|
STENT DE PROMUS 2.50mm x 24mm
|
Facility
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973863
|
|
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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$12,537.60
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
STENT DE PROMUS 2.50mm x 28mm
|
Facility
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.88 |
| 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: 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: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
STENT DE PROMUS 2.50mm x 28mm
|
Facility
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973864
|
|
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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$12,537.60
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
STENT DE PROMUS 2.56 x 18
|
Facility
OP
|
$10,067.00
|
|
| Hospital Charge Code |
2973855
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,818.76 |
| Max. Negotiated Rate |
$40,268.00 |
| Rate for Payer: Aetna Commercial |
$9,060.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,657.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,818.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,543.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,033.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,832.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,335.51
|
| Rate for Payer: Cash Price |
$3,020.10
|
| Rate for Payer: Cigna Commercial |
$9,261.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,633.49
|
| Rate for Payer: Health EOS Commercial |
$8,959.63
|
| Rate for Payer: HFN Commercial |
$9,261.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,550.25
|
| Rate for Payer: Multiplan Commercial |
$8,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,040.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,261.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.83
|
| Rate for Payer: Quartz Commercial |
$6,543.55
|
| Rate for Payer: Quartz Medicare Advantage |
$6,040.20
|
| Rate for Payer: The Alliance Commercial |
$40,268.00
|
| Rate for Payer: WEA Trust Commercial |
$5,536.85
|
| Rate for Payer: WPS Commercial |
$7,456.63
|
|
|
STENT DE PROMUS 2.56 x 18
|
Facility
IP
|
$10,067.00
|
|
| Hospital Charge Code |
2973855
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,932.83 |
| Max. Negotiated Rate |
$9,261.64 |
| Rate for Payer: Aetna Commercial |
$9,060.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,335.51
|
| Rate for Payer: Cash Price |
$3,020.10
|
| Rate for Payer: Cigna Commercial |
$9,261.64
|
| Rate for Payer: Health EOS Commercial |
$8,959.63
|
| Rate for Payer: HFN Commercial |
$9,261.64
|
| Rate for Payer: Multiplan Commercial |
$8,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,040.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,261.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.83
|
| Rate for Payer: Quartz Commercial |
$6,040.20
|
| Rate for Payer: WEA Trust Commercial |
$5,536.85
|
| Rate for Payer: WPS Commercial |
$7,456.63
|
|
|
STENT DE PROMUS 2.5 x 12
|
Facility
IP
|
$9,159.00
|
|
| Hospital Charge Code |
2973787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,487.91 |
| Max. Negotiated Rate |
$8,426.28 |
| Rate for Payer: Aetna Commercial |
$8,243.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,854.27
|
| Rate for Payer: Cash Price |
$2,747.70
|
| Rate for Payer: Cigna Commercial |
$8,426.28
|
| Rate for Payer: Health EOS Commercial |
$8,151.51
|
| Rate for Payer: HFN Commercial |
$8,426.28
|
| Rate for Payer: Multiplan Commercial |
$7,327.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,495.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,426.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,487.91
|
| Rate for Payer: Quartz Commercial |
$5,495.40
|
| Rate for Payer: WEA Trust Commercial |
$5,037.45
|
| Rate for Payer: WPS Commercial |
$6,784.07
|
|
|
STENT DE PROMUS 2.5 x 12
|
Facility
OP
|
$9,159.00
|
|
| Hospital Charge Code |
2973787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,564.52 |
| Max. Negotiated Rate |
$36,636.00 |
| Rate for Payer: Aetna Commercial |
$8,243.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,876.74
|
| Rate for Payer: Aetna Managed Medicare |
$2,564.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,953.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,579.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,396.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,854.27
|
| Rate for Payer: Cash Price |
$2,747.70
|
| Rate for Payer: Cigna Commercial |
$8,426.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,125.38
|
| Rate for Payer: Health EOS Commercial |
$8,151.51
|
| Rate for Payer: HFN Commercial |
$8,426.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,869.25
|
| Rate for Payer: Multiplan Commercial |
$7,327.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,495.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,426.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,487.91
|
| Rate for Payer: Quartz Commercial |
$5,953.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,495.40
|
| Rate for Payer: The Alliance Commercial |
$36,636.00
|
| Rate for Payer: WEA Trust Commercial |
$5,037.45
|
| Rate for Payer: WPS Commercial |
$6,784.07
|
|
|
STENT DE PROMUS 2.5 x 15
|
Facility
IP
|
$10,067.00
|
|
| Hospital Charge Code |
2973854
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,932.83 |
| Max. Negotiated Rate |
$9,261.64 |
| Rate for Payer: Aetna Commercial |
$9,060.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,335.51
|
| Rate for Payer: Cash Price |
$3,020.10
|
| Rate for Payer: Cigna Commercial |
$9,261.64
|
| Rate for Payer: Health EOS Commercial |
$8,959.63
|
| Rate for Payer: HFN Commercial |
$9,261.64
|
| Rate for Payer: Multiplan Commercial |
$8,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,040.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,261.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.83
|
| Rate for Payer: Quartz Commercial |
$6,040.20
|
| Rate for Payer: WEA Trust Commercial |
$5,536.85
|
| Rate for Payer: WPS Commercial |
$7,456.63
|
|
|
STENT DE PROMUS 2.5 x 15
|
Facility
OP
|
$10,067.00
|
|
| Hospital Charge Code |
2973854
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,818.76 |
| Max. Negotiated Rate |
$40,268.00 |
| Rate for Payer: Aetna Commercial |
$9,060.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,657.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,818.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,543.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,033.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,832.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,335.51
|
| Rate for Payer: Cash Price |
$3,020.10
|
| Rate for Payer: Cigna Commercial |
$9,261.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,633.49
|
| Rate for Payer: Health EOS Commercial |
$8,959.63
|
| Rate for Payer: HFN Commercial |
$9,261.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,550.25
|
| Rate for Payer: Multiplan Commercial |
$8,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,040.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,261.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.83
|
| Rate for Payer: Quartz Commercial |
$6,543.55
|
| Rate for Payer: Quartz Medicare Advantage |
$6,040.20
|
| Rate for Payer: The Alliance Commercial |
$40,268.00
|
| Rate for Payer: WEA Trust Commercial |
$5,536.85
|
| Rate for Payer: WPS Commercial |
$7,456.63
|
|
|
STENT DE PROMUS 2.5 x 23
|
Facility
OP
|
$10,067.00
|
|
| Hospital Charge Code |
2973856
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,818.76 |
| Max. Negotiated Rate |
$40,268.00 |
| Rate for Payer: Aetna Commercial |
$9,060.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,657.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,818.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,543.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,033.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,832.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,335.51
|
| Rate for Payer: Cash Price |
$3,020.10
|
| Rate for Payer: Cigna Commercial |
$9,261.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,633.49
|
| Rate for Payer: Health EOS Commercial |
$8,959.63
|
| Rate for Payer: HFN Commercial |
$9,261.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,550.25
|
| Rate for Payer: Multiplan Commercial |
$8,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,040.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,261.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.83
|
| Rate for Payer: Quartz Commercial |
$6,543.55
|
| Rate for Payer: Quartz Medicare Advantage |
$6,040.20
|
| Rate for Payer: The Alliance Commercial |
$40,268.00
|
| Rate for Payer: WEA Trust Commercial |
$5,536.85
|
| Rate for Payer: WPS Commercial |
$7,456.63
|
|
|
STENT DE PROMUS 2.5 x 23
|
Facility
IP
|
$10,067.00
|
|
| Hospital Charge Code |
2973856
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,932.83 |
| Max. Negotiated Rate |
$9,261.64 |
| Rate for Payer: Aetna Commercial |
$9,060.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,335.51
|
| Rate for Payer: Cash Price |
$3,020.10
|
| Rate for Payer: Cigna Commercial |
$9,261.64
|
| Rate for Payer: Health EOS Commercial |
$8,959.63
|
| Rate for Payer: HFN Commercial |
$9,261.64
|
| Rate for Payer: Multiplan Commercial |
$8,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,040.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,261.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.83
|
| Rate for Payer: Quartz Commercial |
$6,040.20
|
| Rate for Payer: WEA Trust Commercial |
$5,536.85
|
| Rate for Payer: WPS Commercial |
$7,456.63
|
|
|
STENT DE PROMUS 2.5x8
|
Facility
OP
|
$9,159.00
|
|
| Hospital Charge Code |
2973858
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,564.52 |
| Max. Negotiated Rate |
$36,636.00 |
| Rate for Payer: Aetna Commercial |
$8,243.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,876.74
|
| Rate for Payer: Aetna Managed Medicare |
$2,564.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,953.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,579.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,396.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,854.27
|
| Rate for Payer: Cash Price |
$2,747.70
|
| Rate for Payer: Cigna Commercial |
$8,426.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,125.38
|
| Rate for Payer: Health EOS Commercial |
$8,151.51
|
| Rate for Payer: HFN Commercial |
$8,426.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,869.25
|
| Rate for Payer: Multiplan Commercial |
$7,327.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,495.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,426.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,487.91
|
| Rate for Payer: Quartz Commercial |
$5,953.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,495.40
|
| Rate for Payer: The Alliance Commercial |
$36,636.00
|
| Rate for Payer: WEA Trust Commercial |
$5,037.45
|
| Rate for Payer: WPS Commercial |
$6,784.07
|
|
|
STENT DE PROMUS 2.5x8
|
Facility
IP
|
$9,159.00
|
|
| Hospital Charge Code |
2973858
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,487.91 |
| Max. Negotiated Rate |
$8,426.28 |
| Rate for Payer: Aetna Commercial |
$8,243.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,854.27
|
| Rate for Payer: Cash Price |
$2,747.70
|
| Rate for Payer: Cigna Commercial |
$8,426.28
|
| Rate for Payer: Health EOS Commercial |
$8,151.51
|
| Rate for Payer: HFN Commercial |
$8,426.28
|
| Rate for Payer: Multiplan Commercial |
$7,327.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,495.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,426.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,487.91
|
| Rate for Payer: Quartz Commercial |
$5,495.40
|
| Rate for Payer: WEA Trust Commercial |
$5,037.45
|
| Rate for Payer: WPS Commercial |
$6,784.07
|
|
|
STENT DE PROMUS 2.75mm x 12mm
|
Facility
OP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.04 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,049.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,756.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,659.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,512.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,095.15
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,488.50
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,756.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE PROMUS 2.75mm x 12mm
|
Facility
IP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.82 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE PROMUS 2.75mm x 16mm
|
Facility
OP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973867
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.04 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,049.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,756.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,659.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,512.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,095.15
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,488.50
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,756.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE PROMUS 2.75mm x 16mm
|
Facility
IP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973867
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.82 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE PROMUS 2.75mm x 20mm
|
Facility
IP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973868
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.82 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE PROMUS 2.75mm x 20mm
|
Facility
OP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973868
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.04 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,049.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,756.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,659.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,512.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,095.15
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,488.50
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,756.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE PROMUS 2.75mm x 24mm
|
Facility
OP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973869
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.04 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,049.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,756.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,659.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,512.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,095.15
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,488.50
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,756.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE PROMUS 2.75mm x 24mm
|
Facility
IP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973869
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.82 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE PROMUS 2.75mm x 28mm
|
Facility
IP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.82 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE PROMUS 2.75mm x 28mm
|
Facility
OP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.04 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,049.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,756.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,659.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,512.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,095.15
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,488.50
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,756.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE PROMUS 2.75mm x 8mm
|
Facility
OP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973865
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.04 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,049.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,756.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,659.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,512.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,095.15
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,488.50
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,756.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
STENT DE PROMUS 2.75mm x 8mm
|
Facility
IP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973865
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.82 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
