|
STENT VERIFLEX 4.0 X 20
|
Facility
|
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974796
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
STENT VERIFLEX 4.0 X 20
|
Facility
|
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974796
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$69,632.00 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: The Alliance Commercial |
$69,632.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
STENT VERIFLEX BARE 3.5 X 8MM
|
Facility
|
OP
|
$14,790.00
|
|
| Hospital Charge Code |
2974795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,141.20 |
| Max. Negotiated Rate |
$59,160.00 |
| Rate for Payer: Aetna Commercial |
$13,311.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,719.40
|
| Rate for Payer: Aetna Managed Medicare |
$4,141.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,613.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,395.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,099.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,838.70
|
| Rate for Payer: Cash Price |
$4,437.00
|
| Rate for Payer: Cigna Commercial |
$13,606.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,276.48
|
| Rate for Payer: Health EOS Commercial |
$13,163.10
|
| Rate for Payer: HFN Commercial |
$13,606.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,092.50
|
| Rate for Payer: Multiplan Commercial |
$11,832.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,874.00
|
| Rate for Payer: Preferred Network Access Commercial |
$13,606.80
|
| Rate for Payer: Quartz Beloit One Network |
$7,247.10
|
| Rate for Payer: Quartz Commercial |
$9,613.50
|
| Rate for Payer: Quartz Medicare Advantage |
$8,874.00
|
| Rate for Payer: The Alliance Commercial |
$59,160.00
|
| Rate for Payer: WEA Trust Commercial |
$8,134.50
|
| Rate for Payer: WPS Commercial |
$10,954.95
|
|
|
STENT VERIFLEX BARE 3.5 X 8MM
|
Facility
|
IP
|
$14,790.00
|
|
| Hospital Charge Code |
2974795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,247.10 |
| Max. Negotiated Rate |
$13,606.80 |
| Rate for Payer: Aetna Commercial |
$13,311.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,719.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,838.70
|
| Rate for Payer: Cash Price |
$4,437.00
|
| Rate for Payer: Cigna Commercial |
$13,606.80
|
| Rate for Payer: Health EOS Commercial |
$13,163.10
|
| Rate for Payer: HFN Commercial |
$13,606.80
|
| Rate for Payer: Multiplan Commercial |
$11,832.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,874.00
|
| Rate for Payer: Preferred Network Access Commercial |
$13,606.80
|
| Rate for Payer: Quartz Beloit One Network |
$7,247.10
|
| Rate for Payer: Quartz Commercial |
$8,874.00
|
| Rate for Payer: WEA Trust Commercial |
$8,134.50
|
| Rate for Payer: WPS Commercial |
$10,954.95
|
|
|
STENT VISION 3.0 x 12mm #1007848-12
|
Facility
|
IP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,528.94 |
| Max. Negotiated Rate |
$16,013.52 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$10,443.60
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION 3.0 x 12mm #1007848-12
|
Facility
|
OP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,873.68 |
| Max. Negotiated Rate |
$69,624.00 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Aetna Managed Medicare |
$4,873.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,313.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,703.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,354.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,740.40
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,054.50
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$11,313.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,443.60
|
| Rate for Payer: The Alliance Commercial |
$69,624.00
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION 3.0 x 18mm
|
Facility
|
OP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974793
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,873.68 |
| Max. Negotiated Rate |
$69,624.00 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Aetna Managed Medicare |
$4,873.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,313.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,703.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,354.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,740.40
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,054.50
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$11,313.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,443.60
|
| Rate for Payer: The Alliance Commercial |
$69,624.00
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION 3.0 x 18mm
|
Facility
|
IP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974793
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,528.94 |
| Max. Negotiated Rate |
$16,013.52 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$10,443.60
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION 3.0 x 28mm
|
Facility
|
IP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974792
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,528.94 |
| Max. Negotiated Rate |
$16,013.52 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$10,443.60
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION 3.0 x 28mm
|
Facility
|
OP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974792
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,873.68 |
| Max. Negotiated Rate |
$69,624.00 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Aetna Managed Medicare |
$4,873.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,313.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,703.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,354.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,740.40
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,054.50
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$11,313.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,443.60
|
| Rate for Payer: The Alliance Commercial |
$69,624.00
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION 3.5 x 12mm
|
Facility
|
OP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974791
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,873.68 |
| Max. Negotiated Rate |
$69,624.00 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Aetna Managed Medicare |
$4,873.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,313.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,703.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,354.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,740.40
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,054.50
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$11,313.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,443.60
|
| Rate for Payer: The Alliance Commercial |
$69,624.00
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION 3.5 x 12mm
|
Facility
|
IP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974791
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,528.94 |
| Max. Negotiated Rate |
$16,013.52 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$10,443.60
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION 3.5 x 18mm
|
Facility
|
OP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974790
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,873.68 |
| Max. Negotiated Rate |
$69,624.00 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Aetna Managed Medicare |
$4,873.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,313.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,703.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,354.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,740.40
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,054.50
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$11,313.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,443.60
|
| Rate for Payer: The Alliance Commercial |
$69,624.00
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION 3.5 x 18mm
|
Facility
|
IP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974790
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,528.94 |
| Max. Negotiated Rate |
$16,013.52 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$10,443.60
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION 3.5 x 28mm
|
Facility
|
IP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,528.94 |
| Max. Negotiated Rate |
$16,013.52 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$10,443.60
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION 3.5 x 28mm
|
Facility
|
OP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,873.68 |
| Max. Negotiated Rate |
$69,624.00 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Aetna Managed Medicare |
$4,873.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,313.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,703.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,354.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,740.40
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,054.50
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$11,313.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,443.60
|
| Rate for Payer: The Alliance Commercial |
$69,624.00
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION MULTI-LINK 4.0 x 12mm
|
Facility
|
OP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3107484
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,873.68 |
| Max. Negotiated Rate |
$69,624.00 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Aetna Managed Medicare |
$4,873.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,313.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,703.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,354.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,740.40
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,054.50
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$11,313.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,443.60
|
| Rate for Payer: The Alliance Commercial |
$69,624.00
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION MULTI-LINK 4.0 x 12mm
|
Facility
|
IP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3107484
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,528.94 |
| Max. Negotiated Rate |
$16,013.52 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$10,443.60
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION MULTI-LINK 4.0 x 18mm
|
Facility
|
OP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3107483
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,873.68 |
| Max. Negotiated Rate |
$69,624.00 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Aetna Managed Medicare |
$4,873.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,313.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,703.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,354.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,740.40
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,054.50
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$11,313.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,443.60
|
| Rate for Payer: The Alliance Commercial |
$69,624.00
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISION MULTI-LINK 4.0 x 18mm
|
Facility
|
IP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3107483
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,528.94 |
| Max. Negotiated Rate |
$16,013.52 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$10,443.60
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
STENT VISI-PRO 7mm X 27mm X135 #PXB35-07-27-135
|
Facility
|
IP
|
$9,692.00
|
|
| Hospital Charge Code |
2974786
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,749.08 |
| Max. Negotiated Rate |
$8,916.64 |
| Rate for Payer: Aetna Commercial |
$8,722.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,335.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,136.76
|
| Rate for Payer: Cash Price |
$2,907.60
|
| Rate for Payer: Cigna Commercial |
$8,916.64
|
| Rate for Payer: Health EOS Commercial |
$8,625.88
|
| Rate for Payer: HFN Commercial |
$8,916.64
|
| Rate for Payer: Multiplan Commercial |
$7,753.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,815.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,916.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,749.08
|
| Rate for Payer: Quartz Commercial |
$5,815.20
|
| Rate for Payer: WEA Trust Commercial |
$5,330.60
|
| Rate for Payer: WPS Commercial |
$7,178.86
|
|
|
STENT VISI-PRO 7mm X 27mm X135 #PXB35-07-27-135
|
Facility
|
OP
|
$9,692.00
|
|
| Hospital Charge Code |
2974786
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,713.76 |
| Max. Negotiated Rate |
$38,768.00 |
| Rate for Payer: Aetna Commercial |
$8,722.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,335.12
|
| Rate for Payer: Aetna Managed Medicare |
$2,713.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,299.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,846.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,652.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,136.76
|
| Rate for Payer: Cash Price |
$2,907.60
|
| Rate for Payer: Cigna Commercial |
$8,916.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,423.64
|
| Rate for Payer: Health EOS Commercial |
$8,625.88
|
| Rate for Payer: HFN Commercial |
$8,916.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,269.00
|
| Rate for Payer: Multiplan Commercial |
$7,753.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,815.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,916.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,749.08
|
| Rate for Payer: Quartz Commercial |
$6,299.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,815.20
|
| Rate for Payer: The Alliance Commercial |
$38,768.00
|
| Rate for Payer: WEA Trust Commercial |
$5,330.60
|
| Rate for Payer: WPS Commercial |
$7,178.86
|
|
|
STENT VISIPRO 7 X 12 #PXB35-07-12-80
|
Facility
|
OP
|
$9,881.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974788
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.68 |
| Max. Negotiated Rate |
$39,524.00 |
| Rate for Payer: Aetna Commercial |
$8,892.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,497.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,422.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,940.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,742.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,236.93
|
| Rate for Payer: Cash Price |
$2,964.30
|
| Rate for Payer: Cigna Commercial |
$9,090.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,529.41
|
| Rate for Payer: Health EOS Commercial |
$8,794.09
|
| Rate for Payer: HFN Commercial |
$9,090.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,410.75
|
| Rate for Payer: Multiplan Commercial |
$7,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,928.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,090.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,841.69
|
| Rate for Payer: Quartz Commercial |
$6,422.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5,928.60
|
| Rate for Payer: The Alliance Commercial |
$39,524.00
|
| Rate for Payer: WEA Trust Commercial |
$5,434.55
|
| Rate for Payer: WPS Commercial |
$7,318.86
|
|
|
STENT VISIPRO 7 X 12 #PXB35-07-12-80
|
Facility
|
IP
|
$9,881.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974788
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,841.69 |
| Max. Negotiated Rate |
$9,090.52 |
| Rate for Payer: Aetna Commercial |
$8,892.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,497.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,236.93
|
| Rate for Payer: Cash Price |
$2,964.30
|
| Rate for Payer: Cigna Commercial |
$9,090.52
|
| Rate for Payer: Health EOS Commercial |
$8,794.09
|
| Rate for Payer: HFN Commercial |
$9,090.52
|
| Rate for Payer: Multiplan Commercial |
$7,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,928.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,090.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,841.69
|
| Rate for Payer: Quartz Commercial |
$5,928.60
|
| Rate for Payer: WEA Trust Commercial |
$5,434.55
|
| Rate for Payer: WPS Commercial |
$7,318.86
|
|
|
STENT VISIPRO 7 X 17 #PXB35-07-17-80
|
Facility
|
IP
|
$9,881.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,841.69 |
| Max. Negotiated Rate |
$9,090.52 |
| Rate for Payer: Aetna Commercial |
$8,892.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,497.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,236.93
|
| Rate for Payer: Cash Price |
$2,964.30
|
| Rate for Payer: Cigna Commercial |
$9,090.52
|
| Rate for Payer: Health EOS Commercial |
$8,794.09
|
| Rate for Payer: HFN Commercial |
$9,090.52
|
| Rate for Payer: Multiplan Commercial |
$7,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,928.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,090.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,841.69
|
| Rate for Payer: Quartz Commercial |
$5,928.60
|
| Rate for Payer: WEA Trust Commercial |
$5,434.55
|
| Rate for Payer: WPS Commercial |
$7,318.86
|
|
