|
STENT VISIPRO 7 X 17 #PXB35-07-17-80
|
Facility
|
OP
|
$9,881.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974787
|
|
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 VISPRO 7mm X 27mm #PXB35-07-27-080
|
Facility
|
IP
|
$9,881.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974785
|
|
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 VISPRO 7mm X 27mm #PXB35-07-27-080
|
Facility
|
OP
|
$9,881.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974785
|
|
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 WALLFLEX 10 X 60MM COVERED M00570370
|
Facility
|
IP
|
$14,941.00
|
|
| Hospital Charge Code |
3455499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,321.09 |
| Max. Negotiated Rate |
$13,745.72 |
| Rate for Payer: Aetna Commercial |
$13,446.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,849.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,918.73
|
| Rate for Payer: Cash Price |
$4,482.30
|
| Rate for Payer: Cigna Commercial |
$13,745.72
|
| Rate for Payer: Health EOS Commercial |
$13,297.49
|
| Rate for Payer: HFN Commercial |
$13,745.72
|
| Rate for Payer: Multiplan Commercial |
$11,952.80
|
| Rate for Payer: NAPHCARE Commercial |
$8,964.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,745.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,321.09
|
| Rate for Payer: Quartz Commercial |
$8,964.60
|
| Rate for Payer: WEA Trust Commercial |
$8,217.55
|
| Rate for Payer: WPS Commercial |
$11,066.80
|
|
|
STENT WALLFLEX 10 X 60MM COVERED M00570370
|
Facility
|
OP
|
$14,941.00
|
|
| Hospital Charge Code |
3455499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,183.48 |
| Max. Negotiated Rate |
$59,764.00 |
| Rate for Payer: Aetna Commercial |
$13,446.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,849.26
|
| Rate for Payer: Aetna Managed Medicare |
$4,183.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,711.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,470.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,171.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,918.73
|
| Rate for Payer: Cash Price |
$4,482.30
|
| Rate for Payer: Cigna Commercial |
$13,745.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,360.98
|
| Rate for Payer: Health EOS Commercial |
$13,297.49
|
| Rate for Payer: HFN Commercial |
$13,745.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,205.75
|
| Rate for Payer: Multiplan Commercial |
$11,952.80
|
| Rate for Payer: NAPHCARE Commercial |
$8,964.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,745.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,321.09
|
| Rate for Payer: Quartz Commercial |
$9,711.65
|
| Rate for Payer: Quartz Medicare Advantage |
$8,964.60
|
| Rate for Payer: The Alliance Commercial |
$59,764.00
|
| Rate for Payer: WEA Trust Commercial |
$8,217.55
|
| Rate for Payer: WPS Commercial |
$11,066.80
|
|
|
STENT WALLFLEX 10 X 60MM UNCOVERED 7064
|
Facility
|
IP
|
$10,067.00
|
|
| Hospital Charge Code |
3072562
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$8,657.62
|
| 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 WALLFLEX 10 X 60MM UNCOVERED 7064
|
Facility
|
OP
|
$10,067.00
|
|
| Hospital Charge Code |
3072562
|
|
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 WALLFLEX 10 X 80MM COVERED M00570380
|
Facility
|
IP
|
$14,941.00
|
|
| Hospital Charge Code |
3455498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,321.09 |
| Max. Negotiated Rate |
$13,745.72 |
| Rate for Payer: Aetna Commercial |
$13,446.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,849.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,918.73
|
| Rate for Payer: Cash Price |
$4,482.30
|
| Rate for Payer: Cigna Commercial |
$13,745.72
|
| Rate for Payer: Health EOS Commercial |
$13,297.49
|
| Rate for Payer: HFN Commercial |
$13,745.72
|
| Rate for Payer: Multiplan Commercial |
$11,952.80
|
| Rate for Payer: NAPHCARE Commercial |
$8,964.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,745.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,321.09
|
| Rate for Payer: Quartz Commercial |
$8,964.60
|
| Rate for Payer: WEA Trust Commercial |
$8,217.55
|
| Rate for Payer: WPS Commercial |
$11,066.80
|
|
|
STENT WALLFLEX 10 X 80MM COVERED M00570380
|
Facility
|
OP
|
$14,941.00
|
|
| Hospital Charge Code |
3455498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,183.48 |
| Max. Negotiated Rate |
$59,764.00 |
| Rate for Payer: Aetna Commercial |
$13,446.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,849.26
|
| Rate for Payer: Aetna Managed Medicare |
$4,183.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,711.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,470.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,171.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,918.73
|
| Rate for Payer: Cash Price |
$4,482.30
|
| Rate for Payer: Cigna Commercial |
$13,745.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,360.98
|
| Rate for Payer: Health EOS Commercial |
$13,297.49
|
| Rate for Payer: HFN Commercial |
$13,745.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,205.75
|
| Rate for Payer: Multiplan Commercial |
$11,952.80
|
| Rate for Payer: NAPHCARE Commercial |
$8,964.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,745.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,321.09
|
| Rate for Payer: Quartz Commercial |
$9,711.65
|
| Rate for Payer: Quartz Medicare Advantage |
$8,964.60
|
| Rate for Payer: The Alliance Commercial |
$59,764.00
|
| Rate for Payer: WEA Trust Commercial |
$8,217.55
|
| Rate for Payer: WPS Commercial |
$11,066.80
|
|
|
STENT WALLFLEX 10 X 80MM UNCOVERED 7065
|
Facility
|
OP
|
$9,030.00
|
|
| Hospital Charge Code |
3072563
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,528.40 |
| Max. Negotiated Rate |
$36,120.00 |
| Rate for Payer: Aetna Commercial |
$8,127.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,765.80
|
| Rate for Payer: Aetna Managed Medicare |
$2,528.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,869.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,515.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,334.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,785.90
|
| Rate for Payer: Cash Price |
$2,709.00
|
| Rate for Payer: Cigna Commercial |
$8,307.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,053.19
|
| Rate for Payer: Health EOS Commercial |
$8,036.70
|
| Rate for Payer: HFN Commercial |
$8,307.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,772.50
|
| Rate for Payer: Multiplan Commercial |
$7,224.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,418.00
|
| Rate for Payer: Preferred Network Access Commercial |
$8,307.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,424.70
|
| Rate for Payer: Quartz Commercial |
$5,869.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,418.00
|
| Rate for Payer: The Alliance Commercial |
$36,120.00
|
| Rate for Payer: WEA Trust Commercial |
$4,966.50
|
| Rate for Payer: WPS Commercial |
$6,688.52
|
|
|
STENT WALLFLEX 10 X 80MM UNCOVERED 7065
|
Facility
|
IP
|
$9,030.00
|
|
| Hospital Charge Code |
3072563
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,424.70 |
| Max. Negotiated Rate |
$8,307.60 |
| Rate for Payer: Aetna Commercial |
$8,127.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,765.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,785.90
|
| Rate for Payer: Cash Price |
$2,709.00
|
| Rate for Payer: Cigna Commercial |
$8,307.60
|
| Rate for Payer: Health EOS Commercial |
$8,036.70
|
| Rate for Payer: HFN Commercial |
$8,307.60
|
| Rate for Payer: Multiplan Commercial |
$7,224.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,418.00
|
| Rate for Payer: Preferred Network Access Commercial |
$8,307.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,424.70
|
| Rate for Payer: Quartz Commercial |
$5,418.00
|
| Rate for Payer: WEA Trust Commercial |
$4,966.50
|
| Rate for Payer: WPS Commercial |
$6,688.52
|
|
|
STENT WALLFLEX 18 X 23CM FULLY COVERED M00516700
|
Facility
|
OP
|
$12,447.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
5432732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,485.16 |
| Max. Negotiated Rate |
$49,788.00 |
| Rate for Payer: Aetna Commercial |
$11,202.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,704.42
|
| Rate for Payer: Aetna Managed Medicare |
$3,485.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,090.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,223.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,974.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,596.91
|
| Rate for Payer: Cash Price |
$3,734.10
|
| Rate for Payer: Cigna Commercial |
$11,451.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,965.34
|
| Rate for Payer: Health EOS Commercial |
$11,077.83
|
| Rate for Payer: HFN Commercial |
$11,451.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,335.25
|
| Rate for Payer: Multiplan Commercial |
$9,957.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,468.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,451.24
|
| Rate for Payer: Quartz Beloit One Network |
$6,099.03
|
| Rate for Payer: Quartz Commercial |
$8,090.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,468.20
|
| Rate for Payer: The Alliance Commercial |
$49,788.00
|
| Rate for Payer: WEA Trust Commercial |
$6,845.85
|
| Rate for Payer: WPS Commercial |
$9,219.49
|
|
|
STENT WALLFLEX 18 X 23CM FULLY COVERED M00516700
|
Facility
|
IP
|
$12,447.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
5432732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,099.03 |
| Max. Negotiated Rate |
$11,451.24 |
| Rate for Payer: Aetna Commercial |
$11,202.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,704.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,596.91
|
| Rate for Payer: Cash Price |
$3,734.10
|
| Rate for Payer: Cigna Commercial |
$11,451.24
|
| Rate for Payer: Health EOS Commercial |
$11,077.83
|
| Rate for Payer: HFN Commercial |
$11,451.24
|
| Rate for Payer: Multiplan Commercial |
$9,957.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,468.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,451.24
|
| Rate for Payer: Quartz Beloit One Network |
$6,099.03
|
| Rate for Payer: Quartz Commercial |
$7,468.20
|
| Rate for Payer: WEA Trust Commercial |
$6,845.85
|
| Rate for Payer: WPS Commercial |
$9,219.49
|
|
|
STENT WALLFLEX 18 X 23CM PARTIAL COVERED 1690
|
Facility
|
IP
|
$13,118.00
|
|
| Hospital Charge Code |
3072560
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,427.82 |
| Max. Negotiated Rate |
$12,068.56 |
| Rate for Payer: Aetna Commercial |
$11,806.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,281.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,952.54
|
| Rate for Payer: Cash Price |
$3,935.40
|
| Rate for Payer: Cigna Commercial |
$12,068.56
|
| Rate for Payer: Health EOS Commercial |
$11,675.02
|
| Rate for Payer: HFN Commercial |
$12,068.56
|
| Rate for Payer: Multiplan Commercial |
$10,494.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,870.80
|
| Rate for Payer: Preferred Network Access Commercial |
$12,068.56
|
| Rate for Payer: Quartz Beloit One Network |
$6,427.82
|
| Rate for Payer: Quartz Commercial |
$7,870.80
|
| Rate for Payer: WEA Trust Commercial |
$7,214.90
|
| Rate for Payer: WPS Commercial |
$9,716.50
|
|
|
STENT WALLFLEX 18 X 23CM PARTIAL COVERED 1690
|
Facility
|
OP
|
$13,118.00
|
|
| Hospital Charge Code |
3072560
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,673.04 |
| Max. Negotiated Rate |
$52,472.00 |
| Rate for Payer: Aetna Commercial |
$11,806.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,281.48
|
| Rate for Payer: Aetna Managed Medicare |
$3,673.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,526.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,559.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,296.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,952.54
|
| Rate for Payer: Cash Price |
$3,935.40
|
| Rate for Payer: Cigna Commercial |
$12,068.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,340.83
|
| Rate for Payer: Health EOS Commercial |
$11,675.02
|
| Rate for Payer: HFN Commercial |
$12,068.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,838.50
|
| Rate for Payer: Multiplan Commercial |
$10,494.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,870.80
|
| Rate for Payer: Preferred Network Access Commercial |
$12,068.56
|
| Rate for Payer: Quartz Beloit One Network |
$6,427.82
|
| Rate for Payer: Quartz Commercial |
$8,526.70
|
| Rate for Payer: Quartz Medicare Advantage |
$7,870.80
|
| Rate for Payer: The Alliance Commercial |
$52,472.00
|
| Rate for Payer: WEA Trust Commercial |
$7,214.90
|
| Rate for Payer: WPS Commercial |
$9,716.50
|
|
|
STENT WALLFLEX COLONIC 22 X 27MM 9CM 6511
|
Facility
|
OP
|
$14,613.00
|
|
| Hospital Charge Code |
3072502
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,091.64 |
| Max. Negotiated Rate |
$58,452.00 |
| Rate for Payer: Aetna Commercial |
$13,151.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,567.18
|
| Rate for Payer: Aetna Managed Medicare |
$4,091.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,498.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,306.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,014.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,744.89
|
| Rate for Payer: Cash Price |
$4,383.90
|
| Rate for Payer: Cigna Commercial |
$13,443.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,177.43
|
| Rate for Payer: Health EOS Commercial |
$13,005.57
|
| Rate for Payer: HFN Commercial |
$13,443.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,959.75
|
| Rate for Payer: Multiplan Commercial |
$11,690.40
|
| Rate for Payer: NAPHCARE Commercial |
$8,767.80
|
| Rate for Payer: Preferred Network Access Commercial |
$13,443.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,160.37
|
| Rate for Payer: Quartz Commercial |
$9,498.45
|
| Rate for Payer: Quartz Medicare Advantage |
$8,767.80
|
| Rate for Payer: The Alliance Commercial |
$58,452.00
|
| Rate for Payer: WEA Trust Commercial |
$8,037.15
|
| Rate for Payer: WPS Commercial |
$10,823.85
|
|
|
STENT WALLFLEX COLONIC 22 X 27MM 9CM 6511
|
Facility
|
IP
|
$14,613.00
|
|
| Hospital Charge Code |
3072502
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,160.37 |
| Max. Negotiated Rate |
$13,443.96 |
| Rate for Payer: Aetna Commercial |
$13,151.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,567.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,744.89
|
| Rate for Payer: Cash Price |
$4,383.90
|
| Rate for Payer: Cigna Commercial |
$13,443.96
|
| Rate for Payer: Health EOS Commercial |
$13,005.57
|
| Rate for Payer: HFN Commercial |
$13,443.96
|
| Rate for Payer: Multiplan Commercial |
$11,690.40
|
| Rate for Payer: NAPHCARE Commercial |
$8,767.80
|
| Rate for Payer: Preferred Network Access Commercial |
$13,443.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,160.37
|
| Rate for Payer: Quartz Commercial |
$8,767.80
|
| Rate for Payer: WEA Trust Commercial |
$8,037.15
|
| Rate for Payer: WPS Commercial |
$10,823.85
|
|
|
STER-DRAPE SMALL 24 X 14 DYNJSD1040
|
Facility
|
IP
|
$102.00
|
|
| Hospital Charge Code |
2963304
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.98 |
| Max. Negotiated Rate |
$93.84 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$61.20
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
STER-DRAPE SMALL 24 X 14 DYNJSD1040
|
Facility
|
OP
|
$102.00
|
|
| Hospital Charge Code |
2963304
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.56 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Aetna Managed Medicare |
$28.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.08
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.50
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$66.30
|
| Rate for Payer: Quartz Medicare Advantage |
$61.20
|
| Rate for Payer: The Alliance Commercial |
$408.00
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
Stereotactic Body Radiation Delivery 77373
|
Professional
|
Both
|
$6,691.00
|
|
|
Service Code
|
CPT 77373
|
| Hospital Charge Code |
5430723
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,944.04 |
| Max. Negotiated Rate |
$6,356.45 |
| Rate for Payer: Aetna Commercial |
$6,356.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,754.26
|
| Rate for Payer: Cash Price |
$2,007.30
|
| Rate for Payer: Cash Price |
$2,007.30
|
| Rate for Payer: Cash Price |
$2,007.30
|
| Rate for Payer: Cigna Commercial |
$6,356.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,345.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,014.60
|
| Rate for Payer: Health EOS Commercial |
$6,088.81
|
| Rate for Payer: HFN Commercial |
$6,356.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,880.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,880.71
|
| Rate for Payer: Multiplan Commercial |
$5,352.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,356.45
|
| Rate for Payer: Quartz Beloit One Network |
$2,944.04
|
| Rate for Payer: Quartz Commercial |
$3,813.87
|
| Rate for Payer: The Alliance Commercial |
$3,345.50
|
| Rate for Payer: WEA Trust Commercial |
$3,680.05
|
| Rate for Payer: WPS Commercial |
$4,956.02
|
|
|
Stereotactic Body Radiation Management 77435
|
Professional
|
Both
|
$8,637.00
|
|
|
Service Code
|
CPT 77435
|
| Hospital Charge Code |
5432657
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,167.53 |
| Max. Negotiated Rate |
$8,205.15 |
| Rate for Payer: Aetna Commercial |
$8,205.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,427.82
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cigna Commercial |
$8,205.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,318.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,182.20
|
| Rate for Payer: Health EOS Commercial |
$7,859.67
|
| Rate for Payer: HFN Commercial |
$8,205.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,167.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,167.53
|
| Rate for Payer: Multiplan Commercial |
$6,909.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,205.15
|
| Rate for Payer: Quartz Beloit One Network |
$3,800.28
|
| Rate for Payer: Quartz Commercial |
$4,923.09
|
| Rate for Payer: The Alliance Commercial |
$4,318.50
|
| Rate for Payer: WEA Trust Commercial |
$4,750.35
|
| Rate for Payer: WPS Commercial |
$6,397.43
|
|
|
Stereotactic Body Radiation Therapy
|
Facility
|
OP
|
$12,381.00
|
|
|
Service Code
|
CPT 77373
|
| Hospital Charge Code |
3970755
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,763.67 |
| Max. Negotiated Rate |
$11,390.52 |
| Rate for Payer: Aetna Commercial |
$11,142.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,647.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,763.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,613.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,291.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,026.46
|
| Rate for Payer: Anthem Medicare Advantage |
$1,763.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,561.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,763.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,763.67
|
| Rate for Payer: Cash Price |
$3,714.30
|
| Rate for Payer: Cash Price |
$3,714.30
|
| Rate for Payer: Cigna Commercial |
$11,390.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,763.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,928.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,763.67
|
| Rate for Payer: Health EOS Commercial |
$11,019.09
|
| Rate for Payer: HFN Commercial |
$11,390.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,560.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,763.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,763.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,763.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,763.67
|
| Rate for Payer: Multiplan Commercial |
$9,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,645.50
|
| Rate for Payer: Preferred Network Access Commercial |
$11,390.52
|
| Rate for Payer: Quartz Beloit One Network |
$6,066.69
|
| Rate for Payer: Quartz Commercial |
$8,047.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,763.67
|
| Rate for Payer: The Alliance Commercial |
$7,054.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,763.67
|
| Rate for Payer: United Healthcare PPO |
$7,428.60
|
| Rate for Payer: WEA Trust Commercial |
$6,809.55
|
| Rate for Payer: Wellcare Medicare |
$1,763.67
|
| Rate for Payer: WPS Commercial |
$9,170.61
|
|
|
Stereotactic Body Radiation Therapy
|
Facility
|
IP
|
$12,381.00
|
|
|
Service Code
|
CPT 77373
|
| Hospital Charge Code |
3970755
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$6,066.69 |
| Max. Negotiated Rate |
$11,390.52 |
| Rate for Payer: Aetna Commercial |
$11,142.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,647.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,561.93
|
| Rate for Payer: Cash Price |
$3,714.30
|
| Rate for Payer: Cigna Commercial |
$11,390.52
|
| Rate for Payer: Health EOS Commercial |
$11,019.09
|
| Rate for Payer: HFN Commercial |
$11,390.52
|
| Rate for Payer: Multiplan Commercial |
$9,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,428.60
|
| Rate for Payer: Preferred Network Access Commercial |
$11,390.52
|
| Rate for Payer: Quartz Beloit One Network |
$6,066.69
|
| Rate for Payer: Quartz Commercial |
$7,428.60
|
| Rate for Payer: WEA Trust Commercial |
$6,809.55
|
| Rate for Payer: WPS Commercial |
$9,170.61
|
|
|
Stereotactic Cranial Linear Radiation Therapy
|
Facility
|
OP
|
$18,484.00
|
|
|
Service Code
|
CPT 77372
|
| Hospital Charge Code |
5586206
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$7,696.99 |
| Max. Negotiated Rate |
$30,787.96 |
| Rate for Payer: Aetna Commercial |
$16,635.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,896.24
|
| Rate for Payer: Aetna Managed Medicare |
$7,696.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,863.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23,090.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,936.42
|
| Rate for Payer: Anthem Medicare Advantage |
$7,696.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,796.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,696.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,696.99
|
| Rate for Payer: Cash Price |
$5,545.20
|
| Rate for Payer: Cash Price |
$5,545.20
|
| Rate for Payer: Cigna Commercial |
$17,005.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,696.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,343.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,696.99
|
| Rate for Payer: Health EOS Commercial |
$16,450.76
|
| Rate for Payer: HFN Commercial |
$17,005.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,632.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,696.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,696.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,696.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,696.99
|
| Rate for Payer: Multiplan Commercial |
$14,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,545.48
|
| Rate for Payer: Preferred Network Access Commercial |
$17,005.28
|
| Rate for Payer: Quartz Beloit One Network |
$9,057.16
|
| Rate for Payer: Quartz Commercial |
$12,014.60
|
| Rate for Payer: Quartz Medicare Advantage |
$7,696.99
|
| Rate for Payer: The Alliance Commercial |
$30,787.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,696.99
|
| Rate for Payer: United Healthcare PPO |
$11,090.40
|
| Rate for Payer: WEA Trust Commercial |
$10,166.20
|
| Rate for Payer: Wellcare Medicare |
$7,696.99
|
| Rate for Payer: WPS Commercial |
$13,691.10
|
|
|
Stereotactic Cranial Linear Radiation Therapy
|
Facility
|
IP
|
$18,484.00
|
|
|
Service Code
|
CPT 77372
|
| Hospital Charge Code |
5586206
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$9,057.16 |
| Max. Negotiated Rate |
$17,005.28 |
| Rate for Payer: Aetna Commercial |
$16,635.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,896.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,796.52
|
| Rate for Payer: Cash Price |
$5,545.20
|
| Rate for Payer: Cigna Commercial |
$17,005.28
|
| Rate for Payer: Health EOS Commercial |
$16,450.76
|
| Rate for Payer: HFN Commercial |
$17,005.28
|
| Rate for Payer: Multiplan Commercial |
$14,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,090.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,005.28
|
| Rate for Payer: Quartz Beloit One Network |
$9,057.16
|
| Rate for Payer: Quartz Commercial |
$11,090.40
|
| Rate for Payer: WEA Trust Commercial |
$10,166.20
|
| Rate for Payer: WPS Commercial |
$13,691.10
|
|
