|
STENT 8MM X 27MM VISI-PRO #PXB350827135
|
Facility
|
OP
|
$9,881.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2973754
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,877.35 |
| Max. Negotiated Rate |
$9,454.14 |
| Rate for Payer: Aetna Commercial |
$9,248.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,837.57
|
| Rate for Payer: Aetna Managed Medicare |
$2,877.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,679.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,138.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,932.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,446.41
|
| Rate for Payer: Cash Price |
$2,964.30
|
| Rate for Payer: Cigna Commercial |
$9,454.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,750.74
|
| Rate for Payer: Health EOS Commercial |
$9,145.85
|
| Rate for Payer: HFN Commercial |
$9,454.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,707.18
|
| Rate for Payer: Multiplan Commercial |
$8,220.99
|
| Rate for Payer: NAPHCARE Commercial |
$6,165.74
|
| Rate for Payer: Preferred Network Access Commercial |
$9,454.14
|
| Rate for Payer: Quartz Beloit One Network |
$5,035.36
|
| Rate for Payer: Quartz Commercial |
$6,679.56
|
| Rate for Payer: Quartz Medicare Advantage |
$6,165.74
|
| Rate for Payer: The Alliance Commercial |
$5,138.12
|
| Rate for Payer: WEA Trust Commercial |
$5,651.93
|
| Rate for Payer: WPS Commercial |
$7,611.33
|
|
|
STENT 8 X 22 BLACK SILICONE LOOP G15127
|
Facility
|
OP
|
$1,805.00
|
|
| Hospital Charge Code |
2965886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$525.62 |
| Max. Negotiated Rate |
$1,727.02 |
| Rate for Payer: Aetna Commercial |
$1,689.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,614.39
|
| Rate for Payer: Aetna Managed Medicare |
$525.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,220.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$938.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$901.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$994.92
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,727.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,050.51
|
| Rate for Payer: Health EOS Commercial |
$1,670.71
|
| Rate for Payer: HFN Commercial |
$1,727.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,407.90
|
| Rate for Payer: Multiplan Commercial |
$1,501.76
|
| Rate for Payer: NAPHCARE Commercial |
$1,126.32
|
| Rate for Payer: Preferred Network Access Commercial |
$1,727.02
|
| Rate for Payer: Quartz Beloit One Network |
$919.83
|
| Rate for Payer: Quartz Commercial |
$1,220.18
|
| Rate for Payer: Quartz Medicare Advantage |
$1,126.32
|
| Rate for Payer: The Alliance Commercial |
$938.60
|
| Rate for Payer: WEA Trust Commercial |
$1,032.46
|
| Rate for Payer: WPS Commercial |
$1,390.39
|
|
|
STENT 8 X 22 BLACK SILICONE LOOP G15127
|
Facility
|
IP
|
$1,805.00
|
|
| Hospital Charge Code |
2965886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$919.83 |
| Max. Negotiated Rate |
$1,727.02 |
| Rate for Payer: Aetna Commercial |
$1,689.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,614.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$994.92
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,727.02
|
| Rate for Payer: Health EOS Commercial |
$1,670.71
|
| Rate for Payer: HFN Commercial |
$1,727.02
|
| Rate for Payer: Multiplan Commercial |
$1,501.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,727.02
|
| Rate for Payer: Quartz Beloit One Network |
$919.83
|
| Rate for Payer: Quartz Commercial |
$1,126.32
|
| Rate for Payer: WEA Trust Commercial |
$1,032.46
|
| Rate for Payer: WPS Commercial |
$1,390.39
|
|
|
STENT 8 X 24 BLACK SILICONE LOOP G15128
|
Facility
|
IP
|
$1,805.00
|
|
| Hospital Charge Code |
2965887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$919.83 |
| Max. Negotiated Rate |
$1,727.02 |
| Rate for Payer: Aetna Commercial |
$1,689.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,614.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$994.92
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,727.02
|
| Rate for Payer: Health EOS Commercial |
$1,670.71
|
| Rate for Payer: HFN Commercial |
$1,727.02
|
| Rate for Payer: Multiplan Commercial |
$1,501.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,727.02
|
| Rate for Payer: Quartz Beloit One Network |
$919.83
|
| Rate for Payer: Quartz Commercial |
$1,126.32
|
| Rate for Payer: WEA Trust Commercial |
$1,032.46
|
| Rate for Payer: WPS Commercial |
$1,390.39
|
|
|
STENT 8 X 24 BLACK SILICONE LOOP G15128
|
Facility
|
OP
|
$1,805.00
|
|
| Hospital Charge Code |
2965887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$525.62 |
| Max. Negotiated Rate |
$1,727.02 |
| Rate for Payer: Aetna Commercial |
$1,689.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,614.39
|
| Rate for Payer: Aetna Managed Medicare |
$525.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,220.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$938.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$901.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$994.92
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,727.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,050.51
|
| Rate for Payer: Health EOS Commercial |
$1,670.71
|
| Rate for Payer: HFN Commercial |
$1,727.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,407.90
|
| Rate for Payer: Multiplan Commercial |
$1,501.76
|
| Rate for Payer: NAPHCARE Commercial |
$1,126.32
|
| Rate for Payer: Preferred Network Access Commercial |
$1,727.02
|
| Rate for Payer: Quartz Beloit One Network |
$919.83
|
| Rate for Payer: Quartz Commercial |
$1,220.18
|
| Rate for Payer: Quartz Medicare Advantage |
$1,126.32
|
| Rate for Payer: The Alliance Commercial |
$938.60
|
| Rate for Payer: WEA Trust Commercial |
$1,032.46
|
| Rate for Payer: WPS Commercial |
$1,390.39
|
|
|
STENT 8 X 26 BLACK SILICONE LOOP G15130
|
Facility
|
OP
|
$1,805.00
|
|
| Hospital Charge Code |
2965888
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$525.62 |
| Max. Negotiated Rate |
$1,727.02 |
| Rate for Payer: Aetna Commercial |
$1,689.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,614.39
|
| Rate for Payer: Aetna Managed Medicare |
$525.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,220.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$938.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$901.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$994.92
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,727.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,050.51
|
| Rate for Payer: Health EOS Commercial |
$1,670.71
|
| Rate for Payer: HFN Commercial |
$1,727.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,407.90
|
| Rate for Payer: Multiplan Commercial |
$1,501.76
|
| Rate for Payer: NAPHCARE Commercial |
$1,126.32
|
| Rate for Payer: Preferred Network Access Commercial |
$1,727.02
|
| Rate for Payer: Quartz Beloit One Network |
$919.83
|
| Rate for Payer: Quartz Commercial |
$1,220.18
|
| Rate for Payer: Quartz Medicare Advantage |
$1,126.32
|
| Rate for Payer: The Alliance Commercial |
$938.60
|
| Rate for Payer: WEA Trust Commercial |
$1,032.46
|
| Rate for Payer: WPS Commercial |
$1,390.39
|
|
|
STENT 8 X 26 BLACK SILICONE LOOP G15130
|
Facility
|
IP
|
$1,805.00
|
|
| Hospital Charge Code |
2965888
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$919.83 |
| Max. Negotiated Rate |
$1,727.02 |
| Rate for Payer: Aetna Commercial |
$1,689.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,614.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$994.92
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,727.02
|
| Rate for Payer: Health EOS Commercial |
$1,670.71
|
| Rate for Payer: HFN Commercial |
$1,727.02
|
| Rate for Payer: Multiplan Commercial |
$1,501.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,727.02
|
| Rate for Payer: Quartz Beloit One Network |
$919.83
|
| Rate for Payer: Quartz Commercial |
$1,126.32
|
| Rate for Payer: WEA Trust Commercial |
$1,032.46
|
| Rate for Payer: WPS Commercial |
$1,390.39
|
|
|
STENT 8 X 28 BLACK SILICONE LOOP G15129
|
Facility
|
OP
|
$1,805.00
|
|
| Hospital Charge Code |
2965889
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$525.62 |
| Max. Negotiated Rate |
$1,727.02 |
| Rate for Payer: Aetna Commercial |
$1,689.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,614.39
|
| Rate for Payer: Aetna Managed Medicare |
$525.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,220.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$938.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$901.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$994.92
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,727.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,050.51
|
| Rate for Payer: Health EOS Commercial |
$1,670.71
|
| Rate for Payer: HFN Commercial |
$1,727.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,407.90
|
| Rate for Payer: Multiplan Commercial |
$1,501.76
|
| Rate for Payer: NAPHCARE Commercial |
$1,126.32
|
| Rate for Payer: Preferred Network Access Commercial |
$1,727.02
|
| Rate for Payer: Quartz Beloit One Network |
$919.83
|
| Rate for Payer: Quartz Commercial |
$1,220.18
|
| Rate for Payer: Quartz Medicare Advantage |
$1,126.32
|
| Rate for Payer: The Alliance Commercial |
$938.60
|
| Rate for Payer: WEA Trust Commercial |
$1,032.46
|
| Rate for Payer: WPS Commercial |
$1,390.39
|
|
|
STENT 8 X 28 BLACK SILICONE LOOP G15129
|
Facility
|
IP
|
$1,805.00
|
|
| Hospital Charge Code |
2965889
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$919.83 |
| Max. Negotiated Rate |
$1,727.02 |
| Rate for Payer: Aetna Commercial |
$1,689.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,614.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$994.92
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,727.02
|
| Rate for Payer: Health EOS Commercial |
$1,670.71
|
| Rate for Payer: HFN Commercial |
$1,727.02
|
| Rate for Payer: Multiplan Commercial |
$1,501.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,727.02
|
| Rate for Payer: Quartz Beloit One Network |
$919.83
|
| Rate for Payer: Quartz Commercial |
$1,126.32
|
| Rate for Payer: WEA Trust Commercial |
$1,032.46
|
| Rate for Payer: WPS Commercial |
$1,390.39
|
|
|
STENT 8 X 28 FIRM G49923
|
Facility
|
OP
|
$1,425.00
|
|
| Hospital Charge Code |
2965890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$414.96 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Aetna Managed Medicare |
$414.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$963.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$741.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$711.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$829.35
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,111.50
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$889.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$963.30
|
| Rate for Payer: Quartz Medicare Advantage |
$889.20
|
| Rate for Payer: The Alliance Commercial |
$741.00
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.68
|
|
|
STENT 8 X 28 FIRM G49923
|
Facility
|
IP
|
$1,425.00
|
|
| Hospital Charge Code |
2965890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$726.18 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$889.20
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.68
|
|
|
STENT 8 X 28 SOFT G49991
|
Facility
|
IP
|
$1,425.00
|
|
| Hospital Charge Code |
2965891
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$726.18 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$889.20
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.68
|
|
|
STENT 8 X 28 SOFT G49991
|
Facility
|
OP
|
$1,425.00
|
|
| Hospital Charge Code |
2965891
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$414.96 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Aetna Managed Medicare |
$414.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$963.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$741.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$711.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$829.35
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,111.50
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$889.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$963.30
|
| Rate for Payer: Quartz Medicare Advantage |
$889.20
|
| Rate for Payer: The Alliance Commercial |
$741.00
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.68
|
|
|
STENT 8 X 30 FIRM G49924
|
Facility
|
IP
|
$1,425.00
|
|
| Hospital Charge Code |
2965892
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$726.18 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$889.20
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.68
|
|
|
STENT 8 X 30 FIRM G49924
|
Facility
|
OP
|
$1,425.00
|
|
| Hospital Charge Code |
2965892
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$414.96 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Aetna Managed Medicare |
$414.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$963.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$741.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$711.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$829.35
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,111.50
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$889.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$963.30
|
| Rate for Payer: Quartz Medicare Advantage |
$889.20
|
| Rate for Payer: The Alliance Commercial |
$741.00
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.68
|
|
|
STENT 8 X 30 SOFT G49992
|
Facility
|
IP
|
$1,425.00
|
|
| Hospital Charge Code |
2965893
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$726.18 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$889.20
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.68
|
|
|
STENT 8 X 30 SOFT G49992
|
Facility
|
OP
|
$1,425.00
|
|
| Hospital Charge Code |
2965893
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$414.96 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Aetna Managed Medicare |
$414.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$963.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$741.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$711.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$829.35
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,111.50
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$889.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$963.30
|
| Rate for Payer: Quartz Medicare Advantage |
$889.20
|
| Rate for Payer: The Alliance Commercial |
$741.00
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.68
|
|
|
STENT 8 x 37mm 80cm PXB35-08-37-080
|
Facility
|
OP
|
$6,442.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3533497
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,875.91 |
| Max. Negotiated Rate |
$6,163.71 |
| Rate for Payer: Aetna Commercial |
$6,029.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,761.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,875.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,354.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,349.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,215.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,550.83
|
| Rate for Payer: Cash Price |
$1,932.60
|
| Rate for Payer: Cigna Commercial |
$6,163.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,749.24
|
| Rate for Payer: Health EOS Commercial |
$5,962.72
|
| Rate for Payer: HFN Commercial |
$6,163.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,024.76
|
| Rate for Payer: Multiplan Commercial |
$5,359.74
|
| Rate for Payer: NAPHCARE Commercial |
$4,019.81
|
| Rate for Payer: Preferred Network Access Commercial |
$6,163.71
|
| Rate for Payer: Quartz Beloit One Network |
$3,282.84
|
| Rate for Payer: Quartz Commercial |
$4,354.79
|
| Rate for Payer: Quartz Medicare Advantage |
$4,019.81
|
| Rate for Payer: The Alliance Commercial |
$3,349.84
|
| Rate for Payer: WEA Trust Commercial |
$3,684.82
|
| Rate for Payer: WPS Commercial |
$4,962.27
|
|
|
STENT 8 x 37mm 80cm PXB35-08-37-080
|
Facility
|
IP
|
$6,442.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3533497
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,282.84 |
| Max. Negotiated Rate |
$6,163.71 |
| Rate for Payer: Aetna Commercial |
$6,029.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,761.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,550.83
|
| Rate for Payer: Cash Price |
$1,932.60
|
| Rate for Payer: Cigna Commercial |
$6,163.71
|
| Rate for Payer: Health EOS Commercial |
$5,962.72
|
| Rate for Payer: HFN Commercial |
$6,163.71
|
| Rate for Payer: Multiplan Commercial |
$5,359.74
|
| Rate for Payer: Preferred Network Access Commercial |
$6,163.71
|
| Rate for Payer: Quartz Beloit One Network |
$3,282.84
|
| Rate for Payer: Quartz Commercial |
$4,019.81
|
| Rate for Payer: WEA Trust Commercial |
$3,684.82
|
| Rate for Payer: WPS Commercial |
$4,962.27
|
|
|
STENT 9 x 37mm 80cm PXB35-09-37-080
|
Facility
|
IP
|
$6,442.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3533498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,282.84 |
| Max. Negotiated Rate |
$6,163.71 |
| Rate for Payer: Aetna Commercial |
$6,029.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,761.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,550.83
|
| Rate for Payer: Cash Price |
$1,932.60
|
| Rate for Payer: Cigna Commercial |
$6,163.71
|
| Rate for Payer: Health EOS Commercial |
$5,962.72
|
| Rate for Payer: HFN Commercial |
$6,163.71
|
| Rate for Payer: Multiplan Commercial |
$5,359.74
|
| Rate for Payer: Preferred Network Access Commercial |
$6,163.71
|
| Rate for Payer: Quartz Beloit One Network |
$3,282.84
|
| Rate for Payer: Quartz Commercial |
$4,019.81
|
| Rate for Payer: WEA Trust Commercial |
$3,684.82
|
| Rate for Payer: WPS Commercial |
$4,962.27
|
|
|
STENT 9 x 37mm 80cm PXB35-09-37-080
|
Facility
|
OP
|
$6,442.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
3533498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,875.91 |
| Max. Negotiated Rate |
$6,163.71 |
| Rate for Payer: Aetna Commercial |
$6,029.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,761.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,875.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,354.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,349.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,215.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,550.83
|
| Rate for Payer: Cash Price |
$1,932.60
|
| Rate for Payer: Cigna Commercial |
$6,163.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,749.24
|
| Rate for Payer: Health EOS Commercial |
$5,962.72
|
| Rate for Payer: HFN Commercial |
$6,163.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,024.76
|
| Rate for Payer: Multiplan Commercial |
$5,359.74
|
| Rate for Payer: NAPHCARE Commercial |
$4,019.81
|
| Rate for Payer: Preferred Network Access Commercial |
$6,163.71
|
| Rate for Payer: Quartz Beloit One Network |
$3,282.84
|
| Rate for Payer: Quartz Commercial |
$4,354.79
|
| Rate for Payer: Quartz Medicare Advantage |
$4,019.81
|
| Rate for Payer: The Alliance Commercial |
$3,349.84
|
| Rate for Payer: WEA Trust Commercial |
$3,684.82
|
| Rate for Payer: WPS Commercial |
$4,962.27
|
|
|
Stent Artery (Ex LE,Car,Cor,Vert) ea add +
|
Facility
|
OP
|
$1,579.00
|
|
|
Service Code
|
CPT 37237
|
| Hospital Charge Code |
4125707
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$459.80 |
| Max. Negotiated Rate |
$12,349.86 |
| Rate for Payer: Aetna Commercial |
$1,477.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.26
|
| Rate for Payer: Aetna Managed Medicare |
$459.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,067.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$821.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$788.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.34
|
| Rate for Payer: Cash Price |
$473.70
|
| Rate for Payer: Cash Price |
$473.70
|
| Rate for Payer: Cigna Commercial |
$1,510.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Health EOS Commercial |
$1,461.52
|
| Rate for Payer: HFN Commercial |
$1,510.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,231.62
|
| Rate for Payer: Multiplan Commercial |
$1,313.73
|
| Rate for Payer: NAPHCARE Commercial |
$985.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,510.79
|
| Rate for Payer: Quartz Beloit One Network |
$804.66
|
| Rate for Payer: Quartz Commercial |
$1,067.40
|
| Rate for Payer: Quartz Medicare Advantage |
$985.30
|
| Rate for Payer: The Alliance Commercial |
$681.95
|
| Rate for Payer: WEA Trust Commercial |
$903.19
|
| Rate for Payer: WPS Commercial |
$1,216.30
|
|
|
Stent Artery (Ex LE,Car,Cor,Vert) ea add +
|
Facility
|
IP
|
$1,579.00
|
|
|
Service Code
|
CPT 37237
|
| Hospital Charge Code |
4125707
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$804.66 |
| Max. Negotiated Rate |
$1,510.79 |
| Rate for Payer: Aetna Commercial |
$1,477.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.34
|
| Rate for Payer: Cash Price |
$473.70
|
| Rate for Payer: Cigna Commercial |
$1,510.79
|
| Rate for Payer: Health EOS Commercial |
$1,461.52
|
| Rate for Payer: HFN Commercial |
$1,510.79
|
| Rate for Payer: Multiplan Commercial |
$1,313.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,510.79
|
| Rate for Payer: Quartz Beloit One Network |
$804.66
|
| Rate for Payer: Quartz Commercial |
$985.30
|
| Rate for Payer: WEA Trust Commercial |
$903.19
|
| Rate for Payer: WPS Commercial |
$1,216.30
|
|
|
Stent Artery (EX LE,Car,Cor,Vert) Incl PTA
|
Facility
|
OP
|
$5,371.00
|
|
|
Service Code
|
CPT 37236
|
| Hospital Charge Code |
4125708
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,737.06 |
| Max. Negotiated Rate |
$48,595.91 |
| Rate for Payer: Aetna Commercial |
$5,027.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,803.82
|
| Rate for Payer: Aetna Managed Medicare |
$12,148.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,394.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,394.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,919.20
|
| Rate for Payer: Anthem Medicare Advantage |
$12,148.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,960.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,148.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,148.98
|
| Rate for Payer: Cash Price |
$1,611.30
|
| Rate for Payer: Cash Price |
$1,611.30
|
| Rate for Payer: Cash Price |
$1,611.30
|
| Rate for Payer: Cigna Commercial |
$5,138.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,148.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,148.98
|
| Rate for Payer: Health EOS Commercial |
$4,971.40
|
| Rate for Payer: HFN Commercial |
$5,138.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45,194.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,148.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,148.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,148.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,148.98
|
| Rate for Payer: Multiplan Commercial |
$4,468.67
|
| Rate for Payer: NAPHCARE Commercial |
$18,223.47
|
| Rate for Payer: Preferred Network Access Commercial |
$5,138.97
|
| Rate for Payer: Quartz Beloit One Network |
$2,737.06
|
| Rate for Payer: Quartz Commercial |
$3,630.80
|
| Rate for Payer: Quartz Medicare Advantage |
$12,148.98
|
| Rate for Payer: The Alliance Commercial |
$48,595.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,148.98
|
| Rate for Payer: United Healthcare PPO |
$9,979.84
|
| Rate for Payer: WEA Trust Commercial |
$3,072.21
|
| Rate for Payer: Wellcare Medicare |
$12,148.98
|
| Rate for Payer: WPS Commercial |
$4,137.28
|
|
|
Stent Artery (EX LE,Car,Cor,Vert) Incl PTA
|
Facility
|
IP
|
$5,371.00
|
|
|
Service Code
|
CPT 37236
|
| Hospital Charge Code |
4125708
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,737.06 |
| Max. Negotiated Rate |
$5,138.97 |
| Rate for Payer: Aetna Commercial |
$5,027.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,803.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,960.50
|
| Rate for Payer: Cash Price |
$1,611.30
|
| Rate for Payer: Cigna Commercial |
$5,138.97
|
| Rate for Payer: Health EOS Commercial |
$4,971.40
|
| Rate for Payer: HFN Commercial |
$5,138.97
|
| Rate for Payer: Multiplan Commercial |
$4,468.67
|
| Rate for Payer: Preferred Network Access Commercial |
$5,138.97
|
| Rate for Payer: Quartz Beloit One Network |
$2,737.06
|
| Rate for Payer: Quartz Commercial |
$3,351.50
|
| Rate for Payer: WEA Trust Commercial |
$3,072.21
|
| Rate for Payer: WPS Commercial |
$4,137.28
|
|
