|
STENT PERCUFLEX NEPHROURETERAL 8FR X 28CM NON-COATED M001221390
|
Facility
|
OP
|
$1,208.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5307026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$338.24 |
| Max. Negotiated Rate |
$4,832.00 |
| Rate for Payer: Aetna Commercial |
$1,087.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,038.88
|
| Rate for Payer: Aetna Managed Medicare |
$338.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$785.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$604.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$579.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$640.24
|
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Cigna Commercial |
$1,111.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$676.00
|
| Rate for Payer: Health EOS Commercial |
$1,075.12
|
| Rate for Payer: HFN Commercial |
$1,111.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$906.00
|
| Rate for Payer: Multiplan Commercial |
$966.40
|
| Rate for Payer: NAPHCARE Commercial |
$724.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,111.36
|
| Rate for Payer: Quartz Beloit One Network |
$591.92
|
| Rate for Payer: Quartz Commercial |
$785.20
|
| Rate for Payer: Quartz Medicare Advantage |
$724.80
|
| Rate for Payer: The Alliance Commercial |
$4,832.00
|
| Rate for Payer: WEA Trust Commercial |
$664.40
|
| Rate for Payer: WPS Commercial |
$894.77
|
|
|
STENT PERCUFLEX PLUS 4.8 X 18 M0061751990
|
Facility
|
OP
|
$1,620.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5348712
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$453.60 |
| Max. Negotiated Rate |
$6,480.00 |
| Rate for Payer: Aetna Commercial |
$1,458.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,393.20
|
| Rate for Payer: Aetna Managed Medicare |
$453.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,053.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$810.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$777.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$858.60
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cigna Commercial |
$1,490.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$906.55
|
| Rate for Payer: Health EOS Commercial |
$1,441.80
|
| Rate for Payer: HFN Commercial |
$1,490.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,215.00
|
| Rate for Payer: Multiplan Commercial |
$1,296.00
|
| Rate for Payer: NAPHCARE Commercial |
$972.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,490.40
|
| Rate for Payer: Quartz Beloit One Network |
$793.80
|
| Rate for Payer: Quartz Commercial |
$1,053.00
|
| Rate for Payer: Quartz Medicare Advantage |
$972.00
|
| Rate for Payer: The Alliance Commercial |
$6,480.00
|
| Rate for Payer: WEA Trust Commercial |
$891.00
|
| Rate for Payer: WPS Commercial |
$1,199.93
|
|
|
STENT PERCUFLEX PLUS 4.8 X 18 M0061751990
|
Facility
|
IP
|
$1,620.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5348712
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$793.80 |
| Max. Negotiated Rate |
$1,490.40 |
| Rate for Payer: Aetna Commercial |
$1,458.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,393.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$858.60
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cigna Commercial |
$1,490.40
|
| Rate for Payer: Health EOS Commercial |
$1,441.80
|
| Rate for Payer: HFN Commercial |
$1,490.40
|
| Rate for Payer: Multiplan Commercial |
$1,296.00
|
| Rate for Payer: NAPHCARE Commercial |
$972.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,490.40
|
| Rate for Payer: Quartz Beloit One Network |
$793.80
|
| Rate for Payer: Quartz Commercial |
$972.00
|
| Rate for Payer: WEA Trust Commercial |
$891.00
|
| Rate for Payer: WPS Commercial |
$1,199.93
|
|
|
STENT PERCUFLEX PLUS 4.8 X 20 M0061752500
|
Facility
|
OP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.76 |
| Max. Negotiated Rate |
$4,768.00 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Aetna Managed Medicare |
$333.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$774.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$596.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$572.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$667.04
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$894.00
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$774.80
|
| Rate for Payer: Quartz Medicare Advantage |
$715.20
|
| Rate for Payer: The Alliance Commercial |
$4,768.00
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 20 M0061752500
|
Facility
|
IP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.08 |
| Max. Negotiated Rate |
$1,096.64 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$715.20
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 22 M0061752510
|
Facility
|
OP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.76 |
| Max. Negotiated Rate |
$4,768.00 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Aetna Managed Medicare |
$333.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$774.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$596.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$572.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$667.04
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$894.00
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$774.80
|
| Rate for Payer: Quartz Medicare Advantage |
$715.20
|
| Rate for Payer: The Alliance Commercial |
$4,768.00
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 22 M0061752510
|
Facility
|
IP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.08 |
| Max. Negotiated Rate |
$1,096.64 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$715.20
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 24 M0061752520
|
Facility
|
OP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.76 |
| Max. Negotiated Rate |
$4,768.00 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Aetna Managed Medicare |
$333.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$774.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$596.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$572.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$667.04
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$894.00
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$774.80
|
| Rate for Payer: Quartz Medicare Advantage |
$715.20
|
| Rate for Payer: The Alliance Commercial |
$4,768.00
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 24 M0061752520
|
Facility
|
IP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.08 |
| Max. Negotiated Rate |
$1,096.64 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$715.20
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 26 M0061752530
|
Facility
|
OP
|
$1,591.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5415129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.48 |
| Max. Negotiated Rate |
$6,364.00 |
| Rate for Payer: Aetna Commercial |
$1,431.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,368.26
|
| Rate for Payer: Aetna Managed Medicare |
$445.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,034.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$795.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$763.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$843.23
|
| Rate for Payer: Cash Price |
$477.30
|
| Rate for Payer: Cigna Commercial |
$1,463.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$890.32
|
| Rate for Payer: Health EOS Commercial |
$1,415.99
|
| Rate for Payer: HFN Commercial |
$1,463.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,193.25
|
| Rate for Payer: Multiplan Commercial |
$1,272.80
|
| Rate for Payer: NAPHCARE Commercial |
$954.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,463.72
|
| Rate for Payer: Quartz Beloit One Network |
$779.59
|
| Rate for Payer: Quartz Commercial |
$1,034.15
|
| Rate for Payer: Quartz Medicare Advantage |
$954.60
|
| Rate for Payer: The Alliance Commercial |
$6,364.00
|
| Rate for Payer: WEA Trust Commercial |
$875.05
|
| Rate for Payer: WPS Commercial |
$1,178.45
|
|
|
STENT PERCUFLEX PLUS 4.8 X 26 M0061752530
|
Facility
|
IP
|
$1,591.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5415129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$779.59 |
| Max. Negotiated Rate |
$1,463.72 |
| Rate for Payer: Aetna Commercial |
$1,431.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,368.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$843.23
|
| Rate for Payer: Cash Price |
$477.30
|
| Rate for Payer: Cigna Commercial |
$1,463.72
|
| Rate for Payer: Health EOS Commercial |
$1,415.99
|
| Rate for Payer: HFN Commercial |
$1,463.72
|
| Rate for Payer: Multiplan Commercial |
$1,272.80
|
| Rate for Payer: NAPHCARE Commercial |
$954.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,463.72
|
| Rate for Payer: Quartz Beloit One Network |
$779.59
|
| Rate for Payer: Quartz Commercial |
$954.60
|
| Rate for Payer: WEA Trust Commercial |
$875.05
|
| Rate for Payer: WPS Commercial |
$1,178.45
|
|
|
STENT PERCUFLEX PLUS 4.8 X 28 M0061752540
|
Facility
|
IP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.08 |
| Max. Negotiated Rate |
$1,096.64 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$715.20
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 28 M0061752540
|
Facility
|
OP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.76 |
| Max. Negotiated Rate |
$4,768.00 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Aetna Managed Medicare |
$333.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$774.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$596.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$572.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$667.04
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$894.00
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$774.80
|
| Rate for Payer: Quartz Medicare Advantage |
$715.20
|
| Rate for Payer: The Alliance Commercial |
$4,768.00
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 30 M0061752550
|
Facility
|
IP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.08 |
| Max. Negotiated Rate |
$1,096.64 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$715.20
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 4.8 X 30 M0061752550
|
Facility
|
OP
|
$1,192.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5685666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.76 |
| Max. Negotiated Rate |
$4,768.00 |
| Rate for Payer: Aetna Commercial |
$1,072.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.12
|
| Rate for Payer: Aetna Managed Medicare |
$333.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$774.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$596.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$572.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.76
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,096.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$667.04
|
| Rate for Payer: Health EOS Commercial |
$1,060.88
|
| Rate for Payer: HFN Commercial |
$1,096.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$894.00
|
| Rate for Payer: Multiplan Commercial |
$953.60
|
| Rate for Payer: NAPHCARE Commercial |
$715.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.64
|
| Rate for Payer: Quartz Beloit One Network |
$584.08
|
| Rate for Payer: Quartz Commercial |
$774.80
|
| Rate for Payer: Quartz Medicare Advantage |
$715.20
|
| Rate for Payer: The Alliance Commercial |
$4,768.00
|
| Rate for Payer: WEA Trust Commercial |
$655.60
|
| Rate for Payer: WPS Commercial |
$882.91
|
|
|
STENT PERCUFLEX PLUS 6 X 20 M0061752600
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$857.99 |
| Max. Negotiated Rate |
$1,610.92 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,050.60
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
STENT PERCUFLEX PLUS 6 X 20 M0061752600
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.28 |
| Max. Negotiated Rate |
$7,004.00 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Aetna Managed Medicare |
$490.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,138.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$875.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$840.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.86
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,313.25
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,138.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,050.60
|
| Rate for Payer: The Alliance Commercial |
$7,004.00
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
STENT PERCUFLEX PLUS 6 X 22 M0061752610
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.28 |
| Max. Negotiated Rate |
$7,004.00 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Aetna Managed Medicare |
$490.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,138.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$875.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$840.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.86
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,313.25
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,138.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,050.60
|
| Rate for Payer: The Alliance Commercial |
$7,004.00
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
STENT PERCUFLEX PLUS 6 X 22 M0061752610
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$857.99 |
| Max. Negotiated Rate |
$1,610.92 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,050.60
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
STENT PERCUFLEX PLUS 6 X 24 M0061752620
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520027
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$857.99 |
| Max. Negotiated Rate |
$1,610.92 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,050.60
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
STENT PERCUFLEX PLUS 6 X 24 M0061752620
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520027
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.28 |
| Max. Negotiated Rate |
$7,004.00 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Aetna Managed Medicare |
$490.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,138.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$875.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$840.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.86
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,313.25
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,138.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,050.60
|
| Rate for Payer: The Alliance Commercial |
$7,004.00
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
STENT PERCUFLEX PLUS 6 X 26 M0061752630
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520028
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.28 |
| Max. Negotiated Rate |
$7,004.00 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Aetna Managed Medicare |
$490.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,138.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$875.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$840.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.86
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,313.25
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,138.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,050.60
|
| Rate for Payer: The Alliance Commercial |
$7,004.00
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
STENT PERCUFLEX PLUS 6 X 26 M0061752630
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520028
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$857.99 |
| Max. Negotiated Rate |
$1,610.92 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,050.60
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
STENT PERCUFLEX PLUS 6 X 28 M0061752640
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520029
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$857.99 |
| Max. Negotiated Rate |
$1,610.92 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,050.60
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
STENT PERCUFLEX PLUS 6 X 28 M0061752640
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520029
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.28 |
| Max. Negotiated Rate |
$7,004.00 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Aetna Managed Medicare |
$490.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,138.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$875.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$840.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.86
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,313.25
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,138.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,050.60
|
| Rate for Payer: The Alliance Commercial |
$7,004.00
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
