|
STENT DE PROMUS 4.00mm x 16mm
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2974864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.60 |
| Max. Negotiated Rate |
$19,993.29 |
| Rate for Payer: Aetna Commercial |
$19,558.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,689.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,993.29
|
| Rate for Payer: Health EOS Commercial |
$19,341.34
|
| Rate for Payer: HFN Commercial |
$19,993.29
|
| Rate for Payer: Multiplan Commercial |
$17,385.47
|
| Rate for Payer: Preferred Network Access Commercial |
$19,993.29
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.60
|
| Rate for Payer: Quartz Commercial |
$13,039.10
|
| Rate for Payer: WEA Trust Commercial |
$11,952.51
|
| Rate for Payer: WPS Commercial |
$16,096.19
|
|
|
STENT DE PROMUS 4.00mm x 20mm
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2974863
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.92 |
| Max. Negotiated Rate |
$19,993.29 |
| Rate for Payer: Aetna Commercial |
$19,558.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,689.38
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,431.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,993.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,161.47
|
| Rate for Payer: Health EOS Commercial |
$19,341.34
|
| Rate for Payer: HFN Commercial |
$19,993.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.88
|
| Rate for Payer: Multiplan Commercial |
$17,385.47
|
| Rate for Payer: NAPHCARE Commercial |
$13,039.10
|
| Rate for Payer: Preferred Network Access Commercial |
$19,993.29
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.60
|
| Rate for Payer: Quartz Commercial |
$14,125.70
|
| Rate for Payer: Quartz Medicare Advantage |
$13,039.10
|
| Rate for Payer: The Alliance Commercial |
$10,865.92
|
| Rate for Payer: WEA Trust Commercial |
$11,952.51
|
| Rate for Payer: WPS Commercial |
$16,096.19
|
|
|
STENT DE PROMUS 4.00mm x 20mm
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2974863
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.60 |
| Max. Negotiated Rate |
$19,993.29 |
| Rate for Payer: Aetna Commercial |
$19,558.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,689.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,993.29
|
| Rate for Payer: Health EOS Commercial |
$19,341.34
|
| Rate for Payer: HFN Commercial |
$19,993.29
|
| Rate for Payer: Multiplan Commercial |
$17,385.47
|
| Rate for Payer: Preferred Network Access Commercial |
$19,993.29
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.60
|
| Rate for Payer: Quartz Commercial |
$13,039.10
|
| Rate for Payer: WEA Trust Commercial |
$11,952.51
|
| Rate for Payer: WPS Commercial |
$16,096.19
|
|
|
STENT DE PROMUS 4.00mm x 24mm
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2974862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.60 |
| Max. Negotiated Rate |
$19,993.29 |
| Rate for Payer: Aetna Commercial |
$19,558.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,689.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,993.29
|
| Rate for Payer: Health EOS Commercial |
$19,341.34
|
| Rate for Payer: HFN Commercial |
$19,993.29
|
| Rate for Payer: Multiplan Commercial |
$17,385.47
|
| Rate for Payer: Preferred Network Access Commercial |
$19,993.29
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.60
|
| Rate for Payer: Quartz Commercial |
$13,039.10
|
| Rate for Payer: WEA Trust Commercial |
$11,952.51
|
| Rate for Payer: WPS Commercial |
$16,096.19
|
|
|
STENT DE PROMUS 4.00mm x 24mm
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2974862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.92 |
| Max. Negotiated Rate |
$19,993.29 |
| Rate for Payer: Aetna Commercial |
$19,558.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,689.38
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,431.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,993.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,161.47
|
| Rate for Payer: Health EOS Commercial |
$19,341.34
|
| Rate for Payer: HFN Commercial |
$19,993.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.88
|
| Rate for Payer: Multiplan Commercial |
$17,385.47
|
| Rate for Payer: NAPHCARE Commercial |
$13,039.10
|
| Rate for Payer: Preferred Network Access Commercial |
$19,993.29
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.60
|
| Rate for Payer: Quartz Commercial |
$14,125.70
|
| Rate for Payer: Quartz Medicare Advantage |
$13,039.10
|
| Rate for Payer: The Alliance Commercial |
$10,865.92
|
| Rate for Payer: WEA Trust Commercial |
$11,952.51
|
| Rate for Payer: WPS Commercial |
$16,096.19
|
|
|
STENT DE PROMUS 4.00mm x 28mm
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2974861
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.92 |
| Max. Negotiated Rate |
$19,993.29 |
| Rate for Payer: Aetna Commercial |
$19,558.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,689.38
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,431.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,993.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,161.47
|
| Rate for Payer: Health EOS Commercial |
$19,341.34
|
| Rate for Payer: HFN Commercial |
$19,993.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.88
|
| Rate for Payer: Multiplan Commercial |
$17,385.47
|
| Rate for Payer: NAPHCARE Commercial |
$13,039.10
|
| Rate for Payer: Preferred Network Access Commercial |
$19,993.29
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.60
|
| Rate for Payer: Quartz Commercial |
$14,125.70
|
| Rate for Payer: Quartz Medicare Advantage |
$13,039.10
|
| Rate for Payer: The Alliance Commercial |
$10,865.92
|
| Rate for Payer: WEA Trust Commercial |
$11,952.51
|
| Rate for Payer: WPS Commercial |
$16,096.19
|
|
|
STENT DE PROMUS 4.00mm x 28mm
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2974861
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.60 |
| Max. Negotiated Rate |
$19,993.29 |
| Rate for Payer: Aetna Commercial |
$19,558.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,689.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,993.29
|
| Rate for Payer: Health EOS Commercial |
$19,341.34
|
| Rate for Payer: HFN Commercial |
$19,993.29
|
| Rate for Payer: Multiplan Commercial |
$17,385.47
|
| Rate for Payer: Preferred Network Access Commercial |
$19,993.29
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.60
|
| Rate for Payer: Quartz Commercial |
$13,039.10
|
| Rate for Payer: WEA Trust Commercial |
$11,952.51
|
| Rate for Payer: WPS Commercial |
$16,096.19
|
|
|
STENT DE PROMUS 4.00mm x 8mm
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2974860
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.92 |
| Max. Negotiated Rate |
$19,993.29 |
| Rate for Payer: Aetna Commercial |
$19,558.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,689.38
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,431.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,993.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,161.47
|
| Rate for Payer: Health EOS Commercial |
$19,341.34
|
| Rate for Payer: HFN Commercial |
$19,993.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.88
|
| Rate for Payer: Multiplan Commercial |
$17,385.47
|
| Rate for Payer: NAPHCARE Commercial |
$13,039.10
|
| Rate for Payer: Preferred Network Access Commercial |
$19,993.29
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.60
|
| Rate for Payer: Quartz Commercial |
$14,125.70
|
| Rate for Payer: Quartz Medicare Advantage |
$13,039.10
|
| Rate for Payer: The Alliance Commercial |
$10,865.92
|
| Rate for Payer: WEA Trust Commercial |
$11,952.51
|
| Rate for Payer: WPS Commercial |
$16,096.19
|
|
|
STENT DE PROMUS 4.00mm x 8mm
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2974860
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.60 |
| Max. Negotiated Rate |
$19,993.29 |
| Rate for Payer: Aetna Commercial |
$19,558.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,689.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,993.29
|
| Rate for Payer: Health EOS Commercial |
$19,341.34
|
| Rate for Payer: HFN Commercial |
$19,993.29
|
| Rate for Payer: Multiplan Commercial |
$17,385.47
|
| Rate for Payer: Preferred Network Access Commercial |
$19,993.29
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.60
|
| Rate for Payer: Quartz Commercial |
$13,039.10
|
| Rate for Payer: WEA Trust Commercial |
$11,952.51
|
| Rate for Payer: WPS Commercial |
$16,096.19
|
|
|
STENT DE PROMUS ELEMENT 3.0 X 32
|
Facility
|
IP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
3595494
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,729.25 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,566.43
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
STENT DE PROMUS ELEMENT 3.0 X 32
|
Facility
|
OP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
3595494
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.00 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Aetna Managed Medicare |
$2,131.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,946.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,805.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,653.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,259.08
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,708.04
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: NAPHCARE Commercial |
$4,566.43
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,946.97
|
| Rate for Payer: Quartz Medicare Advantage |
$4,566.43
|
| Rate for Payer: The Alliance Commercial |
$3,805.36
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
STENT DE PROMUS ELEMENT 3.5 X 32
|
Facility
|
IP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
3595495
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,729.25 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,566.43
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
STENT DE PROMUS ELEMENT 3.5 X 32
|
Facility
|
OP
|
$7,318.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
3595495
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.00 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Aetna Managed Medicare |
$2,131.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,946.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,805.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,653.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,259.08
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,708.04
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: NAPHCARE Commercial |
$4,566.43
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,946.97
|
| Rate for Payer: Quartz Medicare Advantage |
$4,566.43
|
| Rate for Payer: The Alliance Commercial |
$3,805.36
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
STENT DE PROMUS MR 2.50mm x 8mm
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.92 |
| Max. Negotiated Rate |
$19,993.29 |
| Rate for Payer: Aetna Commercial |
$19,558.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,689.38
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,431.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,993.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,161.47
|
| Rate for Payer: Health EOS Commercial |
$19,341.34
|
| Rate for Payer: HFN Commercial |
$19,993.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.88
|
| Rate for Payer: Multiplan Commercial |
$17,385.47
|
| Rate for Payer: NAPHCARE Commercial |
$13,039.10
|
| Rate for Payer: Preferred Network Access Commercial |
$19,993.29
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.60
|
| Rate for Payer: Quartz Commercial |
$14,125.70
|
| Rate for Payer: Quartz Medicare Advantage |
$13,039.10
|
| Rate for Payer: The Alliance Commercial |
$10,865.92
|
| Rate for Payer: WEA Trust Commercial |
$11,952.51
|
| Rate for Payer: WPS Commercial |
$16,096.19
|
|
|
STENT DE PROMUS MR 2.50mm x 8mm
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.60 |
| Max. Negotiated Rate |
$19,993.29 |
| Rate for Payer: Aetna Commercial |
$19,558.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,689.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,993.29
|
| Rate for Payer: Health EOS Commercial |
$19,341.34
|
| Rate for Payer: HFN Commercial |
$19,993.29
|
| Rate for Payer: Multiplan Commercial |
$17,385.47
|
| Rate for Payer: Preferred Network Access Commercial |
$19,993.29
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.60
|
| Rate for Payer: Quartz Commercial |
$13,039.10
|
| Rate for Payer: WEA Trust Commercial |
$11,952.51
|
| Rate for Payer: WPS Commercial |
$16,096.19
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 10FR X 12CM M00534350
|
Facility
|
OP
|
$2,125.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092798
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$618.80 |
| Max. Negotiated Rate |
$2,033.20 |
| Rate for Payer: Aetna Commercial |
$1,989.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,900.60
|
| Rate for Payer: Aetna Managed Medicare |
$618.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,436.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,105.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,060.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,171.30
|
| Rate for Payer: Cash Price |
$637.50
|
| Rate for Payer: Cigna Commercial |
$2,033.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,236.75
|
| Rate for Payer: Health EOS Commercial |
$1,966.90
|
| Rate for Payer: HFN Commercial |
$2,033.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,657.50
|
| Rate for Payer: Multiplan Commercial |
$1,768.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,326.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,033.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,082.90
|
| Rate for Payer: Quartz Commercial |
$1,436.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,326.00
|
| Rate for Payer: The Alliance Commercial |
$1,105.00
|
| Rate for Payer: WEA Trust Commercial |
$1,215.50
|
| Rate for Payer: WPS Commercial |
$1,636.89
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 10FR X 12CM M00534350
|
Facility
|
IP
|
$2,125.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092798
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,082.90 |
| Max. Negotiated Rate |
$2,033.20 |
| Rate for Payer: Aetna Commercial |
$1,989.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,900.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,171.30
|
| Rate for Payer: Cash Price |
$637.50
|
| Rate for Payer: Cigna Commercial |
$2,033.20
|
| Rate for Payer: Health EOS Commercial |
$1,966.90
|
| Rate for Payer: HFN Commercial |
$2,033.20
|
| Rate for Payer: Multiplan Commercial |
$1,768.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,033.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,082.90
|
| Rate for Payer: Quartz Commercial |
$1,326.00
|
| Rate for Payer: WEA Trust Commercial |
$1,215.50
|
| Rate for Payer: WPS Commercial |
$1,636.89
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 10FR X 15CM
|
Facility
|
OP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092799
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$595.80 |
| Max. Negotiated Rate |
$1,957.61 |
| Rate for Payer: Aetna Commercial |
$1,915.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,829.94
|
| Rate for Payer: Aetna Managed Medicare |
$595.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,383.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,063.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,021.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,127.76
|
| Rate for Payer: Cash Price |
$613.80
|
| Rate for Payer: Cigna Commercial |
$1,957.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,190.77
|
| Rate for Payer: Health EOS Commercial |
$1,893.78
|
| Rate for Payer: HFN Commercial |
$1,957.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,595.88
|
| Rate for Payer: Multiplan Commercial |
$1,702.27
|
| Rate for Payer: NAPHCARE Commercial |
$1,276.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,957.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,042.64
|
| Rate for Payer: Quartz Commercial |
$1,383.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,276.70
|
| Rate for Payer: The Alliance Commercial |
$1,063.92
|
| Rate for Payer: WEA Trust Commercial |
$1,170.31
|
| Rate for Payer: WPS Commercial |
$1,576.03
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 10FR X 15CM
|
Facility
|
IP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092799
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,042.64 |
| Max. Negotiated Rate |
$1,957.61 |
| Rate for Payer: Aetna Commercial |
$1,915.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,829.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,127.76
|
| Rate for Payer: Cash Price |
$613.80
|
| Rate for Payer: Cigna Commercial |
$1,957.61
|
| Rate for Payer: Health EOS Commercial |
$1,893.78
|
| Rate for Payer: HFN Commercial |
$1,957.61
|
| Rate for Payer: Multiplan Commercial |
$1,702.27
|
| Rate for Payer: Preferred Network Access Commercial |
$1,957.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,042.64
|
| Rate for Payer: Quartz Commercial |
$1,276.70
|
| Rate for Payer: WEA Trust Commercial |
$1,170.31
|
| Rate for Payer: WPS Commercial |
$1,576.03
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 10FR X 5CM M00534320
|
Facility
|
OP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$595.80 |
| Max. Negotiated Rate |
$1,957.61 |
| Rate for Payer: Aetna Commercial |
$1,915.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,829.94
|
| Rate for Payer: Aetna Managed Medicare |
$595.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,383.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,063.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,021.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,127.76
|
| Rate for Payer: Cash Price |
$613.80
|
| Rate for Payer: Cigna Commercial |
$1,957.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,190.77
|
| Rate for Payer: Health EOS Commercial |
$1,893.78
|
| Rate for Payer: HFN Commercial |
$1,957.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,595.88
|
| Rate for Payer: Multiplan Commercial |
$1,702.27
|
| Rate for Payer: NAPHCARE Commercial |
$1,276.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,957.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,042.64
|
| Rate for Payer: Quartz Commercial |
$1,383.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,276.70
|
| Rate for Payer: The Alliance Commercial |
$1,063.92
|
| Rate for Payer: WEA Trust Commercial |
$1,170.31
|
| Rate for Payer: WPS Commercial |
$1,576.03
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 10FR X 5CM M00534320
|
Facility
|
IP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,042.64 |
| Max. Negotiated Rate |
$1,957.61 |
| Rate for Payer: Aetna Commercial |
$1,915.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,829.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,127.76
|
| Rate for Payer: Cash Price |
$613.80
|
| Rate for Payer: Cigna Commercial |
$1,957.61
|
| Rate for Payer: Health EOS Commercial |
$1,893.78
|
| Rate for Payer: HFN Commercial |
$1,957.61
|
| Rate for Payer: Multiplan Commercial |
$1,702.27
|
| Rate for Payer: Preferred Network Access Commercial |
$1,957.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,042.64
|
| Rate for Payer: Quartz Commercial |
$1,276.70
|
| Rate for Payer: WEA Trust Commercial |
$1,170.31
|
| Rate for Payer: WPS Commercial |
$1,576.03
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 10FR X 7CM M00534330
|
Facility
|
IP
|
$2,125.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092796
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,082.90 |
| Max. Negotiated Rate |
$2,033.20 |
| Rate for Payer: Aetna Commercial |
$1,989.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,900.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,171.30
|
| Rate for Payer: Cash Price |
$637.50
|
| Rate for Payer: Cigna Commercial |
$2,033.20
|
| Rate for Payer: Health EOS Commercial |
$1,966.90
|
| Rate for Payer: HFN Commercial |
$2,033.20
|
| Rate for Payer: Multiplan Commercial |
$1,768.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,033.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,082.90
|
| Rate for Payer: Quartz Commercial |
$1,326.00
|
| Rate for Payer: WEA Trust Commercial |
$1,215.50
|
| Rate for Payer: WPS Commercial |
$1,636.89
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 10FR X 7CM M00534330
|
Facility
|
OP
|
$2,125.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092796
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$618.80 |
| Max. Negotiated Rate |
$2,033.20 |
| Rate for Payer: Aetna Commercial |
$1,989.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,900.60
|
| Rate for Payer: Aetna Managed Medicare |
$618.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,436.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,105.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,060.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,171.30
|
| Rate for Payer: Cash Price |
$637.50
|
| Rate for Payer: Cigna Commercial |
$2,033.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,236.75
|
| Rate for Payer: Health EOS Commercial |
$1,966.90
|
| Rate for Payer: HFN Commercial |
$2,033.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,657.50
|
| Rate for Payer: Multiplan Commercial |
$1,768.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,326.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,033.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,082.90
|
| Rate for Payer: Quartz Commercial |
$1,436.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,326.00
|
| Rate for Payer: The Alliance Commercial |
$1,105.00
|
| Rate for Payer: WEA Trust Commercial |
$1,215.50
|
| Rate for Payer: WPS Commercial |
$1,636.89
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 10FR X 9CM M00534340
|
Facility
|
IP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092797
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,042.64 |
| Max. Negotiated Rate |
$1,957.61 |
| Rate for Payer: Aetna Commercial |
$1,915.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,829.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,127.76
|
| Rate for Payer: Cash Price |
$613.80
|
| Rate for Payer: Cigna Commercial |
$1,957.61
|
| Rate for Payer: Health EOS Commercial |
$1,893.78
|
| Rate for Payer: HFN Commercial |
$1,957.61
|
| Rate for Payer: Multiplan Commercial |
$1,702.27
|
| Rate for Payer: Preferred Network Access Commercial |
$1,957.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,042.64
|
| Rate for Payer: Quartz Commercial |
$1,276.70
|
| Rate for Payer: WEA Trust Commercial |
$1,170.31
|
| Rate for Payer: WPS Commercial |
$1,576.03
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 10FR X 9CM M00534340
|
Facility
|
OP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092797
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$595.80 |
| Max. Negotiated Rate |
$1,957.61 |
| Rate for Payer: Aetna Commercial |
$1,915.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,829.94
|
| Rate for Payer: Aetna Managed Medicare |
$595.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,383.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,063.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,021.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,127.76
|
| Rate for Payer: Cash Price |
$613.80
|
| Rate for Payer: Cigna Commercial |
$1,957.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,190.77
|
| Rate for Payer: Health EOS Commercial |
$1,893.78
|
| Rate for Payer: HFN Commercial |
$1,957.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,595.88
|
| Rate for Payer: Multiplan Commercial |
$1,702.27
|
| Rate for Payer: NAPHCARE Commercial |
$1,276.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,957.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,042.64
|
| Rate for Payer: Quartz Commercial |
$1,383.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,276.70
|
| Rate for Payer: The Alliance Commercial |
$1,063.92
|
| Rate for Payer: WEA Trust Commercial |
$1,170.31
|
| Rate for Payer: WPS Commercial |
$1,576.03
|
|
