|
STENT GENESIS 7mm x 17mm PG1870BAX
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974844
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,216.94 |
| Max. Negotiated Rate |
$7,917.52 |
| Rate for Payer: Aetna Commercial |
$7,745.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,401.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,561.18
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,917.52
|
| Rate for Payer: Health EOS Commercial |
$7,659.34
|
| Rate for Payer: HFN Commercial |
$7,917.52
|
| Rate for Payer: Multiplan Commercial |
$6,884.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,917.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,216.94
|
| Rate for Payer: Quartz Commercial |
$5,163.60
|
| Rate for Payer: WEA Trust Commercial |
$4,733.30
|
| Rate for Payer: WPS Commercial |
$6,374.23
|
|
|
STENT GENESIS 7mm x 17mm PG1870BAX
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974844
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,409.68 |
| Max. Negotiated Rate |
$7,917.52 |
| Rate for Payer: Aetna Commercial |
$7,745.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,401.16
|
| Rate for Payer: Aetna Managed Medicare |
$2,409.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,593.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,303.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,130.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,561.18
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,917.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,816.05
|
| Rate for Payer: Health EOS Commercial |
$7,659.34
|
| Rate for Payer: HFN Commercial |
$7,917.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,454.50
|
| Rate for Payer: Multiplan Commercial |
$6,884.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,163.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,917.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,216.94
|
| Rate for Payer: Quartz Commercial |
$5,593.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,163.60
|
| Rate for Payer: The Alliance Commercial |
$4,303.00
|
| Rate for Payer: WEA Trust Commercial |
$4,733.30
|
| Rate for Payer: WPS Commercial |
$6,374.23
|
|
|
STENT GENESIS 7MM X 18MM PG1870BSX
|
Facility
|
OP
|
$8,817.00
|
|
| Hospital Charge Code |
2974843
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,567.51 |
| Max. Negotiated Rate |
$8,436.11 |
| Rate for Payer: Aetna Commercial |
$8,252.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,885.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,567.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,960.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,584.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,401.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,859.93
|
| Rate for Payer: Cash Price |
$2,645.10
|
| Rate for Payer: Cigna Commercial |
$8,436.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,131.49
|
| Rate for Payer: Health EOS Commercial |
$8,161.02
|
| Rate for Payer: HFN Commercial |
$8,436.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,877.26
|
| Rate for Payer: Multiplan Commercial |
$7,335.74
|
| Rate for Payer: NAPHCARE Commercial |
$5,501.81
|
| Rate for Payer: Preferred Network Access Commercial |
$8,436.11
|
| Rate for Payer: Quartz Beloit One Network |
$4,493.14
|
| Rate for Payer: Quartz Commercial |
$5,960.29
|
| Rate for Payer: Quartz Medicare Advantage |
$5,501.81
|
| Rate for Payer: The Alliance Commercial |
$4,584.84
|
| Rate for Payer: WEA Trust Commercial |
$5,043.32
|
| Rate for Payer: WPS Commercial |
$6,791.74
|
|
|
STENT GENESIS 7MM X 18MM PG1870BSX
|
Facility
|
IP
|
$8,817.00
|
|
| Hospital Charge Code |
2974843
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,493.14 |
| Max. Negotiated Rate |
$8,436.11 |
| Rate for Payer: Aetna Commercial |
$8,252.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,885.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,859.93
|
| Rate for Payer: Cash Price |
$2,645.10
|
| Rate for Payer: Cigna Commercial |
$8,436.11
|
| Rate for Payer: Health EOS Commercial |
$8,161.02
|
| Rate for Payer: HFN Commercial |
$8,436.11
|
| Rate for Payer: Multiplan Commercial |
$7,335.74
|
| Rate for Payer: Preferred Network Access Commercial |
$8,436.11
|
| Rate for Payer: Quartz Beloit One Network |
$4,493.14
|
| Rate for Payer: Quartz Commercial |
$5,501.81
|
| Rate for Payer: WEA Trust Commercial |
$5,043.32
|
| Rate for Payer: WPS Commercial |
$6,791.74
|
|
|
STENT GENESIS 7 X 14mm PG1570BAX
|
Facility
|
OP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974846
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,353.48 |
| Max. Negotiated Rate |
$7,732.86 |
| Rate for Payer: Aetna Commercial |
$7,564.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,228.54
|
| Rate for Payer: Aetna Managed Medicare |
$2,353.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,463.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,202.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,034.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,454.80
|
| Rate for Payer: Cash Price |
$2,424.60
|
| Rate for Payer: Cigna Commercial |
$7,732.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,703.72
|
| Rate for Payer: Health EOS Commercial |
$7,480.70
|
| Rate for Payer: HFN Commercial |
$7,732.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,303.96
|
| Rate for Payer: Multiplan Commercial |
$6,724.22
|
| Rate for Payer: NAPHCARE Commercial |
$5,043.17
|
| Rate for Payer: Preferred Network Access Commercial |
$7,732.86
|
| Rate for Payer: Quartz Beloit One Network |
$4,118.59
|
| Rate for Payer: Quartz Commercial |
$5,463.43
|
| Rate for Payer: Quartz Medicare Advantage |
$5,043.17
|
| Rate for Payer: The Alliance Commercial |
$4,202.64
|
| Rate for Payer: WEA Trust Commercial |
$4,622.90
|
| Rate for Payer: WPS Commercial |
$6,225.56
|
|
|
STENT GENESIS 7 X 14mm PG1570BAX
|
Facility
|
IP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974846
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,118.59 |
| Max. Negotiated Rate |
$7,732.86 |
| Rate for Payer: Aetna Commercial |
$7,564.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,228.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,454.80
|
| Rate for Payer: Cash Price |
$2,424.60
|
| Rate for Payer: Cigna Commercial |
$7,732.86
|
| Rate for Payer: Health EOS Commercial |
$7,480.70
|
| Rate for Payer: HFN Commercial |
$7,732.86
|
| Rate for Payer: Multiplan Commercial |
$6,724.22
|
| Rate for Payer: Preferred Network Access Commercial |
$7,732.86
|
| Rate for Payer: Quartz Beloit One Network |
$4,118.59
|
| Rate for Payer: Quartz Commercial |
$5,043.17
|
| Rate for Payer: WEA Trust Commercial |
$4,622.90
|
| Rate for Payer: WPS Commercial |
$6,225.56
|
|
|
STENT GRAFT 3.0 x 12mm JOS #12744-12
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973904
|
|
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 GRAFT 3.0 x 12mm JOS #12744-12
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973904
|
|
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 GRAFT 3.0 x 16mm JOS #12744-16
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973905
|
|
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 GRAFT 3.0 x 16mm JOS #12744-16
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973905
|
|
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 GRAFT 3.0 x 19mm JOS #12744-19
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973906
|
|
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 GRAFT 3.0 x 19mm JOS #12744-19
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973906
|
|
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 GRAFT 4.0 x 16mm ***DISCONTINUED
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973907
|
|
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 GRAFT 4.0 x 16mm ***DISCONTINUED
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973907
|
|
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 GRAFT 4.0 x 19mm JOS #12746-19
|
Facility
|
IP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973908
|
|
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 GRAFT 4.0 x 19mm JOS #12746-19
|
Facility
|
OP
|
$20,896.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973908
|
|
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 GRAFT FLUENCY 12MM X 60MM X 80CM FEM12060
|
Facility
|
IP
|
$11,348.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,782.94 |
| Max. Negotiated Rate |
$10,857.77 |
| Rate for Payer: Aetna Commercial |
$10,621.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,149.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,255.02
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,857.77
|
| Rate for Payer: Health EOS Commercial |
$10,503.71
|
| Rate for Payer: HFN Commercial |
$10,857.77
|
| Rate for Payer: Multiplan Commercial |
$9,441.54
|
| Rate for Payer: Preferred Network Access Commercial |
$10,857.77
|
| Rate for Payer: Quartz Beloit One Network |
$5,782.94
|
| Rate for Payer: Quartz Commercial |
$7,081.15
|
| Rate for Payer: WEA Trust Commercial |
$6,491.06
|
| Rate for Payer: WPS Commercial |
$8,741.36
|
|
|
STENT GRAFT FLUENCY 12MM X 60MM X 80CM FEM12060
|
Facility
|
OP
|
$11,348.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,304.54 |
| Max. Negotiated Rate |
$10,857.77 |
| Rate for Payer: Aetna Commercial |
$10,621.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,149.65
|
| Rate for Payer: Aetna Managed Medicare |
$3,304.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,671.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,900.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,664.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,255.02
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,857.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,604.54
|
| Rate for Payer: Health EOS Commercial |
$10,503.71
|
| Rate for Payer: HFN Commercial |
$10,857.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,851.44
|
| Rate for Payer: Multiplan Commercial |
$9,441.54
|
| Rate for Payer: NAPHCARE Commercial |
$7,081.15
|
| Rate for Payer: Preferred Network Access Commercial |
$10,857.77
|
| Rate for Payer: Quartz Beloit One Network |
$5,782.94
|
| Rate for Payer: Quartz Commercial |
$7,671.25
|
| Rate for Payer: Quartz Medicare Advantage |
$7,081.15
|
| Rate for Payer: The Alliance Commercial |
$5,900.96
|
| Rate for Payer: WEA Trust Commercial |
$6,491.06
|
| Rate for Payer: WPS Commercial |
$8,741.36
|
|
|
STENT GRAFT FLUENCY 13.5MM X 60MM X 80CM FEM14060
|
Facility
|
IP
|
$11,348.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,782.94 |
| Max. Negotiated Rate |
$10,857.77 |
| Rate for Payer: Aetna Commercial |
$10,621.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,149.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,255.02
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,857.77
|
| Rate for Payer: Health EOS Commercial |
$10,503.71
|
| Rate for Payer: HFN Commercial |
$10,857.77
|
| Rate for Payer: Multiplan Commercial |
$9,441.54
|
| Rate for Payer: Preferred Network Access Commercial |
$10,857.77
|
| Rate for Payer: Quartz Beloit One Network |
$5,782.94
|
| Rate for Payer: Quartz Commercial |
$7,081.15
|
| Rate for Payer: WEA Trust Commercial |
$6,491.06
|
| Rate for Payer: WPS Commercial |
$8,741.36
|
|
|
STENT GRAFT FLUENCY 13.5MM X 60MM X 80CM FEM14060
|
Facility
|
OP
|
$11,348.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
6204962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,304.54 |
| Max. Negotiated Rate |
$10,857.77 |
| Rate for Payer: Aetna Commercial |
$10,621.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,149.65
|
| Rate for Payer: Aetna Managed Medicare |
$3,304.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,671.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,900.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,664.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,255.02
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,857.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,604.54
|
| Rate for Payer: Health EOS Commercial |
$10,503.71
|
| Rate for Payer: HFN Commercial |
$10,857.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,851.44
|
| Rate for Payer: Multiplan Commercial |
$9,441.54
|
| Rate for Payer: NAPHCARE Commercial |
$7,081.15
|
| Rate for Payer: Preferred Network Access Commercial |
$10,857.77
|
| Rate for Payer: Quartz Beloit One Network |
$5,782.94
|
| Rate for Payer: Quartz Commercial |
$7,671.25
|
| Rate for Payer: Quartz Medicare Advantage |
$7,081.15
|
| Rate for Payer: The Alliance Commercial |
$5,900.96
|
| Rate for Payer: WEA Trust Commercial |
$6,491.06
|
| Rate for Payer: WPS Commercial |
$8,741.36
|
|
|
STENT ICAST 10mm x 38mm X 120 85424
|
Facility
|
IP
|
$16,316.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973919
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,314.63 |
| Max. Negotiated Rate |
$15,611.15 |
| Rate for Payer: Aetna Commercial |
$15,271.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,593.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,993.38
|
| Rate for Payer: Cash Price |
$4,894.80
|
| Rate for Payer: Cigna Commercial |
$15,611.15
|
| Rate for Payer: Health EOS Commercial |
$15,102.09
|
| Rate for Payer: HFN Commercial |
$15,611.15
|
| Rate for Payer: Multiplan Commercial |
$13,574.91
|
| Rate for Payer: Preferred Network Access Commercial |
$15,611.15
|
| Rate for Payer: Quartz Beloit One Network |
$8,314.63
|
| Rate for Payer: Quartz Commercial |
$10,181.18
|
| Rate for Payer: WEA Trust Commercial |
$9,332.75
|
| Rate for Payer: WPS Commercial |
$12,568.21
|
|
|
STENT ICAST 10mm x 38mm X 120 85424
|
Facility
|
OP
|
$16,316.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973919
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,751.22 |
| Max. Negotiated Rate |
$15,611.15 |
| Rate for Payer: Aetna Commercial |
$15,271.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,593.03
|
| Rate for Payer: Aetna Managed Medicare |
$4,751.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,029.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,484.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,144.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,993.38
|
| Rate for Payer: Cash Price |
$4,894.80
|
| Rate for Payer: Cigna Commercial |
$15,611.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,495.91
|
| Rate for Payer: Health EOS Commercial |
$15,102.09
|
| Rate for Payer: HFN Commercial |
$15,611.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,726.48
|
| Rate for Payer: Multiplan Commercial |
$13,574.91
|
| Rate for Payer: NAPHCARE Commercial |
$10,181.18
|
| Rate for Payer: Preferred Network Access Commercial |
$15,611.15
|
| Rate for Payer: Quartz Beloit One Network |
$8,314.63
|
| Rate for Payer: Quartz Commercial |
$11,029.62
|
| Rate for Payer: Quartz Medicare Advantage |
$10,181.18
|
| Rate for Payer: The Alliance Commercial |
$8,484.32
|
| Rate for Payer: WEA Trust Commercial |
$9,332.75
|
| Rate for Payer: WPS Commercial |
$12,568.21
|
|
|
STENT INFRAVISION LIGHTED 0220-180-517
|
Facility
|
OP
|
$3,078.00
|
|
| Hospital Charge Code |
2966089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$896.31 |
| Max. Negotiated Rate |
$2,945.03 |
| Rate for Payer: Aetna Commercial |
$2,881.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,752.96
|
| Rate for Payer: Aetna Managed Medicare |
$896.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,080.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,600.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,536.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,696.59
|
| Rate for Payer: Cash Price |
$923.40
|
| Rate for Payer: Cigna Commercial |
$2,945.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,791.40
|
| Rate for Payer: Health EOS Commercial |
$2,849.00
|
| Rate for Payer: HFN Commercial |
$2,945.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,400.84
|
| Rate for Payer: Multiplan Commercial |
$2,560.90
|
| Rate for Payer: NAPHCARE Commercial |
$1,920.67
|
| Rate for Payer: Preferred Network Access Commercial |
$2,945.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,568.55
|
| Rate for Payer: Quartz Commercial |
$2,080.73
|
| Rate for Payer: Quartz Medicare Advantage |
$1,920.67
|
| Rate for Payer: The Alliance Commercial |
$1,600.56
|
| Rate for Payer: WEA Trust Commercial |
$1,760.62
|
| Rate for Payer: WPS Commercial |
$2,370.98
|
|
|
STENT INFRAVISION LIGHTED 0220-180-517
|
Facility
|
IP
|
$3,078.00
|
|
| Hospital Charge Code |
2966089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,568.55 |
| Max. Negotiated Rate |
$2,945.03 |
| Rate for Payer: Aetna Commercial |
$2,881.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,752.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,696.59
|
| Rate for Payer: Cash Price |
$923.40
|
| Rate for Payer: Cigna Commercial |
$2,945.03
|
| Rate for Payer: Health EOS Commercial |
$2,849.00
|
| Rate for Payer: HFN Commercial |
$2,945.03
|
| Rate for Payer: Multiplan Commercial |
$2,560.90
|
| Rate for Payer: Preferred Network Access Commercial |
$2,945.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,568.55
|
| Rate for Payer: Quartz Commercial |
$1,920.67
|
| Rate for Payer: WEA Trust Commercial |
$1,760.62
|
| Rate for Payer: WPS Commercial |
$2,370.98
|
|
|
STENT IRIS LIGHTED URETERAL 0220-180-518
|
Facility
|
IP
|
$2,537.00
|
|
| Hospital Charge Code |
5306838
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,292.86 |
| Max. Negotiated Rate |
$2,427.40 |
| Rate for Payer: Aetna Commercial |
$2,374.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,269.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,398.39
|
| Rate for Payer: Cash Price |
$761.10
|
| Rate for Payer: Cigna Commercial |
$2,427.40
|
| Rate for Payer: Health EOS Commercial |
$2,348.25
|
| Rate for Payer: HFN Commercial |
$2,427.40
|
| Rate for Payer: Multiplan Commercial |
$2,110.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,427.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,292.86
|
| Rate for Payer: Quartz Commercial |
$1,583.09
|
| Rate for Payer: WEA Trust Commercial |
$1,451.16
|
| Rate for Payer: WPS Commercial |
$1,954.25
|
|
