50
|
| Rate for Payer: Cigna Commercial |
$6,987.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,250.16
|
| Rate for Payer: Health EOS Commercial |
$6,759.55
|
| Rate for Payer: HFN Commercial |
$6,987.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,696.25
|
| Rate for Payer: Multiplan Commercial |
$6,076.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,557.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,987.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,721.55
|
| Rate for Payer: Quartz Commercial |
$4,936.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,557.00
|
| Rate for Payer: WEA Trust Commercial |
$4,177.25
|
| Rate for Payer: WPS Commercial |
$5,625.62
|
|
|
Stent-Coronary DES
|
Facility
IP
|
$7,595.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
4001126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,721.55 |
| Max. Negotiated Rate |
$6,987.40 |
| Rate for Payer: Aetna Commercial |
$6,835.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,025.35
|
| Rate for Payer: Cash Price |
$2,278.50
|
| Rate for Payer: Cigna Commercial |
$6,987.40
|
| Rate for Payer: Health EOS Commercial |
$6,759.55
|
| Rate for Payer: HFN Commercial |
$6,987.40
|
| Rate for Payer: Multiplan Commercial |
$6,076.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,557.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,987.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,721.55
|
| Rate for Payer: Quartz Commercial |
$4,557.00
|
| Rate for Payer: WEA Trust Commercial |
$4,177.25
|
| Rate for Payer: WPS Commercial |
$5,625.62
|
|
|
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: 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 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 |
$10,875.32 |
| 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: 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 |
$10,875.32 |
| 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: 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: 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 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: 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 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 |
$10,875.32 |
| 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: 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: 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 |
$10,875.32 |
| 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: 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 |
$10,875.32 |
| 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: 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: 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 |
$10,875.32 |
| 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: 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: 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 |
$10,875.32 |
| 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: 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: 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 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: 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 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 |
$10,875.32 |
| 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: WEA Trust Commercial |
$6,501.55
|
| Rate for Payer: WPS Commercial |
$8,755.81
|
|
