|
STENT TRIA FIRM WITH SIDE HOLES 6 X 20 M0061902200
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5617782
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 22 M0061902210
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5617783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 22 M0061902210
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5617783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 24 M0061902220
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5547376
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 24 M0061902220
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5547376
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 26 M0061902230
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5685838
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 26 M0061902230
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5685838
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 28 M0061902240
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5685839
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 28 M0061902240
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5685839
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 30 M0061902250
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
6169845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA FIRM WITH SIDE HOLES 6 X 30 M0061902250
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
6169845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 20 M0061903200
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5617784
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 20 M0061903200
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5617784
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 22 M0061903210
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5617785
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 22 M0061903210
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5617785
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 24 M0061903220
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5547375
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 24 M0061903220
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5547375
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 26 M0061903230
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5641677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 26 M0061903230
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5641677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 28 M0061903240
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5641678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 28 M0061903240
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5641678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 30 M0061903250
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5861682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.71 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Aetna Managed Medicare |
$598.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,389.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.59
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,603.68
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: NAPHCARE Commercial |
$1,282.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,389.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,282.94
|
| Rate for Payer: The Alliance Commercial |
$1,069.12
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT TRIA SOFT WITH SIDE HOLES 6 X 30 M0061903250
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
5861682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,967.18 |
| Rate for Payer: Aetna Commercial |
$1,924.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,838.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.27
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna Commercial |
$1,967.18
|
| Rate for Payer: Health EOS Commercial |
$1,903.03
|
| Rate for Payer: HFN Commercial |
$1,967.18
|
| Rate for Payer: Multiplan Commercial |
$1,710.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.18
|
| Rate for Payer: Quartz Beloit One Network |
$1,047.74
|
| Rate for Payer: Quartz Commercial |
$1,282.94
|
| Rate for Payer: WEA Trust Commercial |
$1,176.03
|
| Rate for Payer: WPS Commercial |
$1,583.74
|
|
|
STENT URETERAL 6X28 FIRM G49907
|
Facility
|
OP
|
$1,425.00
|
|
| Hospital Charge Code |
2965881
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$414.96 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Aetna Managed Medicare |
$414.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$963.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$741.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$711.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$829.35
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,111.50
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$889.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$963.30
|
| Rate for Payer: Quartz Medicare Advantage |
$889.20
|
| Rate for Payer: The Alliance Commercial |
$741.00
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.68
|
|
|
STENT URETERAL 6X28 FIRM G49907
|
Facility
|
IP
|
$1,425.00
|
|
| Hospital Charge Code |
2965881
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$726.18 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$889.20
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.68
|
|
