|
STENT DUODENAL BEND PRELOADED ADVANIX 7FR X 12CM M00534230
|
Facility
|
OP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092793
|
|
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 7FR X 12CM M00534230
|
Facility
|
IP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092793
|
|
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 7FR X 15CM
|
Facility
|
OP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092794
|
|
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 7FR X 15CM
|
Facility
|
IP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092794
|
|
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 7FR X 5CM M00534200
|
Facility
|
IP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092792
|
|
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 7FR X 5CM M00534200
|
Facility
|
OP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092792
|
|
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 7FR X 7CM M00534210
|
Facility
|
IP
|
$2,122.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
2972822
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,081.37 |
| Max. Negotiated Rate |
$2,030.33 |
| Rate for Payer: Aetna Commercial |
$1,986.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,897.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,169.65
|
| Rate for Payer: Cash Price |
$636.60
|
| Rate for Payer: Cigna Commercial |
$2,030.33
|
| Rate for Payer: Health EOS Commercial |
$1,964.12
|
| Rate for Payer: HFN Commercial |
$2,030.33
|
| Rate for Payer: Multiplan Commercial |
$1,765.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,030.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,081.37
|
| Rate for Payer: Quartz Commercial |
$1,324.13
|
| Rate for Payer: WEA Trust Commercial |
$1,213.78
|
| Rate for Payer: WPS Commercial |
$1,634.58
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 7FR X 7CM M00534210
|
Facility
|
OP
|
$2,122.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
2972822
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.93 |
| Max. Negotiated Rate |
$2,030.33 |
| Rate for Payer: Aetna Commercial |
$1,986.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,897.92
|
| Rate for Payer: Aetna Managed Medicare |
$617.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,434.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,103.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,059.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,169.65
|
| Rate for Payer: Cash Price |
$636.60
|
| Rate for Payer: Cigna Commercial |
$2,030.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,235.00
|
| Rate for Payer: Health EOS Commercial |
$1,964.12
|
| Rate for Payer: HFN Commercial |
$2,030.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,655.16
|
| Rate for Payer: Multiplan Commercial |
$1,765.50
|
| Rate for Payer: NAPHCARE Commercial |
$1,324.13
|
| Rate for Payer: Preferred Network Access Commercial |
$2,030.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,081.37
|
| Rate for Payer: Quartz Commercial |
$1,434.47
|
| Rate for Payer: Quartz Medicare Advantage |
$1,324.13
|
| Rate for Payer: The Alliance Commercial |
$1,103.44
|
| Rate for Payer: WEA Trust Commercial |
$1,213.78
|
| Rate for Payer: WPS Commercial |
$1,634.58
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 7FR X 9CM M00534220
|
Facility
|
IP
|
$2,045.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
2972823
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,042.13 |
| Max. Negotiated Rate |
$1,956.66 |
| Rate for Payer: Aetna Commercial |
$1,914.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,829.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,127.20
|
| Rate for Payer: Cash Price |
$613.50
|
| Rate for Payer: Cigna Commercial |
$1,956.66
|
| Rate for Payer: Health EOS Commercial |
$1,892.85
|
| Rate for Payer: HFN Commercial |
$1,956.66
|
| Rate for Payer: Multiplan Commercial |
$1,701.44
|
| Rate for Payer: Preferred Network Access Commercial |
$1,956.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,042.13
|
| Rate for Payer: Quartz Commercial |
$1,276.08
|
| Rate for Payer: WEA Trust Commercial |
$1,169.74
|
| Rate for Payer: WPS Commercial |
$1,575.26
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 7FR X 9CM M00534220
|
Facility
|
OP
|
$2,045.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
2972823
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$595.50 |
| Max. Negotiated Rate |
$1,956.66 |
| Rate for Payer: Aetna Commercial |
$1,914.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,829.05
|
| Rate for Payer: Aetna Managed Medicare |
$595.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,382.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,063.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,020.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,127.20
|
| Rate for Payer: Cash Price |
$613.50
|
| Rate for Payer: Cigna Commercial |
$1,956.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,190.19
|
| Rate for Payer: Health EOS Commercial |
$1,892.85
|
| Rate for Payer: HFN Commercial |
$1,956.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,595.10
|
| Rate for Payer: Multiplan Commercial |
$1,701.44
|
| Rate for Payer: NAPHCARE Commercial |
$1,276.08
|
| Rate for Payer: Preferred Network Access Commercial |
$1,956.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,042.13
|
| Rate for Payer: Quartz Commercial |
$1,382.42
|
| Rate for Payer: Quartz Medicare Advantage |
$1,276.08
|
| Rate for Payer: The Alliance Commercial |
$1,063.40
|
| Rate for Payer: WEA Trust Commercial |
$1,169.74
|
| Rate for Payer: WPS Commercial |
$1,575.26
|
|
|
STENT DUODENAL BEND PRELOADED ADVANIX 8.5FR X 5CM M00534260
|
Facility
|
OP
|
$2,125.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092800
|
|
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 8.5FR X 5CM M00534260
|
Facility
|
IP
|
$2,125.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092800
|
|
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 8.5FR X 7CM M00534270
|
Facility
|
OP
|
$2,125.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092801
|
|
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 8.5FR X 7CM M00534270
|
Facility
|
IP
|
$2,125.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092801
|
|
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 8.5FR X 9CM M00534280
|
Facility
|
IP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092802
|
|
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 8.5FR X 9CM M00534280
|
Facility
|
OP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3092802
|
|
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 8.5F X 12CM 3429
|
Facility
|
OP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3949318
|
|
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 8.5F X 12CM 3429
|
Facility
|
IP
|
$2,046.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
3949318
|
|
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 EVERFLEX 7mm X 20mm X120 #PRB35-07-20-120
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
STENT EVERFLEX 7mm X 20mm X120 #PRB35-07-20-120
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
STENT EVERFLEX 7mm X 40mm X120 #PRB35-07-40-120
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974858
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
STENT EVERFLEX 7mm X 40mm X120 #PRB35-07-40-120
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974858
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
STENT EVERFLEX 7 X 150mm #PRB35-07-150-120
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3107482
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
STENT EVERFLEX 7 X 150mm #PRB35-07-150-120
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3107482
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
Stent Fem/Pop incl PTA
|
Facility
|
IP
|
$9,389.00
|
|
|
Service Code
|
CPT 37226
|
| Hospital Charge Code |
3052447
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,784.63 |
| Max. Negotiated Rate |
$8,983.40 |
| Rate for Payer: Aetna Commercial |
$8,788.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,397.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,175.22
|
| Rate for Payer: Cash Price |
$2,816.70
|
| Rate for Payer: Cigna Commercial |
$8,983.40
|
| Rate for Payer: Health EOS Commercial |
$8,690.46
|
| Rate for Payer: HFN Commercial |
$8,983.40
|
| Rate for Payer: Multiplan Commercial |
$7,811.65
|
| Rate for Payer: Preferred Network Access Commercial |
$8,983.40
|
| Rate for Payer: Quartz Beloit One Network |
$4,784.63
|
| Rate for Payer: Quartz Commercial |
$5,858.74
|
| Rate for Payer: WEA Trust Commercial |
$5,370.51
|
| Rate for Payer: WPS Commercial |
$7,232.35
|
|
