|
STENT ICAST 10mm x 38mm X 120 85424
|
Facility
IP
|
$16,316.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973919
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,994.84 |
| Max. Negotiated Rate |
$15,010.72 |
| Rate for Payer: Aetna Commercial |
$14,684.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,647.48
|
| Rate for Payer: Cash Price |
$4,894.80
|
| Rate for Payer: Cigna Commercial |
$15,010.72
|
| Rate for Payer: Health EOS Commercial |
$14,521.24
|
| Rate for Payer: HFN Commercial |
$15,010.72
|
| Rate for Payer: Multiplan Commercial |
$13,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,789.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,010.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,994.84
|
| Rate for Payer: Quartz Commercial |
$9,789.60
|
| Rate for Payer: WEA Trust Commercial |
$8,973.80
|
| Rate for Payer: WPS Commercial |
$12,085.26
|
|
|
STENT INFRAVISION LIGHTED 0220-180-517
|
Facility
IP
|
$3,078.00
|
|
| Hospital Charge Code |
2966089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,508.22 |
| Max. Negotiated Rate |
$2,831.76 |
| Rate for Payer: Aetna Commercial |
$2,770.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,631.34
|
| Rate for Payer: Cash Price |
$923.40
|
| Rate for Payer: Cigna Commercial |
$2,831.76
|
| Rate for Payer: Health EOS Commercial |
$2,739.42
|
| Rate for Payer: HFN Commercial |
$2,831.76
|
| Rate for Payer: Multiplan Commercial |
$2,462.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,846.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,831.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,508.22
|
| Rate for Payer: Quartz Commercial |
$1,846.80
|
| Rate for Payer: WEA Trust Commercial |
$1,692.90
|
| Rate for Payer: WPS Commercial |
$2,279.87
|
|
|
STENT INFRAVISION LIGHTED 0220-180-517
|
Facility
OP
|
$3,078.00
|
|
| Hospital Charge Code |
2966089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$861.84 |
| Max. Negotiated Rate |
$12,312.00 |
| Rate for Payer: Aetna Commercial |
$2,770.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,647.08
|
| Rate for Payer: Aetna Managed Medicare |
$861.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,000.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,539.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,477.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,631.34
|
| Rate for Payer: Cash Price |
$923.40
|
| Rate for Payer: Cigna Commercial |
$2,831.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,722.45
|
| Rate for Payer: Health EOS Commercial |
$2,739.42
|
| Rate for Payer: HFN Commercial |
$2,831.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,308.50
|
| Rate for Payer: Multiplan Commercial |
$2,462.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,846.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,831.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,508.22
|
| Rate for Payer: Quartz Commercial |
$2,000.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,846.80
|
| Rate for Payer: The Alliance Commercial |
$12,312.00
|
| Rate for Payer: WEA Trust Commercial |
$1,692.90
|
| Rate for Payer: WPS Commercial |
$2,279.87
|
|
|
STENT IRIS LIGHTED URETERAL 0220-180-518
|
Facility
IP
|
$2,537.00
|
|
| Hospital Charge Code |
5306838
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,243.13 |
| Max. Negotiated Rate |
$2,334.04 |
| Rate for Payer: Aetna Commercial |
$2,283.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,344.61
|
| Rate for Payer: Cash Price |
$761.10
|
| Rate for Payer: Cigna Commercial |
$2,334.04
|
| Rate for Payer: Health EOS Commercial |
$2,257.93
|
| Rate for Payer: HFN Commercial |
$2,334.04
|
| Rate for Payer: Multiplan Commercial |
$2,029.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,522.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,334.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,243.13
|
| Rate for Payer: Quartz Commercial |
$1,522.20
|
| Rate for Payer: WEA Trust Commercial |
$1,395.35
|
| Rate for Payer: WPS Commercial |
$1,879.16
|
|
|
STENT IRIS LIGHTED URETERAL 0220-180-518
|
Facility
OP
|
$2,537.00
|
|
| Hospital Charge Code |
5306838
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$710.36 |
| Max. Negotiated Rate |
$10,148.00 |
| Rate for Payer: Aetna Commercial |
$2,283.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,181.82
|
| Rate for Payer: Aetna Managed Medicare |
$710.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,649.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,268.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,217.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,344.61
|
| Rate for Payer: Cash Price |
$761.10
|
| Rate for Payer: Cigna Commercial |
$2,334.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,419.71
|
| Rate for Payer: Health EOS Commercial |
$2,257.93
|
| Rate for Payer: HFN Commercial |
$2,334.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,902.75
|
| Rate for Payer: Multiplan Commercial |
$2,029.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,522.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,334.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,243.13
|
| Rate for Payer: Quartz Commercial |
$1,649.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,522.20
|
| Rate for Payer: The Alliance Commercial |
$10,148.00
|
| Rate for Payer: WEA Trust Commercial |
$1,395.35
|
| Rate for Payer: WPS Commercial |
$1,879.16
|
|
|
STENT LOOP 8 X 28 POLARIS 155-254
|
Facility
OP
|
$1,805.00
|
|
| Hospital Charge Code |
2964819
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.40 |
| Max. Negotiated Rate |
$7,220.00 |
| Rate for Payer: Aetna Commercial |
$1,624.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,552.30
|
| Rate for Payer: Aetna Managed Medicare |
$505.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,173.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$902.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$866.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$956.65
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,660.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,010.08
|
| Rate for Payer: Health EOS Commercial |
$1,606.45
|
| Rate for Payer: HFN Commercial |
$1,660.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,353.75
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,083.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,660.60
|
| Rate for Payer: Quartz Beloit One Network |
$884.45
|
| Rate for Payer: Quartz Commercial |
$1,173.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,083.00
|
| Rate for Payer: The Alliance Commercial |
$7,220.00
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$1,336.96
|
|
|
STENT LOOP 8 X 28 POLARIS 155-254
|
Facility
IP
|
$1,805.00
|
|
| Hospital Charge Code |
2964819
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.45 |
| Max. Negotiated Rate |
$1,660.60 |
| Rate for Payer: Aetna Commercial |
$1,624.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$956.65
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,660.60
|
| Rate for Payer: Health EOS Commercial |
$1,606.45
|
| Rate for Payer: HFN Commercial |
$1,660.60
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,083.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,660.60
|
| Rate for Payer: Quartz Beloit One Network |
$884.45
|
| Rate for Payer: Quartz Commercial |
$1,083.00
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$1,336.96
|
|
|
STENT LOOP 8 X 30 POLARIS 155-255
|
Facility
IP
|
$1,805.00
|
|
| Hospital Charge Code |
2964820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.45 |
| Max. Negotiated Rate |
$1,660.60 |
| Rate for Payer: Aetna Commercial |
$1,624.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$956.65
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,660.60
|
| Rate for Payer: Health EOS Commercial |
$1,606.45
|
| Rate for Payer: HFN Commercial |
$1,660.60
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,083.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,660.60
|
| Rate for Payer: Quartz Beloit One Network |
$884.45
|
| Rate for Payer: Quartz Commercial |
$1,083.00
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$1,336.96
|
|
|
STENT LOOP 8 X 30 POLARIS 155-255
|
Facility
OP
|
$1,805.00
|
|
| Hospital Charge Code |
2964820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.40 |
| Max. Negotiated Rate |
$7,220.00 |
| Rate for Payer: Aetna Commercial |
$1,624.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,552.30
|
| Rate for Payer: Aetna Managed Medicare |
$505.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,173.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$902.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$866.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$956.65
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,660.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,010.08
|
| Rate for Payer: Health EOS Commercial |
$1,606.45
|
| Rate for Payer: HFN Commercial |
$1,660.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,353.75
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,083.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,660.60
|
| Rate for Payer: Quartz Beloit One Network |
$884.45
|
| Rate for Payer: Quartz Commercial |
$1,173.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,083.00
|
| Rate for Payer: The Alliance Commercial |
$7,220.00
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$1,336.96
|
|
|
STENT METALLIC 6X22 URETERAL G34109
|
Facility
IP
|
$8,256.00
|
|
| Hospital Charge Code |
2964978
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,045.44 |
| Max. Negotiated Rate |
$7,595.52 |
| Rate for Payer: Aetna Commercial |
$7,430.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,375.68
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$7,595.52
|
| Rate for Payer: Health EOS Commercial |
$7,347.84
|
| Rate for Payer: HFN Commercial |
$7,595.52
|
| Rate for Payer: Multiplan Commercial |
$6,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,953.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,595.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,045.44
|
| Rate for Payer: Quartz Commercial |
$4,953.60
|
| Rate for Payer: WEA Trust Commercial |
$4,540.80
|
| Rate for Payer: WPS Commercial |
$6,115.22
|
|
|
STENT METALLIC 6X22 URETERAL G34109
|
Facility
OP
|
$8,256.00
|
|
| Hospital Charge Code |
2964978
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,311.68 |
| Max. Negotiated Rate |
$33,024.00 |
| Rate for Payer: Aetna Commercial |
$7,430.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,100.16
|
| Rate for Payer: Aetna Managed Medicare |
$2,311.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,366.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,128.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,962.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,375.68
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$7,595.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,620.06
|
| Rate for Payer: Health EOS Commercial |
$7,347.84
|
| Rate for Payer: HFN Commercial |
$7,595.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,192.00
|
| Rate for Payer: Multiplan Commercial |
$6,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,953.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,595.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,045.44
|
| Rate for Payer: Quartz Commercial |
$5,366.40
|
| Rate for Payer: Quartz Medicare Advantage |
$4,953.60
|
| Rate for Payer: The Alliance Commercial |
$33,024.00
|
| Rate for Payer: WEA Trust Commercial |
$4,540.80
|
| Rate for Payer: WPS Commercial |
$6,115.22
|
|
|
STENT METALLIC 6X24 URETERAL G34110
|
Facility
IP
|
$8,574.00
|
|
| Hospital Charge Code |
2964979
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,201.26 |
| Max. Negotiated Rate |
$7,888.08 |
| Rate for Payer: Aetna Commercial |
$7,716.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,544.22
|
| Rate for Payer: Cash Price |
$2,572.20
|
| Rate for Payer: Cigna Commercial |
$7,888.08
|
| Rate for Payer: Health EOS Commercial |
$7,630.86
|
| Rate for Payer: HFN Commercial |
$7,888.08
|
| Rate for Payer: Multiplan Commercial |
$6,859.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,144.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,888.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,201.26
|
| Rate for Payer: Quartz Commercial |
$5,144.40
|
| Rate for Payer: WEA Trust Commercial |
$4,715.70
|
| Rate for Payer: WPS Commercial |
$6,350.76
|
|
|
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
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 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: 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 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: 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 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-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 |
$10,555.16 |
| 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: WEA Trust Commercial |
$6,310.15
|
| Rate for Payer: WPS Commercial |
$8,498.05
|
|
|
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: 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 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 |
$10,555.16 |
| 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: 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: 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: 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 |
$10,555.16 |
| 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: 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: 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 |
$10,555.16 |
| 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: WEA Trust Commercial |
$6,310.15
|
| Rate for Payer: WPS Commercial |
$8,498.05
|
|
