|
STENT TRIA FIRM WITH SIDE HOLES 6 X 24 M0061902220
|
Facility
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5547376
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$575.68 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,768.16
|
| Rate for Payer: Aetna Managed Medicare |
$575.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,336.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,028.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$986.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,150.54
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,542.00
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,336.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 26 M0061902230
|
Facility
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5685838
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$575.68 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,768.16
|
| Rate for Payer: Aetna Managed Medicare |
$575.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,336.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,028.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$986.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,150.54
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,542.00
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,336.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 26 M0061902230
|
Facility
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5685838
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,007.44 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 28 M0061902240
|
Facility
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5685839
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$575.68 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,768.16
|
| Rate for Payer: Aetna Managed Medicare |
$575.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,336.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,028.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$986.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,150.54
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,542.00
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,336.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 28 M0061902240
|
Facility
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5685839
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,007.44 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 30 M0061902250
|
Facility
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
6169845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$575.68 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,768.16
|
| Rate for Payer: Aetna Managed Medicare |
$575.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,336.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,028.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$986.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,150.54
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,542.00
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,336.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 30 M0061902250
|
Facility
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
6169845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,007.44 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 20 M0061903200
|
Facility
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5617784
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,007.44 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 20 M0061903200
|
Facility
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5617784
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$575.68 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,768.16
|
| Rate for Payer: Aetna Managed Medicare |
$575.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,336.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,028.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$986.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,150.54
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,542.00
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,336.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 22 M0061903210
|
Facility
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5617785
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,007.44 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 22 M0061903210
|
Facility
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5617785
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$575.68 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,768.16
|
| Rate for Payer: Aetna Managed Medicare |
$575.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,336.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,028.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$986.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,150.54
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,542.00
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,336.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 24 M0061903220
|
Facility
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5547375
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$575.68 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,768.16
|
| Rate for Payer: Aetna Managed Medicare |
$575.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,336.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,028.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$986.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,150.54
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,542.00
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,336.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 24 M0061903220
|
Facility
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5547375
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,007.44 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 26 M0061903230
|
Facility
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5641677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,007.44 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 26 M0061903230
|
Facility
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5641677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$575.68 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Quartz Medicare Advantage |
$1,233.60
|
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,768.16
|
| Rate for Payer: Aetna Managed Medicare |
$575.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,336.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,028.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$986.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,150.54
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,542.00
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,336.40
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 28 M0061903240
|
Facility
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5641678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$575.68 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,768.16
|
| Rate for Payer: Aetna Managed Medicare |
$575.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,336.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,028.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$986.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,150.54
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,542.00
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,336.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 28 M0061903240
|
Facility
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5641678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,007.44 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 30 M0061903250
|
Facility
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5861682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$575.68 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,768.16
|
| Rate for Payer: Aetna Managed Medicare |
$575.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,336.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,028.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$986.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,150.54
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,542.00
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,336.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 30 M0061903250
|
Facility
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5861682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,007.44 |
| Max. Negotiated Rate |
$1,891.52 |
| Rate for Payer: Aetna Commercial |
$1,850.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,089.68
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,891.52
|
| Rate for Payer: Health EOS Commercial |
$1,829.84
|
| Rate for Payer: HFN Commercial |
$1,891.52
|
| Rate for Payer: Multiplan Commercial |
$1,644.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,233.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.44
|
| Rate for Payer: Quartz Commercial |
$1,233.60
|
| Rate for Payer: WEA Trust Commercial |
$1,130.80
|
| Rate for Payer: WPS Commercial |
$1,522.88
|
|
|
STENT URETERAL 6X28 FIRM G49907
|
Facility
OP
|
$1,425.00
|
|
| Hospital Charge Code |
2965881
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$399.00 |
| Max. Negotiated Rate |
$5,700.00 |
| Rate for Payer: Aetna Commercial |
$1,282.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,225.50
|
| Rate for Payer: Aetna Managed Medicare |
$399.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$926.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$712.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$684.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$755.25
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,311.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$797.43
|
| Rate for Payer: Health EOS Commercial |
$1,268.25
|
| Rate for Payer: HFN Commercial |
$1,311.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,068.75
|
| Rate for Payer: Multiplan Commercial |
$1,140.00
|
| Rate for Payer: NAPHCARE Commercial |
$855.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,311.00
|
| Rate for Payer: Quartz Beloit One Network |
$698.25
|
| Rate for Payer: Quartz Commercial |
$926.25
|
| Rate for Payer: Quartz Medicare Advantage |
$855.00
|
| Rate for Payer: The Alliance Commercial |
$5,700.00
|
| Rate for Payer: WEA Trust Commercial |
$783.75
|
| Rate for Payer: WPS Commercial |
$1,055.50
|
|
|
STENT URETERAL 6X28 FIRM G49907
|
Facility
IP
|
$1,425.00
|
|
| Hospital Charge Code |
2965881
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$698.25 |
| Max. Negotiated Rate |
$1,311.00 |
| Rate for Payer: Aetna Commercial |
$1,282.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$755.25
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,311.00
|
| Rate for Payer: Health EOS Commercial |
$1,268.25
|
| Rate for Payer: HFN Commercial |
$1,311.00
|
| Rate for Payer: Multiplan Commercial |
$1,140.00
|
| Rate for Payer: NAPHCARE Commercial |
$855.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,311.00
|
| Rate for Payer: Quartz Beloit One Network |
$698.25
|
| Rate for Payer: Quartz Commercial |
$855.00
|
| Rate for Payer: WEA Trust Commercial |
$783.75
|
| Rate for Payer: WPS Commercial |
$1,055.50
|
|
|
Stent Venous
|
Facility
OP
|
$5,572.00
|
|
|
Service Code
|
CPT 37238
|
| Hospital Charge Code |
4125709
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,730.28 |
| Max. Negotiated Rate |
$66,829.24 |
| Rate for Payer: Aetna Commercial |
$5,014.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,791.92
|
| Rate for Payer: Aetna Managed Medicare |
$10,873.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,649.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,649.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,230.00
|
| Rate for Payer: Anthem Medicare Advantage |
$10,873.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,953.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,873.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,873.62
|
| Rate for Payer: Cash Price |
$1,671.60
|
| Rate for Payer: Cash Price |
$1,671.60
|
| Rate for Payer: Cash Price |
$1,671.60
|
| Rate for Payer: Cigna Commercial |
$5,126.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,873.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,873.62
|
| Rate for Payer: Health EOS Commercial |
$4,959.08
|
| Rate for Payer: HFN Commercial |
$5,126.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40,449.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,873.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,873.62
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,873.62
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,873.62
|
| Rate for Payer: Multiplan Commercial |
$4,457.60
|
| Rate for Payer: NAPHCARE Commercial |
$16,310.43
|
| Rate for Payer: Preferred Network Access Commercial |
$5,126.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,730.28
|
| Rate for Payer: Quartz Commercial |
$3,621.80
|
| Rate for Payer: Quartz Medicare Advantage |
$10,873.62
|
| Rate for Payer: The Alliance Commercial |
$66,829.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,873.62
|
| Rate for Payer: United Healthcare PPO |
$9,596.00
|
| Rate for Payer: WEA Trust Commercial |
$3,064.60
|
| Rate for Payer: Wellcare Medicare |
$10,873.62
|
| Rate for Payer: WPS Commercial |
$4,127.18
|
|
|
Stent Venous
|
Facility
IP
|
$5,572.00
|
|
|
Service Code
|
CPT 37238
|
| Hospital Charge Code |
4125709
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,730.28 |
| Max. Negotiated Rate |
$5,126.24 |
| Rate for Payer: Aetna Commercial |
$5,014.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,953.16
|
| Rate for Payer: Cash Price |
$1,671.60
|
| Rate for Payer: Cigna Commercial |
$5,126.24
|
| Rate for Payer: Health EOS Commercial |
$4,959.08
|
| Rate for Payer: HFN Commercial |
$5,126.24
|
| Rate for Payer: Multiplan Commercial |
$4,457.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,343.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,126.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,730.28
|
| Rate for Payer: Quartz Commercial |
$3,343.20
|
| Rate for Payer: WEA Trust Commercial |
$3,064.60
|
| Rate for Payer: WPS Commercial |
$4,127.18
|
|
|
Stent Venous ea add +
|
Facility
IP
|
$1,853.00
|
|
|
Service Code
|
CPT 37239
|
| Hospital Charge Code |
4125710
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$907.97 |
| Max. Negotiated Rate |
$1,704.76 |
| Rate for Payer: Aetna Commercial |
$1,667.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$982.09
|
| Rate for Payer: Cash Price |
$555.90
|
| Rate for Payer: Cigna Commercial |
$1,704.76
|
| Rate for Payer: Health EOS Commercial |
$1,649.17
|
| Rate for Payer: HFN Commercial |
$1,704.76
|
| Rate for Payer: Multiplan Commercial |
$1,482.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,111.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,704.76
|
| Rate for Payer: Quartz Beloit One Network |
$907.97
|
| Rate for Payer: Quartz Commercial |
$1,111.80
|
| Rate for Payer: WEA Trust Commercial |
$1,019.15
|
| Rate for Payer: WPS Commercial |
$1,372.52
|
|
|
Stent Venous ea add +
|
Facility
OP
|
$1,853.00
|
|
|
Service Code
|
CPT 37239
|
| Hospital Charge Code |
4125710
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$518.84 |
| Max. Negotiated Rate |
$66,829.24 |
| Rate for Payer: Aetna Commercial |
$1,667.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,593.58
|
| Rate for Payer: Aetna Managed Medicare |
$518.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,204.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$926.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$889.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$982.09
|
| Rate for Payer: Cash Price |
$555.90
|
| Rate for Payer: Cash Price |
$555.90
|
| Rate for Payer: Cigna Commercial |
$1,704.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$1,649.17
|
| Rate for Payer: HFN Commercial |
$1,704.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,389.75
|
| Rate for Payer: Multiplan Commercial |
$1,482.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,111.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,704.76
|
| Rate for Payer: Quartz Beloit One Network |
$907.97
|
| Rate for Payer: Quartz Commercial |
$1,204.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,111.80
|
| Rate for Payer: The Alliance Commercial |
$66,829.24
|
| Rate for Payer: WEA Trust Commercial |
$1,019.15
|
| Rate for Payer: WPS Commercial |
$1,372.52
|
|
