|
STENT GENESIS 4 x 14mm PG1540BAX
|
Facility
|
IP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974856
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,960.18 |
| Max. Negotiated Rate |
$7,435.44 |
| Rate for Payer: Aetna Commercial |
$7,273.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,950.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,283.46
|
| Rate for Payer: Cash Price |
$2,424.60
|
| Rate for Payer: Cigna Commercial |
$7,435.44
|
| Rate for Payer: Health EOS Commercial |
$7,192.98
|
| Rate for Payer: HFN Commercial |
$7,435.44
|
| Rate for Payer: Multiplan Commercial |
$6,465.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,849.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,435.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,960.18
|
| Rate for Payer: Quartz Commercial |
$4,849.20
|
| Rate for Payer: WEA Trust Commercial |
$4,445.10
|
| Rate for Payer: WPS Commercial |
$5,986.34
|
|
|
STENT GENESIS 4 x 14mm PG1540BAX
|
Facility
|
OP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974856
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,262.96 |
| Max. Negotiated Rate |
$32,328.00 |
| Rate for Payer: Aetna Commercial |
$7,273.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,950.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,262.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,253.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,041.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,879.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,283.46
|
| Rate for Payer: Cash Price |
$2,424.60
|
| Rate for Payer: Cigna Commercial |
$7,435.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,522.69
|
| Rate for Payer: Health EOS Commercial |
$7,192.98
|
| Rate for Payer: HFN Commercial |
$7,435.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,061.50
|
| Rate for Payer: Multiplan Commercial |
$6,465.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,849.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,435.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,960.18
|
| Rate for Payer: Quartz Commercial |
$5,253.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,849.20
|
| Rate for Payer: The Alliance Commercial |
$32,328.00
|
| Rate for Payer: WEA Trust Commercial |
$4,445.10
|
| Rate for Payer: WPS Commercial |
$5,986.34
|
|
|
STENT GENESIS 4 X 17mm PG1840BAX
|
Facility
|
OP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974855
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,262.96 |
| Max. Negotiated Rate |
$32,328.00 |
| Rate for Payer: Aetna Commercial |
$7,273.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,950.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,262.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,253.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,041.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,879.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,283.46
|
| Rate for Payer: Cash Price |
$2,424.60
|
| Rate for Payer: Cigna Commercial |
$7,435.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,522.69
|
| Rate for Payer: Health EOS Commercial |
$7,192.98
|
| Rate for Payer: HFN Commercial |
$7,435.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,061.50
|
| Rate for Payer: Multiplan Commercial |
$6,465.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,849.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,435.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,960.18
|
| Rate for Payer: Quartz Commercial |
$5,253.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,849.20
|
| Rate for Payer: The Alliance Commercial |
$32,328.00
|
| Rate for Payer: WEA Trust Commercial |
$4,445.10
|
| Rate for Payer: WPS Commercial |
$5,986.34
|
|
|
STENT GENESIS 4 X 17mm PG1840BAX
|
Facility
|
IP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974855
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,960.18 |
| Max. Negotiated Rate |
$7,435.44 |
| Rate for Payer: Aetna Commercial |
$7,273.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,950.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,283.46
|
| Rate for Payer: Cash Price |
$2,424.60
|
| Rate for Payer: Cigna Commercial |
$7,435.44
|
| Rate for Payer: Health EOS Commercial |
$7,192.98
|
| Rate for Payer: HFN Commercial |
$7,435.44
|
| Rate for Payer: Multiplan Commercial |
$6,465.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,849.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,435.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,960.18
|
| Rate for Payer: Quartz Commercial |
$4,849.20
|
| Rate for Payer: WEA Trust Commercial |
$4,445.10
|
| Rate for Payer: WPS Commercial |
$5,986.34
|
|
|
STENT GENESIS 5mm X 14mm PG1550BSS
|
Facility
|
OP
|
$8,817.00
|
|
| Hospital Charge Code |
2974852
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,468.76 |
| Max. Negotiated Rate |
$35,268.00 |
| Rate for Payer: Aetna Commercial |
$7,935.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,582.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,468.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,731.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,408.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,232.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,673.01
|
| Rate for Payer: Cash Price |
$2,645.10
|
| Rate for Payer: Cigna Commercial |
$8,111.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,933.99
|
| Rate for Payer: Health EOS Commercial |
$7,847.13
|
| Rate for Payer: HFN Commercial |
$8,111.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,612.75
|
| Rate for Payer: Multiplan Commercial |
$7,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,290.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,111.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,320.33
|
| Rate for Payer: Quartz Commercial |
$5,731.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5,290.20
|
| Rate for Payer: The Alliance Commercial |
$35,268.00
|
| Rate for Payer: WEA Trust Commercial |
$4,849.35
|
| Rate for Payer: WPS Commercial |
$6,530.75
|
|
|
STENT GENESIS 5mm X 14mm PG1550BSS
|
Facility
|
IP
|
$8,817.00
|
|
| Hospital Charge Code |
2974852
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,320.33 |
| Max. Negotiated Rate |
$8,111.64 |
| Rate for Payer: Aetna Commercial |
$7,935.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,582.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,673.01
|
| Rate for Payer: Cash Price |
$2,645.10
|
| Rate for Payer: Cigna Commercial |
$8,111.64
|
| Rate for Payer: Health EOS Commercial |
$7,847.13
|
| Rate for Payer: HFN Commercial |
$8,111.64
|
| Rate for Payer: Multiplan Commercial |
$7,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,290.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,111.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,320.33
|
| Rate for Payer: Quartz Commercial |
$5,290.20
|
| Rate for Payer: WEA Trust Commercial |
$4,849.35
|
| Rate for Payer: WPS Commercial |
$6,530.75
|
|
|
STENT GENESIS 5mm X 17mm PG1850BSS
|
Facility
|
IP
|
$8,817.00
|
|
| Hospital Charge Code |
2974851
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,320.33 |
| Max. Negotiated Rate |
$8,111.64 |
| Rate for Payer: Aetna Commercial |
$7,935.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,582.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,673.01
|
| Rate for Payer: Cash Price |
$2,645.10
|
| Rate for Payer: Cigna Commercial |
$8,111.64
|
| Rate for Payer: Health EOS Commercial |
$7,847.13
|
| Rate for Payer: HFN Commercial |
$8,111.64
|
| Rate for Payer: Multiplan Commercial |
$7,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,290.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,111.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,320.33
|
| Rate for Payer: Quartz Commercial |
$5,290.20
|
| Rate for Payer: WEA Trust Commercial |
$4,849.35
|
| Rate for Payer: WPS Commercial |
$6,530.75
|
|
|
STENT GENESIS 5mm X 17mm PG1850BSS
|
Facility
|
OP
|
$8,817.00
|
|
| Hospital Charge Code |
2974851
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,468.76 |
| Max. Negotiated Rate |
$35,268.00 |
| Rate for Payer: Aetna Commercial |
$7,935.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,582.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,468.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,731.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,408.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,232.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,673.01
|
| Rate for Payer: Cash Price |
$2,645.10
|
| Rate for Payer: Cigna Commercial |
$8,111.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,933.99
|
| Rate for Payer: Health EOS Commercial |
$7,847.13
|
| Rate for Payer: HFN Commercial |
$8,111.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,612.75
|
| Rate for Payer: Multiplan Commercial |
$7,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,290.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,111.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,320.33
|
| Rate for Payer: Quartz Commercial |
$5,731.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5,290.20
|
| Rate for Payer: The Alliance Commercial |
$35,268.00
|
| Rate for Payer: WEA Trust Commercial |
$4,849.35
|
| Rate for Payer: WPS Commercial |
$6,530.75
|
|
|
STENT GENESIS 5 X 14mm PG1550BAX
|
Facility
|
OP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974854
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,262.96 |
| Max. Negotiated Rate |
$32,328.00 |
| Rate for Payer: Aetna Commercial |
$7,273.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,950.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,262.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,253.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,041.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,879.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,283.46
|
| Rate for Payer: Cash Price |
$2,424.60
|
| Rate for Payer: Cigna Commercial |
$7,435.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,522.69
|
| Rate for Payer: Health EOS Commercial |
$7,192.98
|
| Rate for Payer: HFN Commercial |
$7,435.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,061.50
|
| Rate for Payer: Multiplan Commercial |
$6,465.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,849.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,435.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,960.18
|
| Rate for Payer: Quartz Commercial |
$5,253.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,849.20
|
| Rate for Payer: The Alliance Commercial |
$32,328.00
|
| Rate for Payer: WEA Trust Commercial |
$4,445.10
|
| Rate for Payer: WPS Commercial |
$5,986.34
|
|
|
STENT GENESIS 5 X 14mm PG1550BAX
|
Facility
|
IP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974854
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,960.18 |
| Max. Negotiated Rate |
$7,435.44 |
| Rate for Payer: Aetna Commercial |
$7,273.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,950.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,283.46
|
| Rate for Payer: Cash Price |
$2,424.60
|
| Rate for Payer: Cigna Commercial |
$7,435.44
|
| Rate for Payer: Health EOS Commercial |
$7,192.98
|
| Rate for Payer: HFN Commercial |
$7,435.44
|
| Rate for Payer: Multiplan Commercial |
$6,465.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,849.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,435.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,960.18
|
| Rate for Payer: Quartz Commercial |
$4,849.20
|
| Rate for Payer: WEA Trust Commercial |
$4,445.10
|
| Rate for Payer: WPS Commercial |
$5,986.34
|
|
|
STENT GENESIS 5 X 17mm PG1850BAX
|
Facility
|
OP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974853
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,262.96 |
| Max. Negotiated Rate |
$32,328.00 |
| Rate for Payer: Aetna Commercial |
$7,273.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,950.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,262.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,253.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,041.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,879.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,283.46
|
| Rate for Payer: Cash Price |
$2,424.60
|
| Rate for Payer: Cigna Commercial |
$7,435.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,522.69
|
| Rate for Payer: Health EOS Commercial |
$7,192.98
|
| Rate for Payer: HFN Commercial |
$7,435.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,061.50
|
| Rate for Payer: Multiplan Commercial |
$6,465.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,849.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,435.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,960.18
|
| Rate for Payer: Quartz Commercial |
$5,253.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,849.20
|
| Rate for Payer: The Alliance Commercial |
$32,328.00
|
| Rate for Payer: WEA Trust Commercial |
$4,445.10
|
| Rate for Payer: WPS Commercial |
$5,986.34
|
|
|
STENT GENESIS 5 X 17mm PG1850BAX
|
Facility
|
IP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974853
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,960.18 |
| Max. Negotiated Rate |
$7,435.44 |
| Rate for Payer: Aetna Commercial |
$7,273.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,950.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,283.46
|
| Rate for Payer: Cash Price |
$2,424.60
|
| Rate for Payer: Cigna Commercial |
$7,435.44
|
| Rate for Payer: Health EOS Commercial |
$7,192.98
|
| Rate for Payer: HFN Commercial |
$7,435.44
|
| Rate for Payer: Multiplan Commercial |
$6,465.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,849.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,435.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,960.18
|
| Rate for Payer: Quartz Commercial |
$4,849.20
|
| Rate for Payer: WEA Trust Commercial |
$4,445.10
|
| Rate for Payer: WPS Commercial |
$5,986.34
|
|
|
STENT GENESIS 6mm X 14mm PG1560BSS
|
Facility
|
IP
|
$8,817.00
|
|
| Hospital Charge Code |
2974848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,320.33 |
| Max. Negotiated Rate |
$8,111.64 |
| Rate for Payer: Aetna Commercial |
$7,935.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,582.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,673.01
|
| Rate for Payer: Cash Price |
$2,645.10
|
| Rate for Payer: Cigna Commercial |
$8,111.64
|
| Rate for Payer: Health EOS Commercial |
$7,847.13
|
| Rate for Payer: HFN Commercial |
$8,111.64
|
| Rate for Payer: Multiplan Commercial |
$7,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,290.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,111.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,320.33
|
| Rate for Payer: Quartz Commercial |
$5,290.20
|
| Rate for Payer: WEA Trust Commercial |
$4,849.35
|
| Rate for Payer: WPS Commercial |
$6,530.75
|
|
|
STENT GENESIS 6mm X 14mm PG1560BSS
|
Facility
|
OP
|
$8,817.00
|
|
| Hospital Charge Code |
2974848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,468.76 |
| Max. Negotiated Rate |
$35,268.00 |
| Rate for Payer: Aetna Commercial |
$7,935.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,582.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,468.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,731.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,408.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,232.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,673.01
|
| Rate for Payer: Cash Price |
$2,645.10
|
| Rate for Payer: Cigna Commercial |
$8,111.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,933.99
|
| Rate for Payer: Health EOS Commercial |
$7,847.13
|
| Rate for Payer: HFN Commercial |
$8,111.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,612.75
|
| Rate for Payer: Multiplan Commercial |
$7,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,290.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,111.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,320.33
|
| Rate for Payer: Quartz Commercial |
$5,731.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5,290.20
|
| Rate for Payer: The Alliance Commercial |
$35,268.00
|
| Rate for Payer: WEA Trust Commercial |
$4,849.35
|
| Rate for Payer: WPS Commercial |
$6,530.75
|
|
|
STENT GENESIS 6mm X 17mm PG1860BSS
|
Facility
|
OP
|
$9,567.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974847
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,678.76 |
| Max. Negotiated Rate |
$38,268.00 |
| Rate for Payer: Aetna Commercial |
$8,610.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,227.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,678.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,218.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,783.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,592.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,070.51
|
| Rate for Payer: Cash Price |
$2,870.10
|
| Rate for Payer: Cigna Commercial |
$8,801.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,353.69
|
| Rate for Payer: Health EOS Commercial |
$8,514.63
|
| Rate for Payer: HFN Commercial |
$8,801.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,175.25
|
| Rate for Payer: Multiplan Commercial |
$7,653.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,740.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,801.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,687.83
|
| Rate for Payer: Quartz Commercial |
$6,218.55
|
| Rate for Payer: Quartz Medicare Advantage |
$5,740.20
|
| Rate for Payer: The Alliance Commercial |
$38,268.00
|
| Rate for Payer: WEA Trust Commercial |
$5,261.85
|
| Rate for Payer: WPS Commercial |
$7,086.28
|
|
|
STENT GENESIS 6mm X 17mm PG1860BSS
|
Facility
|
IP
|
$9,567.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974847
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,687.83 |
| Max. Negotiated Rate |
$8,801.64 |
| Rate for Payer: Aetna Commercial |
$8,610.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,227.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,070.51
|
| Rate for Payer: Cash Price |
$2,870.10
|
| Rate for Payer: Cigna Commercial |
$8,801.64
|
| Rate for Payer: Health EOS Commercial |
$8,514.63
|
| Rate for Payer: HFN Commercial |
$8,801.64
|
| Rate for Payer: Multiplan Commercial |
$7,653.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,740.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,801.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,687.83
|
| Rate for Payer: Quartz Commercial |
$5,740.20
|
| Rate for Payer: WEA Trust Commercial |
$5,261.85
|
| Rate for Payer: WPS Commercial |
$7,086.28
|
|
|
STENT GENESIS 6 x 13mm PG1560BAX
|
Facility
|
OP
|
$7,448.00
|
|
| Hospital Charge Code |
2974850
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,085.44 |
| Max. Negotiated Rate |
$29,792.00 |
| Rate for Payer: Aetna Commercial |
$6,703.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,405.28
|
| Rate for Payer: Aetna Managed Medicare |
$2,085.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,841.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,724.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,575.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,947.44
|
| Rate for Payer: Cash Price |
$2,234.40
|
| Rate for Payer: Cigna Commercial |
$6,852.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,167.90
|
| Rate for Payer: Health EOS Commercial |
$6,628.72
|
| Rate for Payer: HFN Commercial |
$6,852.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,586.00
|
| Rate for Payer: Multiplan Commercial |
$5,958.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,468.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,852.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,649.52
|
| Rate for Payer: Quartz Commercial |
$4,841.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,468.80
|
| Rate for Payer: The Alliance Commercial |
$29,792.00
|
| Rate for Payer: WEA Trust Commercial |
$4,096.40
|
| Rate for Payer: WPS Commercial |
$5,516.73
|
|
|
STENT GENESIS 6 x 13mm PG1560BAX
|
Facility
|
IP
|
$7,448.00
|
|
| Hospital Charge Code |
2974850
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,649.52 |
| Max. Negotiated Rate |
$6,852.16 |
| Rate for Payer: Aetna Commercial |
$6,703.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,405.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,947.44
|
| Rate for Payer: Cash Price |
$2,234.40
|
| Rate for Payer: Cigna Commercial |
$6,852.16
|
| Rate for Payer: Health EOS Commercial |
$6,628.72
|
| Rate for Payer: HFN Commercial |
$6,852.16
|
| Rate for Payer: Multiplan Commercial |
$5,958.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,468.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,852.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,649.52
|
| Rate for Payer: Quartz Commercial |
$4,468.80
|
| Rate for Payer: WEA Trust Commercial |
$4,096.40
|
| Rate for Payer: WPS Commercial |
$5,516.73
|
|
|
STENT GENESIS 6 X 15mm PG1860BAX
|
Facility
|
OP
|
$1,854.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974849
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$519.12 |
| Max. Negotiated Rate |
$7,416.00 |
| Rate for Payer: Aetna Commercial |
$1,668.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,594.44
|
| Rate for Payer: Aetna Managed Medicare |
$519.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,205.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$927.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$889.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$982.62
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cigna Commercial |
$1,705.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,037.50
|
| Rate for Payer: Health EOS Commercial |
$1,650.06
|
| Rate for Payer: HFN Commercial |
$1,705.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,390.50
|
| Rate for Payer: Multiplan Commercial |
$1,483.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,112.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,705.68
|
| Rate for Payer: Quartz Beloit One Network |
$908.46
|
| Rate for Payer: Quartz Commercial |
$1,205.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,112.40
|
| Rate for Payer: The Alliance Commercial |
$7,416.00
|
| Rate for Payer: WEA Trust Commercial |
$1,019.70
|
| Rate for Payer: WPS Commercial |
$1,373.26
|
|
|
STENT GENESIS 6 X 15mm PG1860BAX
|
Facility
|
IP
|
$1,854.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974849
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$908.46 |
| Max. Negotiated Rate |
$1,705.68 |
| Rate for Payer: Aetna Commercial |
$1,668.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,594.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$982.62
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cigna Commercial |
$1,705.68
|
| Rate for Payer: Health EOS Commercial |
$1,650.06
|
| Rate for Payer: HFN Commercial |
$1,705.68
|
| Rate for Payer: Multiplan Commercial |
$1,483.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,112.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,705.68
|
| Rate for Payer: Quartz Beloit One Network |
$908.46
|
| Rate for Payer: Quartz Commercial |
$1,112.40
|
| Rate for Payer: WEA Trust Commercial |
$1,019.70
|
| Rate for Payer: WPS Commercial |
$1,373.26
|
|
|
STENT GENESIS 7MM X 15MM PG1570BSX
|
Facility
|
OP
|
$8,817.00
|
|
| Hospital Charge Code |
2974845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,468.76 |
| Max. Negotiated Rate |
$35,268.00 |
| Rate for Payer: Aetna Commercial |
$7,935.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,582.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,468.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,731.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,408.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,232.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,673.01
|
| Rate for Payer: Cash Price |
$2,645.10
|
| Rate for Payer: Cigna Commercial |
$8,111.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,933.99
|
| Rate for Payer: Health EOS Commercial |
$7,847.13
|
| Rate for Payer: HFN Commercial |
$8,111.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,612.75
|
| Rate for Payer: Multiplan Commercial |
$7,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,290.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,111.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,320.33
|
| Rate for Payer: Quartz Commercial |
$5,731.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5,290.20
|
| Rate for Payer: The Alliance Commercial |
$35,268.00
|
| Rate for Payer: WEA Trust Commercial |
$4,849.35
|
| Rate for Payer: WPS Commercial |
$6,530.75
|
|
|
STENT GENESIS 7MM X 15MM PG1570BSX
|
Facility
|
IP
|
$8,817.00
|
|
| Hospital Charge Code |
2974845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,320.33 |
| Max. Negotiated Rate |
$8,111.64 |
| Rate for Payer: Aetna Commercial |
$7,935.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,582.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,673.01
|
| Rate for Payer: Cash Price |
$2,645.10
|
| Rate for Payer: Cigna Commercial |
$8,111.64
|
| Rate for Payer: Health EOS Commercial |
$7,847.13
|
| Rate for Payer: HFN Commercial |
$8,111.64
|
| Rate for Payer: Multiplan Commercial |
$7,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,290.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,111.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,320.33
|
| Rate for Payer: Quartz Commercial |
$5,290.20
|
| Rate for Payer: WEA Trust Commercial |
$4,849.35
|
| Rate for Payer: WPS Commercial |
$6,530.75
|
|
|
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 |
$4,054.75 |
| Max. Negotiated Rate |
$7,613.00 |
| Rate for Payer: Aetna Commercial |
$7,447.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,116.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,385.75
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,613.00
|
| Rate for Payer: Health EOS Commercial |
$7,364.75
|
| Rate for Payer: HFN Commercial |
$7,613.00
|
| Rate for Payer: Multiplan Commercial |
$6,620.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,965.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,613.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,054.75
|
| Rate for Payer: Quartz Commercial |
$4,965.00
|
| Rate for Payer: WEA Trust Commercial |
$4,551.25
|
| Rate for Payer: WPS Commercial |
$6,129.29
|
|
|
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 |
$2,317.00 |
| Max. Negotiated Rate |
$33,100.00 |
| Rate for Payer: Aetna Commercial |
$7,447.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,116.50
|
| Rate for Payer: Aetna Managed Medicare |
$2,317.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,378.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,137.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,972.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,385.75
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,613.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,630.69
|
| Rate for Payer: Health EOS Commercial |
$7,364.75
|
| Rate for Payer: HFN Commercial |
$7,613.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,206.25
|
| Rate for Payer: Multiplan Commercial |
$6,620.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,965.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,613.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,054.75
|
| Rate for Payer: Quartz Commercial |
$5,378.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,965.00
|
| Rate for Payer: The Alliance Commercial |
$33,100.00
|
| Rate for Payer: WEA Trust Commercial |
$4,551.25
|
| Rate for Payer: WPS Commercial |
$6,129.29
|
|
|
STENT GENESIS 7MM X 18MM PG1870BSX
|
Facility
|
IP
|
$8,817.00
|
|
| Hospital Charge Code |
2974843
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,320.33 |
| Max. Negotiated Rate |
$8,111.64 |
| Rate for Payer: Aetna Commercial |
$7,935.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,582.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,673.01
|
| Rate for Payer: Cash Price |
$2,645.10
|
| Rate for Payer: Cigna Commercial |
$8,111.64
|
| Rate for Payer: Health EOS Commercial |
$7,847.13
|
| Rate for Payer: HFN Commercial |
$8,111.64
|
| Rate for Payer: Multiplan Commercial |
$7,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,290.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,111.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,320.33
|
| Rate for Payer: Quartz Commercial |
$5,290.20
|
| Rate for Payer: WEA Trust Commercial |
$4,849.35
|
| Rate for Payer: WPS Commercial |
$6,530.75
|
|
