|
STENT PERCUFLEX PLUS 6 X 30 M0061752650
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520030
|
|
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 30 M0061752650
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520030
|
|
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 8 X 20 M0061752800
|
Facility
|
IP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4595201
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$794.78 |
| Max. Negotiated Rate |
$1,492.24 |
| Rate for Payer: Aetna Commercial |
$1,459.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,394.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.66
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,492.24
|
| Rate for Payer: Health EOS Commercial |
$1,443.58
|
| Rate for Payer: HFN Commercial |
$1,492.24
|
| Rate for Payer: Multiplan Commercial |
$1,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$973.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.24
|
| Rate for Payer: Quartz Beloit One Network |
$794.78
|
| Rate for Payer: Quartz Commercial |
$973.20
|
| Rate for Payer: WEA Trust Commercial |
$892.10
|
| Rate for Payer: WPS Commercial |
$1,201.42
|
|
|
STENT PERCUFLEX PLUS 8 X 20 M0061752800
|
Facility
|
OP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4595201
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$454.16 |
| Max. Negotiated Rate |
$6,488.00 |
| Rate for Payer: Aetna Commercial |
$1,459.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,394.92
|
| Rate for Payer: Aetna Managed Medicare |
$454.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,054.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$811.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$778.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.66
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,492.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$907.67
|
| Rate for Payer: Health EOS Commercial |
$1,443.58
|
| Rate for Payer: HFN Commercial |
$1,492.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,216.50
|
| Rate for Payer: Multiplan Commercial |
$1,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$973.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.24
|
| Rate for Payer: Quartz Beloit One Network |
$794.78
|
| Rate for Payer: Quartz Commercial |
$1,054.30
|
| Rate for Payer: Quartz Medicare Advantage |
$973.20
|
| Rate for Payer: The Alliance Commercial |
$6,488.00
|
| Rate for Payer: WEA Trust Commercial |
$892.10
|
| Rate for Payer: WPS Commercial |
$1,201.42
|
|
|
STENT PERCUFLEX PLUS 8 X 22 M0061752810
|
Facility
|
OP
|
$1,685.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4595301
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$471.80 |
| Max. Negotiated Rate |
$6,740.00 |
| Rate for Payer: Aetna Commercial |
$1,516.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,449.10
|
| Rate for Payer: Aetna Managed Medicare |
$471.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,095.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$842.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$808.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$893.05
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,550.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$942.93
|
| Rate for Payer: Health EOS Commercial |
$1,499.65
|
| Rate for Payer: HFN Commercial |
$1,550.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,263.75
|
| Rate for Payer: Multiplan Commercial |
$1,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,011.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.20
|
| Rate for Payer: Quartz Beloit One Network |
$825.65
|
| Rate for Payer: Quartz Commercial |
$1,095.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,011.00
|
| Rate for Payer: The Alliance Commercial |
$6,740.00
|
| Rate for Payer: WEA Trust Commercial |
$926.75
|
| Rate for Payer: WPS Commercial |
$1,248.08
|
|
|
STENT PERCUFLEX PLUS 8 X 22 M0061752810
|
Facility
|
IP
|
$1,685.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4595301
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.65 |
| Max. Negotiated Rate |
$1,550.20 |
| Rate for Payer: Aetna Commercial |
$1,516.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,449.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$893.05
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,550.20
|
| Rate for Payer: Health EOS Commercial |
$1,499.65
|
| Rate for Payer: HFN Commercial |
$1,550.20
|
| Rate for Payer: Multiplan Commercial |
$1,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,011.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.20
|
| Rate for Payer: Quartz Beloit One Network |
$825.65
|
| Rate for Payer: Quartz Commercial |
$1,011.00
|
| Rate for Payer: WEA Trust Commercial |
$926.75
|
| Rate for Payer: WPS Commercial |
$1,248.08
|
|
|
STENT PERCUFLEX PLUS 8 X 24 M0061752820
|
Facility
|
IP
|
$1,685.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4595303
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.65 |
| Max. Negotiated Rate |
$1,550.20 |
| Rate for Payer: Aetna Commercial |
$1,516.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,449.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$893.05
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,550.20
|
| Rate for Payer: Health EOS Commercial |
$1,499.65
|
| Rate for Payer: HFN Commercial |
$1,550.20
|
| Rate for Payer: Multiplan Commercial |
$1,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,011.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.20
|
| Rate for Payer: Quartz Beloit One Network |
$825.65
|
| Rate for Payer: Quartz Commercial |
$1,011.00
|
| Rate for Payer: WEA Trust Commercial |
$926.75
|
| Rate for Payer: WPS Commercial |
$1,248.08
|
|
|
STENT PERCUFLEX PLUS 8 X 24 M0061752820
|
Facility
|
OP
|
$1,685.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4595303
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$471.80 |
| Max. Negotiated Rate |
$6,740.00 |
| Rate for Payer: Aetna Commercial |
$1,516.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,449.10
|
| Rate for Payer: Aetna Managed Medicare |
$471.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,095.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$842.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$808.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$893.05
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,550.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$942.93
|
| Rate for Payer: Health EOS Commercial |
$1,499.65
|
| Rate for Payer: HFN Commercial |
$1,550.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,263.75
|
| Rate for Payer: Multiplan Commercial |
$1,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,011.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.20
|
| Rate for Payer: Quartz Beloit One Network |
$825.65
|
| Rate for Payer: Quartz Commercial |
$1,095.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,011.00
|
| Rate for Payer: The Alliance Commercial |
$6,740.00
|
| Rate for Payer: WEA Trust Commercial |
$926.75
|
| Rate for Payer: WPS Commercial |
$1,248.08
|
|
|
STENT PERCUFLEX PLUS 8 X 26 M0061752830
|
Facility
|
OP
|
$1,685.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4595302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$471.80 |
| Max. Negotiated Rate |
$6,740.00 |
| Rate for Payer: Aetna Commercial |
$1,516.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,449.10
|
| Rate for Payer: Aetna Managed Medicare |
$471.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,095.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$842.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$808.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$893.05
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,550.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$942.93
|
| Rate for Payer: Health EOS Commercial |
$1,499.65
|
| Rate for Payer: HFN Commercial |
$1,550.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,263.75
|
| Rate for Payer: Multiplan Commercial |
$1,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,011.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.20
|
| Rate for Payer: Quartz Beloit One Network |
$825.65
|
| Rate for Payer: Quartz Commercial |
$1,095.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,011.00
|
| Rate for Payer: The Alliance Commercial |
$6,740.00
|
| Rate for Payer: WEA Trust Commercial |
$926.75
|
| Rate for Payer: WPS Commercial |
$1,248.08
|
|
|
STENT PERCUFLEX PLUS 8 X 26 M0061752830
|
Facility
|
IP
|
$1,685.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4595302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.65 |
| Max. Negotiated Rate |
$1,550.20 |
| Rate for Payer: Aetna Commercial |
$1,516.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,449.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$893.05
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,550.20
|
| Rate for Payer: Health EOS Commercial |
$1,499.65
|
| Rate for Payer: HFN Commercial |
$1,550.20
|
| Rate for Payer: Multiplan Commercial |
$1,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,011.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.20
|
| Rate for Payer: Quartz Beloit One Network |
$825.65
|
| Rate for Payer: Quartz Commercial |
$1,011.00
|
| Rate for Payer: WEA Trust Commercial |
$926.75
|
| Rate for Payer: WPS Commercial |
$1,248.08
|
|
|
STENT PERCUFLEX PLUS 8 X 28 M0061752840
|
Facility
|
OP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$454.16 |
| Max. Negotiated Rate |
$6,488.00 |
| Rate for Payer: Aetna Commercial |
$1,459.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,394.92
|
| Rate for Payer: Aetna Managed Medicare |
$454.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,054.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$811.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$778.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.66
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,492.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$907.67
|
| Rate for Payer: Health EOS Commercial |
$1,443.58
|
| Rate for Payer: HFN Commercial |
$1,492.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,216.50
|
| Rate for Payer: Multiplan Commercial |
$1,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$973.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.24
|
| Rate for Payer: Quartz Beloit One Network |
$794.78
|
| Rate for Payer: Quartz Commercial |
$1,054.30
|
| Rate for Payer: Quartz Medicare Advantage |
$973.20
|
| Rate for Payer: The Alliance Commercial |
$6,488.00
|
| Rate for Payer: WEA Trust Commercial |
$892.10
|
| Rate for Payer: WPS Commercial |
$1,201.42
|
|
|
STENT PERCUFLEX PLUS 8 X 28 M0061752840
|
Facility
|
IP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$794.78 |
| Max. Negotiated Rate |
$1,492.24 |
| Rate for Payer: Aetna Commercial |
$1,459.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,394.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.66
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,492.24
|
| Rate for Payer: Health EOS Commercial |
$1,443.58
|
| Rate for Payer: HFN Commercial |
$1,492.24
|
| Rate for Payer: Multiplan Commercial |
$1,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$973.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.24
|
| Rate for Payer: Quartz Beloit One Network |
$794.78
|
| Rate for Payer: Quartz Commercial |
$973.20
|
| Rate for Payer: WEA Trust Commercial |
$892.10
|
| Rate for Payer: WPS Commercial |
$1,201.42
|
|
|
STENT PERCUFLEX PLUS 8 X 30 M0061752850
|
Facility
|
OP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520049
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$454.16 |
| Max. Negotiated Rate |
$6,488.00 |
| Rate for Payer: Aetna Commercial |
$1,459.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,394.92
|
| Rate for Payer: Aetna Managed Medicare |
$454.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,054.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$811.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$778.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.66
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,492.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$907.67
|
| Rate for Payer: Health EOS Commercial |
$1,443.58
|
| Rate for Payer: HFN Commercial |
$1,492.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,216.50
|
| Rate for Payer: Multiplan Commercial |
$1,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$973.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.24
|
| Rate for Payer: Quartz Beloit One Network |
$794.78
|
| Rate for Payer: Quartz Commercial |
$1,054.30
|
| Rate for Payer: Quartz Medicare Advantage |
$973.20
|
| Rate for Payer: The Alliance Commercial |
$6,488.00
|
| Rate for Payer: WEA Trust Commercial |
$892.10
|
| Rate for Payer: WPS Commercial |
$1,201.42
|
|
|
STENT PERCUFLEX PLUS 8 X 30 M0061752850
|
Facility
|
IP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520049
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$794.78 |
| Max. Negotiated Rate |
$1,492.24 |
| Rate for Payer: Aetna Commercial |
$1,459.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,394.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$859.66
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,492.24
|
| Rate for Payer: Health EOS Commercial |
$1,443.58
|
| Rate for Payer: HFN Commercial |
$1,492.24
|
| Rate for Payer: Multiplan Commercial |
$1,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$973.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,492.24
|
| Rate for Payer: Quartz Beloit One Network |
$794.78
|
| Rate for Payer: Quartz Commercial |
$973.20
|
| Rate for Payer: WEA Trust Commercial |
$892.10
|
| Rate for Payer: WPS Commercial |
$1,201.42
|
|
|
STENT PERCUFLEX URINARY DIVERSION 7FR X 80CM M0061602100
|
Facility
|
IP
|
$2,872.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4595299
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,407.28 |
| Max. Negotiated Rate |
$2,642.24 |
| Rate for Payer: Aetna Commercial |
$2,584.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,469.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,522.16
|
| Rate for Payer: Cash Price |
$861.60
|
| Rate for Payer: Cigna Commercial |
$2,642.24
|
| Rate for Payer: Health EOS Commercial |
$2,556.08
|
| Rate for Payer: HFN Commercial |
$2,642.24
|
| Rate for Payer: Multiplan Commercial |
$2,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,723.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,642.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,407.28
|
| Rate for Payer: Quartz Commercial |
$1,723.20
|
| Rate for Payer: WEA Trust Commercial |
$1,579.60
|
| Rate for Payer: WPS Commercial |
$2,127.29
|
|
|
STENT PERCUFLEX URINARY DIVERSION 7FR X 80CM M0061602100
|
Facility
|
OP
|
$2,872.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4595299
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$804.16 |
| Max. Negotiated Rate |
$11,488.00 |
| Rate for Payer: Aetna Commercial |
$2,584.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,469.92
|
| Rate for Payer: Aetna Managed Medicare |
$804.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,866.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,436.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,378.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,522.16
|
| Rate for Payer: Cash Price |
$861.60
|
| Rate for Payer: Cigna Commercial |
$2,642.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,607.17
|
| Rate for Payer: Health EOS Commercial |
$2,556.08
|
| Rate for Payer: HFN Commercial |
$2,642.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,154.00
|
| Rate for Payer: Multiplan Commercial |
$2,297.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,723.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,642.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,407.28
|
| Rate for Payer: Quartz Commercial |
$1,866.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,723.20
|
| Rate for Payer: The Alliance Commercial |
$11,488.00
|
| Rate for Payer: WEA Trust Commercial |
$1,579.60
|
| Rate for Payer: WPS Commercial |
$2,127.29
|
|
|
Stent-Peripheral Balloon Expandible
|
Facility
|
IP
|
$9,929.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,865.21 |
| Max. Negotiated Rate |
$9,134.68 |
| Rate for Payer: Aetna Commercial |
$8,936.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,538.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,262.37
|
| Rate for Payer: Cash Price |
$2,978.70
|
| Rate for Payer: Cigna Commercial |
$9,134.68
|
| Rate for Payer: Health EOS Commercial |
$8,836.81
|
| Rate for Payer: HFN Commercial |
$9,134.68
|
| Rate for Payer: Multiplan Commercial |
$7,943.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,957.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,134.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,865.21
|
| Rate for Payer: Quartz Commercial |
$5,957.40
|
| Rate for Payer: WEA Trust Commercial |
$5,460.95
|
| Rate for Payer: WPS Commercial |
$7,354.41
|
|
|
Stent-Peripheral Balloon Expandible
|
Facility
|
OP
|
$9,929.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,780.12 |
| Max. Negotiated Rate |
$39,716.00 |
| Rate for Payer: Aetna Commercial |
$8,936.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,538.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,780.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,453.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,964.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,765.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,262.37
|
| Rate for Payer: Cash Price |
$2,978.70
|
| Rate for Payer: Cigna Commercial |
$9,134.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,556.27
|
| Rate for Payer: Health EOS Commercial |
$8,836.81
|
| Rate for Payer: HFN Commercial |
$9,134.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,446.75
|
| Rate for Payer: Multiplan Commercial |
$7,943.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,957.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,134.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,865.21
|
| Rate for Payer: Quartz Commercial |
$6,453.85
|
| Rate for Payer: Quartz Medicare Advantage |
$5,957.40
|
| Rate for Payer: The Alliance Commercial |
$39,716.00
|
| Rate for Payer: WEA Trust Commercial |
$5,460.95
|
| Rate for Payer: WPS Commercial |
$7,354.41
|
|
|
Stent-Peripheral Self Expanding
|
Facility
|
IP
|
$9,929.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001131
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,865.21 |
| Max. Negotiated Rate |
$9,134.68 |
| Rate for Payer: Aetna Commercial |
$8,936.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,538.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,262.37
|
| Rate for Payer: Cash Price |
$2,978.70
|
| Rate for Payer: Cigna Commercial |
$9,134.68
|
| Rate for Payer: Health EOS Commercial |
$8,836.81
|
| Rate for Payer: HFN Commercial |
$9,134.68
|
| Rate for Payer: Multiplan Commercial |
$7,943.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,957.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,134.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,865.21
|
| Rate for Payer: Quartz Commercial |
$5,957.40
|
| Rate for Payer: WEA Trust Commercial |
$5,460.95
|
| Rate for Payer: WPS Commercial |
$7,354.41
|
|
|
Stent-Peripheral Self Expanding
|
Facility
|
OP
|
$9,929.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001131
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,780.12 |
| Max. Negotiated Rate |
$39,716.00 |
| Rate for Payer: Aetna Commercial |
$8,936.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,538.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,780.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,453.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,964.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,765.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,262.37
|
| Rate for Payer: Cash Price |
$2,978.70
|
| Rate for Payer: Cigna Commercial |
$9,134.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,556.27
|
| Rate for Payer: Health EOS Commercial |
$8,836.81
|
| Rate for Payer: HFN Commercial |
$9,134.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,446.75
|
| Rate for Payer: Multiplan Commercial |
$7,943.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,957.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,134.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,865.21
|
| Rate for Payer: Quartz Commercial |
$6,453.85
|
| Rate for Payer: Quartz Medicare Advantage |
$5,957.40
|
| Rate for Payer: The Alliance Commercial |
$39,716.00
|
| Rate for Payer: WEA Trust Commercial |
$5,460.95
|
| Rate for Payer: WPS Commercial |
$7,354.41
|
|
|
STENT PLACEMENT
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960389
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
STENT PLACEMENT
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960389
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
STENT POLARIS LOOP 8 X 24 M0061552520
|
Facility
|
IP
|
$2,362.00
|
|
| Hospital Charge Code |
4519302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,157.38 |
| Max. Negotiated Rate |
$2,173.04 |
| Rate for Payer: Aetna Commercial |
$2,125.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,031.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,251.86
|
| Rate for Payer: Cash Price |
$708.60
|
| Rate for Payer: Cigna Commercial |
$2,173.04
|
| Rate for Payer: Health EOS Commercial |
$2,102.18
|
| Rate for Payer: HFN Commercial |
$2,173.04
|
| Rate for Payer: Multiplan Commercial |
$1,889.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,417.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,173.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,157.38
|
| Rate for Payer: Quartz Commercial |
$1,417.20
|
| Rate for Payer: WEA Trust Commercial |
$1,299.10
|
| Rate for Payer: WPS Commercial |
$1,749.53
|
|
|
STENT POLARIS LOOP 8 X 24 M0061552520
|
Facility
|
OP
|
$2,362.00
|
|
| Hospital Charge Code |
4519302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$661.36 |
| Max. Negotiated Rate |
$9,448.00 |
| Rate for Payer: Aetna Commercial |
$2,125.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,031.32
|
| Rate for Payer: Aetna Managed Medicare |
$661.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,535.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,181.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,133.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,251.86
|
| Rate for Payer: Cash Price |
$708.60
|
| Rate for Payer: Cigna Commercial |
$2,173.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,321.78
|
| Rate for Payer: Health EOS Commercial |
$2,102.18
|
| Rate for Payer: HFN Commercial |
$2,173.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,771.50
|
| Rate for Payer: Multiplan Commercial |
$1,889.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,417.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,173.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,157.38
|
| Rate for Payer: Quartz Commercial |
$1,535.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,417.20
|
| Rate for Payer: The Alliance Commercial |
$9,448.00
|
| Rate for Payer: WEA Trust Commercial |
$1,299.10
|
| Rate for Payer: WPS Commercial |
$1,749.53
|
|
|
STENT POLARIS ULTRA 6 X 20 M0061921300
|
Facility
|
OP
|
$2,121.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4594911
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$593.88 |
| Max. Negotiated Rate |
$8,484.00 |
| Rate for Payer: Aetna Commercial |
$1,908.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,824.06
|
| Rate for Payer: Aetna Managed Medicare |
$593.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,378.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,060.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,018.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,124.13
|
| Rate for Payer: Cash Price |
$636.30
|
| Rate for Payer: Cigna Commercial |
$1,951.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,186.91
|
| Rate for Payer: Health EOS Commercial |
$1,887.69
|
| Rate for Payer: HFN Commercial |
$1,951.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,590.75
|
| Rate for Payer: Multiplan Commercial |
$1,696.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,272.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,951.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,039.29
|
| Rate for Payer: Quartz Commercial |
$1,378.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,272.60
|
| Rate for Payer: The Alliance Commercial |
$8,484.00
|
| Rate for Payer: WEA Trust Commercial |
$1,166.55
|
| Rate for Payer: WPS Commercial |
$1,571.02
|
|
