|
STENT GENESIS 7MM X 18MM PG1870BSX
|
Facility
|
OP
|
$8,817.00
|
|
| Hospital Charge Code |
2974843
|
|
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 7 X 14mm PG1570BAX
|
Facility
|
OP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974846
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,262.96 |
| 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 7 X 14mm PG1570BAX
|
Facility
|
IP
|
$8,082.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974846
|
|
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 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 |
$10,239.04 |
| Max. Negotiated Rate |
$19,224.32 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$12,537.60
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
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 |
$5,850.88 |
| Max. Negotiated Rate |
$83,584.00 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,582.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,448.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,030.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,693.40
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,672.00
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$13,582.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.60
|
| Rate for Payer: The Alliance Commercial |
$83,584.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
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 |
$10,239.04 |
| Max. Negotiated Rate |
$19,224.32 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$12,537.60
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
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 |
$5,850.88 |
| Max. Negotiated Rate |
$83,584.00 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,582.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,448.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,030.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,693.40
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,672.00
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$13,582.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.60
|
| Rate for Payer: The Alliance Commercial |
$83,584.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
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 |
$5,850.88 |
| Max. Negotiated Rate |
$83,584.00 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,582.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,448.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,030.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,693.40
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,672.00
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$13,582.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.60
|
| Rate for Payer: The Alliance Commercial |
$83,584.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
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 |
$10,239.04 |
| Max. Negotiated Rate |
$19,224.32 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$12,537.60
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
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 |
$5,850.88 |
| Max. Negotiated Rate |
$83,584.00 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,582.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,448.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,030.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,693.40
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,672.00
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$13,582.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.60
|
| Rate for Payer: The Alliance Commercial |
$83,584.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
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 |
$10,239.04 |
| Max. Negotiated Rate |
$19,224.32 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$12,537.60
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
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 |
$10,239.04 |
| Max. Negotiated Rate |
$19,224.32 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$12,537.60
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
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 |
$5,850.88 |
| Max. Negotiated Rate |
$83,584.00 |
| Rate for Payer: Aetna Commercial |
$18,806.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,970.56
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,582.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,448.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,030.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.88
|
| Rate for Payer: Cash Price |
$6,268.80
|
| Rate for Payer: Cigna Commercial |
$19,224.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,693.40
|
| Rate for Payer: Health EOS Commercial |
$18,597.44
|
| Rate for Payer: HFN Commercial |
$19,224.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,672.00
|
| Rate for Payer: Multiplan Commercial |
$16,716.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,224.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,239.04
|
| Rate for Payer: Quartz Commercial |
$13,582.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.60
|
| Rate for Payer: The Alliance Commercial |
$83,584.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.80
|
| Rate for Payer: WPS Commercial |
$15,477.67
|
|
|
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 |
$5,560.52 |
| Max. Negotiated Rate |
$10,440.16 |
| Rate for Payer: Aetna Commercial |
$10,213.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,759.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,014.44
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,440.16
|
| Rate for Payer: Health EOS Commercial |
$10,099.72
|
| Rate for Payer: HFN Commercial |
$10,440.16
|
| Rate for Payer: Multiplan Commercial |
$9,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,808.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,440.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,560.52
|
| Rate for Payer: Quartz Commercial |
$6,808.80
|
| Rate for Payer: WEA Trust Commercial |
$6,241.40
|
| Rate for Payer: WPS Commercial |
$8,405.46
|
|
|
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 |
$3,177.44 |
| Max. Negotiated Rate |
$45,392.00 |
| Rate for Payer: Aetna Commercial |
$10,213.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,759.28
|
| Rate for Payer: Aetna Managed Medicare |
$3,177.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,376.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,674.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,447.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,014.44
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,440.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,350.34
|
| Rate for Payer: Health EOS Commercial |
$10,099.72
|
| Rate for Payer: HFN Commercial |
$10,440.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,511.00
|
| Rate for Payer: Multiplan Commercial |
$9,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,808.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,440.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,560.52
|
| Rate for Payer: Quartz Commercial |
$7,376.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,808.80
|
| Rate for Payer: The Alliance Commercial |
$45,392.00
|
| Rate for Payer: WEA Trust Commercial |
$6,241.40
|
| Rate for Payer: WPS Commercial |
$8,405.46
|
|
|
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 |
$5,560.52 |
| Max. Negotiated Rate |
$10,440.16 |
| Rate for Payer: Aetna Commercial |
$10,213.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,759.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,014.44
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,440.16
|
| Rate for Payer: Health EOS Commercial |
$10,099.72
|
| Rate for Payer: HFN Commercial |
$10,440.16
|
| Rate for Payer: Multiplan Commercial |
$9,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,808.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,440.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,560.52
|
| Rate for Payer: Quartz Commercial |
$6,808.80
|
| Rate for Payer: WEA Trust Commercial |
$6,241.40
|
| Rate for Payer: WPS Commercial |
$8,405.46
|
|
|
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 |
$3,177.44 |
| Max. Negotiated Rate |
$45,392.00 |
| Rate for Payer: Aetna Commercial |
$10,213.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,759.28
|
| Rate for Payer: Aetna Managed Medicare |
$3,177.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,376.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,674.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,447.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,014.44
|
| Rate for Payer: Cash Price |
$3,404.40
|
| Rate for Payer: Cigna Commercial |
$10,440.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,350.34
|
| Rate for Payer: Health EOS Commercial |
$10,099.72
|
| Rate for Payer: HFN Commercial |
$10,440.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,511.00
|
| Rate for Payer: Multiplan Commercial |
$9,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,808.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,440.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,560.52
|
| Rate for Payer: Quartz Commercial |
$7,376.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,808.80
|
| Rate for Payer: The Alliance Commercial |
$45,392.00
|
| Rate for Payer: WEA Trust Commercial |
$6,241.40
|
| Rate for Payer: WPS Commercial |
$8,405.46
|
|
|
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 |
$7,994.84 |
| Max. Negotiated Rate |
$15,010.72 |
| Rate for Payer: Aetna Commercial |
$14,684.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,031.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,647.48
|
| Rate for Payer: Cash Price |
$4,894.80
|
| Rate for Payer: Cigna Commercial |
$15,010.72
|
| Rate for Payer: Health EOS Commercial |
$14,521.24
|
| Rate for Payer: HFN Commercial |
$15,010.72
|
| Rate for Payer: Multiplan Commercial |
$13,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,789.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,010.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,994.84
|
| Rate for Payer: Quartz Commercial |
$9,789.60
|
| Rate for Payer: WEA Trust Commercial |
$8,973.80
|
| Rate for Payer: WPS Commercial |
$12,085.26
|
|
|
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 |
$4,568.48 |
| Max. Negotiated Rate |
$65,264.00 |
| Rate for Payer: Aetna Commercial |
$14,684.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,031.76
|
| Rate for Payer: Aetna Managed Medicare |
$4,568.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,605.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,158.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,831.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,647.48
|
| Rate for Payer: Cash Price |
$4,894.80
|
| Rate for Payer: Cigna Commercial |
$15,010.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,130.43
|
| Rate for Payer: Health EOS Commercial |
$14,521.24
|
| Rate for Payer: HFN Commercial |
$15,010.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,237.00
|
| Rate for Payer: Multiplan Commercial |
$13,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,789.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,010.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,994.84
|
| Rate for Payer: Quartz Commercial |
$10,605.40
|
| Rate for Payer: Quartz Medicare Advantage |
$9,789.60
|
| Rate for Payer: The Alliance Commercial |
$65,264.00
|
| Rate for Payer: WEA Trust Commercial |
$8,973.80
|
| Rate for Payer: WPS Commercial |
$12,085.26
|
|
|
STENT INFRAVISION LIGHTED 0220-180-517
|
Facility
|
IP
|
$3,078.00
|
|
| Hospital Charge Code |
2966089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,508.22 |
| Max. Negotiated Rate |
$2,831.76 |
| Rate for Payer: Aetna Commercial |
$2,770.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,647.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,631.34
|
| Rate for Payer: Cash Price |
$923.40
|
| Rate for Payer: Cigna Commercial |
$2,831.76
|
| Rate for Payer: Health EOS Commercial |
$2,739.42
|
| Rate for Payer: HFN Commercial |
$2,831.76
|
| Rate for Payer: Multiplan Commercial |
$2,462.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,846.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,831.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,508.22
|
| Rate for Payer: Quartz Commercial |
$1,846.80
|
| Rate for Payer: WEA Trust Commercial |
$1,692.90
|
| Rate for Payer: WPS Commercial |
$2,279.87
|
|
|
STENT INFRAVISION LIGHTED 0220-180-517
|
Facility
|
OP
|
$3,078.00
|
|
| Hospital Charge Code |
2966089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$861.84 |
| Max. Negotiated Rate |
$12,312.00 |
| Rate for Payer: Aetna Commercial |
$2,770.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,647.08
|
| Rate for Payer: Aetna Managed Medicare |
$861.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,000.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,539.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,477.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,631.34
|
| Rate for Payer: Cash Price |
$923.40
|
| Rate for Payer: Cigna Commercial |
$2,831.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,722.45
|
| Rate for Payer: Health EOS Commercial |
$2,739.42
|
| Rate for Payer: HFN Commercial |
$2,831.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,308.50
|
| Rate for Payer: Multiplan Commercial |
$2,462.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,846.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,831.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,508.22
|
| Rate for Payer: Quartz Commercial |
$2,000.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,846.80
|
| Rate for Payer: The Alliance Commercial |
$12,312.00
|
| Rate for Payer: WEA Trust Commercial |
$1,692.90
|
| Rate for Payer: WPS Commercial |
$2,279.87
|
|
|
STENT IRIS LIGHTED URETERAL 0220-180-518
|
Facility
|
IP
|
$2,537.00
|
|
| Hospital Charge Code |
5306838
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,243.13 |
| Max. Negotiated Rate |
$2,334.04 |
| Rate for Payer: Aetna Commercial |
$2,283.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,181.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,344.61
|
| Rate for Payer: Cash Price |
$761.10
|
| Rate for Payer: Cigna Commercial |
$2,334.04
|
| Rate for Payer: Health EOS Commercial |
$2,257.93
|
| Rate for Payer: HFN Commercial |
$2,334.04
|
| Rate for Payer: Multiplan Commercial |
$2,029.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,522.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,334.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,243.13
|
| Rate for Payer: Quartz Commercial |
$1,522.20
|
| Rate for Payer: WEA Trust Commercial |
$1,395.35
|
| Rate for Payer: WPS Commercial |
$1,879.16
|
|
|
STENT IRIS LIGHTED URETERAL 0220-180-518
|
Facility
|
OP
|
$2,537.00
|
|
| Hospital Charge Code |
5306838
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$710.36 |
| Max. Negotiated Rate |
$10,148.00 |
| Rate for Payer: Aetna Commercial |
$2,283.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,181.82
|
| Rate for Payer: Aetna Managed Medicare |
$710.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,649.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,268.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,217.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,344.61
|
| Rate for Payer: Cash Price |
$761.10
|
| Rate for Payer: Cigna Commercial |
$2,334.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,419.71
|
| Rate for Payer: Health EOS Commercial |
$2,257.93
|
| Rate for Payer: HFN Commercial |
$2,334.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,902.75
|
| Rate for Payer: Multiplan Commercial |
$2,029.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,522.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,334.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,243.13
|
| Rate for Payer: Quartz Commercial |
$1,649.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,522.20
|
| Rate for Payer: The Alliance Commercial |
$10,148.00
|
| Rate for Payer: WEA Trust Commercial |
$1,395.35
|
| Rate for Payer: WPS Commercial |
$1,879.16
|
|
|
STENT LOOP 8 X 28 POLARIS 155-254
|
Facility
|
IP
|
$1,805.00
|
|
| Hospital Charge Code |
2964819
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.45 |
| Max. Negotiated Rate |
$1,660.60 |
| Rate for Payer: Aetna Commercial |
$1,624.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,552.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$956.65
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,660.60
|
| Rate for Payer: Health EOS Commercial |
$1,606.45
|
| Rate for Payer: HFN Commercial |
$1,660.60
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,083.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,660.60
|
| Rate for Payer: Quartz Beloit One Network |
$884.45
|
| Rate for Payer: Quartz Commercial |
$1,083.00
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$1,336.96
|
|
|
STENT LOOP 8 X 28 POLARIS 155-254
|
Facility
|
OP
|
$1,805.00
|
|
| Hospital Charge Code |
2964819
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.40 |
| Max. Negotiated Rate |
$7,220.00 |
| Rate for Payer: Aetna Commercial |
$1,624.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,552.30
|
| Rate for Payer: Aetna Managed Medicare |
$505.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,173.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$902.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$866.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$956.65
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,660.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,010.08
|
| Rate for Payer: Health EOS Commercial |
$1,606.45
|
| Rate for Payer: HFN Commercial |
$1,660.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,353.75
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,083.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,660.60
|
| Rate for Payer: Quartz Beloit One Network |
$884.45
|
| Rate for Payer: Quartz Commercial |
$1,173.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,083.00
|
| Rate for Payer: The Alliance Commercial |
$7,220.00
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$1,336.96
|
|
