|
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 |
$347.11 |
| Max. Negotiated Rate |
$1,140.51 |
| Rate for Payer: Aetna Commercial |
$1,115.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,066.12
|
| Rate for Payer: Aetna Managed Medicare |
$347.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$805.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$619.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$595.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$657.03
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,140.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$693.74
|
| Rate for Payer: Health EOS Commercial |
$1,103.32
|
| Rate for Payer: HFN Commercial |
$1,140.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$929.76
|
| Rate for Payer: Multiplan Commercial |
$991.74
|
| Rate for Payer: NAPHCARE Commercial |
$743.81
|
| Rate for Payer: Preferred Network Access Commercial |
$1,140.51
|
| Rate for Payer: Quartz Beloit One Network |
$607.44
|
| Rate for Payer: Quartz Commercial |
$805.79
|
| Rate for Payer: Quartz Medicare Advantage |
$743.81
|
| Rate for Payer: The Alliance Commercial |
$619.84
|
| Rate for Payer: WEA Trust Commercial |
$681.82
|
| Rate for Payer: WPS Commercial |
$918.20
|
|
|
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 |
$347.11 |
| Max. Negotiated Rate |
$1,140.51 |
| Rate for Payer: Aetna Commercial |
$1,115.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,066.12
|
| Rate for Payer: Aetna Managed Medicare |
$347.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$805.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$619.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$595.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$657.03
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,140.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$693.74
|
| Rate for Payer: Health EOS Commercial |
$1,103.32
|
| Rate for Payer: HFN Commercial |
$1,140.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$929.76
|
| Rate for Payer: Multiplan Commercial |
$991.74
|
| Rate for Payer: NAPHCARE Commercial |
$743.81
|
| Rate for Payer: Preferred Network Access Commercial |
$1,140.51
|
| Rate for Payer: Quartz Beloit One Network |
$607.44
|
| Rate for Payer: Quartz Commercial |
$805.79
|
| Rate for Payer: Quartz Medicare Advantage |
$743.81
|
| Rate for Payer: The Alliance Commercial |
$619.84
|
| Rate for Payer: WEA Trust Commercial |
$681.82
|
| Rate for Payer: WPS Commercial |
$918.20
|
|
|
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 |
$607.44 |
| Max. Negotiated Rate |
$1,140.51 |
| Rate for Payer: Aetna Commercial |
$1,115.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$657.03
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,140.51
|
| Rate for Payer: Health EOS Commercial |
$1,103.32
|
| Rate for Payer: HFN Commercial |
$1,140.51
|
| Rate for Payer: Multiplan Commercial |
$991.74
|
| Rate for Payer: Preferred Network Access Commercial |
$1,140.51
|
| Rate for Payer: Quartz Beloit One Network |
$607.44
|
| Rate for Payer: Quartz Commercial |
$743.81
|
| Rate for Payer: WEA Trust Commercial |
$681.82
|
| Rate for Payer: WPS Commercial |
$918.20
|
|
|
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 |
$463.30 |
| Max. Negotiated Rate |
$1,522.27 |
| Rate for Payer: Aetna Commercial |
$1,489.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,422.99
|
| Rate for Payer: Aetna Managed Medicare |
$463.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,075.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$827.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$794.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$876.96
|
| Rate for Payer: Cash Price |
$477.30
|
| Rate for Payer: Cigna Commercial |
$1,522.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$925.96
|
| Rate for Payer: Health EOS Commercial |
$1,472.63
|
| Rate for Payer: HFN Commercial |
$1,522.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,240.98
|
| Rate for Payer: Multiplan Commercial |
$1,323.71
|
| Rate for Payer: NAPHCARE Commercial |
$992.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,522.27
|
| Rate for Payer: Quartz Beloit One Network |
$810.77
|
| Rate for Payer: Quartz Commercial |
$1,075.52
|
| Rate for Payer: Quartz Medicare Advantage |
$992.78
|
| Rate for Payer: The Alliance Commercial |
$827.32
|
| Rate for Payer: WEA Trust Commercial |
$910.05
|
| Rate for Payer: WPS Commercial |
$1,225.55
|
|
|
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 |
$810.77 |
| Max. Negotiated Rate |
$1,522.27 |
| Rate for Payer: Aetna Commercial |
$1,489.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,422.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$876.96
|
| Rate for Payer: Cash Price |
$477.30
|
| Rate for Payer: Cigna Commercial |
$1,522.27
|
| Rate for Payer: Health EOS Commercial |
$1,472.63
|
| Rate for Payer: HFN Commercial |
$1,522.27
|
| Rate for Payer: Multiplan Commercial |
$1,323.71
|
| Rate for Payer: Preferred Network Access Commercial |
$1,522.27
|
| Rate for Payer: Quartz Beloit One Network |
$810.77
|
| Rate for Payer: Quartz Commercial |
$992.78
|
| Rate for Payer: WEA Trust Commercial |
$910.05
|
| Rate for Payer: WPS Commercial |
$1,225.55
|
|
|
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 |
$347.11 |
| Max. Negotiated Rate |
$1,140.51 |
| Rate for Payer: Aetna Commercial |
$1,115.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,066.12
|
| Rate for Payer: Aetna Managed Medicare |
$347.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$805.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$619.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$595.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$657.03
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,140.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$693.74
|
| Rate for Payer: Health EOS Commercial |
$1,103.32
|
| Rate for Payer: HFN Commercial |
$1,140.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$929.76
|
| Rate for Payer: Multiplan Commercial |
$991.74
|
| Rate for Payer: NAPHCARE Commercial |
$743.81
|
| Rate for Payer: Preferred Network Access Commercial |
$1,140.51
|
| Rate for Payer: Quartz Beloit One Network |
$607.44
|
| Rate for Payer: Quartz Commercial |
$805.79
|
| Rate for Payer: Quartz Medicare Advantage |
$743.81
|
| Rate for Payer: The Alliance Commercial |
$619.84
|
| Rate for Payer: WEA Trust Commercial |
$681.82
|
| Rate for Payer: WPS Commercial |
$918.20
|
|
|
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 |
$607.44 |
| Max. Negotiated Rate |
$1,140.51 |
| Rate for Payer: Aetna Commercial |
$1,115.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$657.03
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,140.51
|
| Rate for Payer: Health EOS Commercial |
$1,103.32
|
| Rate for Payer: HFN Commercial |
$1,140.51
|
| Rate for Payer: Multiplan Commercial |
$991.74
|
| Rate for Payer: Preferred Network Access Commercial |
$1,140.51
|
| Rate for Payer: Quartz Beloit One Network |
$607.44
|
| Rate for Payer: Quartz Commercial |
$743.81
|
| Rate for Payer: WEA Trust Commercial |
$681.82
|
| Rate for Payer: WPS Commercial |
$918.20
|
|
|
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 |
$347.11 |
| Max. Negotiated Rate |
$1,140.51 |
| Rate for Payer: Aetna Commercial |
$1,115.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,066.12
|
| Rate for Payer: Aetna Managed Medicare |
$347.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$805.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$619.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$595.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$657.03
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,140.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$693.74
|
| Rate for Payer: Health EOS Commercial |
$1,103.32
|
| Rate for Payer: HFN Commercial |
$1,140.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$929.76
|
| Rate for Payer: Multiplan Commercial |
$991.74
|
| Rate for Payer: NAPHCARE Commercial |
$743.81
|
| Rate for Payer: Preferred Network Access Commercial |
$1,140.51
|
| Rate for Payer: Quartz Beloit One Network |
$607.44
|
| Rate for Payer: Quartz Commercial |
$805.79
|
| Rate for Payer: Quartz Medicare Advantage |
$743.81
|
| Rate for Payer: The Alliance Commercial |
$619.84
|
| Rate for Payer: WEA Trust Commercial |
$681.82
|
| Rate for Payer: WPS Commercial |
$918.20
|
|
|
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 |
$607.44 |
| Max. Negotiated Rate |
$1,140.51 |
| Rate for Payer: Aetna Commercial |
$1,115.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$657.03
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$1,140.51
|
| Rate for Payer: Health EOS Commercial |
$1,103.32
|
| Rate for Payer: HFN Commercial |
$1,140.51
|
| Rate for Payer: Multiplan Commercial |
$991.74
|
| Rate for Payer: Preferred Network Access Commercial |
$1,140.51
|
| Rate for Payer: Quartz Beloit One Network |
$607.44
|
| Rate for Payer: Quartz Commercial |
$743.81
|
| Rate for Payer: WEA Trust Commercial |
$681.82
|
| Rate for Payer: WPS Commercial |
$918.20
|
|
|
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 |
$892.31 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,092.62
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$509.89 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Aetna Managed Medicare |
$509.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,183.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$910.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$874.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,019.08
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.78
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: NAPHCARE Commercial |
$1,092.62
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,183.68
|
| Rate for Payer: Quartz Medicare Advantage |
$1,092.62
|
| Rate for Payer: The Alliance Commercial |
$910.52
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$892.31 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,092.62
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$509.89 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Aetna Managed Medicare |
$509.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,183.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$910.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$874.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,019.08
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.78
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: NAPHCARE Commercial |
$1,092.62
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,183.68
|
| Rate for Payer: Quartz Medicare Advantage |
$1,092.62
|
| Rate for Payer: The Alliance Commercial |
$910.52
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$509.89 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Aetna Managed Medicare |
$509.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,183.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$910.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$874.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,019.08
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.78
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: NAPHCARE Commercial |
$1,092.62
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,183.68
|
| Rate for Payer: Quartz Medicare Advantage |
$1,092.62
|
| Rate for Payer: The Alliance Commercial |
$910.52
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$892.31 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,092.62
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$509.89 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Aetna Managed Medicare |
$509.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,183.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$910.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$874.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,019.08
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.78
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: NAPHCARE Commercial |
$1,092.62
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,183.68
|
| Rate for Payer: Quartz Medicare Advantage |
$1,092.62
|
| Rate for Payer: The Alliance Commercial |
$910.52
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$892.31 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,092.62
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$892.31 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,092.62
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$509.89 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Aetna Managed Medicare |
$509.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,183.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$910.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$874.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,019.08
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.78
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: NAPHCARE Commercial |
$1,092.62
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,183.68
|
| Rate for Payer: Quartz Medicare Advantage |
$1,092.62
|
| Rate for Payer: The Alliance Commercial |
$910.52
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$892.31 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,092.62
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$509.89 |
| Max. Negotiated Rate |
$1,675.36 |
| Rate for Payer: Aetna Commercial |
$1,638.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.09
|
| Rate for Payer: Aetna Managed Medicare |
$509.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,183.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$910.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$874.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.15
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,675.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,019.08
|
| Rate for Payer: Health EOS Commercial |
$1,620.73
|
| Rate for Payer: HFN Commercial |
$1,675.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.78
|
| Rate for Payer: Multiplan Commercial |
$1,456.83
|
| Rate for Payer: NAPHCARE Commercial |
$1,092.62
|
| Rate for Payer: Preferred Network Access Commercial |
$1,675.36
|
| Rate for Payer: Quartz Beloit One Network |
$892.31
|
| Rate for Payer: Quartz Commercial |
$1,183.68
|
| Rate for Payer: Quartz Medicare Advantage |
$1,092.62
|
| Rate for Payer: The Alliance Commercial |
$910.52
|
| Rate for Payer: WEA Trust Commercial |
$1,001.57
|
| Rate for Payer: WPS Commercial |
$1,348.80
|
|
|
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 |
$472.33 |
| Max. Negotiated Rate |
$1,551.93 |
| Rate for Payer: Aetna Commercial |
$1,518.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,450.72
|
| Rate for Payer: Aetna Managed Medicare |
$472.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,096.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$843.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$809.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$894.05
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,551.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$944.00
|
| Rate for Payer: Health EOS Commercial |
$1,501.32
|
| Rate for Payer: HFN Commercial |
$1,551.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,265.16
|
| Rate for Payer: Multiplan Commercial |
$1,349.50
|
| Rate for Payer: NAPHCARE Commercial |
$1,012.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,551.93
|
| Rate for Payer: Quartz Beloit One Network |
$826.57
|
| Rate for Payer: Quartz Commercial |
$1,096.47
|
| Rate for Payer: Quartz Medicare Advantage |
$1,012.13
|
| Rate for Payer: The Alliance Commercial |
$843.44
|
| Rate for Payer: WEA Trust Commercial |
$927.78
|
| Rate for Payer: WPS Commercial |
$1,249.43
|
|
|
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 |
$826.57 |
| Max. Negotiated Rate |
$1,551.93 |
| Rate for Payer: Aetna Commercial |
$1,518.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,450.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$894.05
|
| Rate for Payer: Cash Price |
$486.60
|
| Rate for Payer: Cigna Commercial |
$1,551.93
|
| Rate for Payer: Health EOS Commercial |
$1,501.32
|
| Rate for Payer: HFN Commercial |
$1,551.93
|
| Rate for Payer: Multiplan Commercial |
$1,349.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,551.93
|
| Rate for Payer: Quartz Beloit One Network |
$826.57
|
| Rate for Payer: Quartz Commercial |
$1,012.13
|
| Rate for Payer: WEA Trust Commercial |
$927.78
|
| Rate for Payer: WPS Commercial |
$1,249.43
|
|
|
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 |
$490.67 |
| Max. Negotiated Rate |
$1,612.21 |
| Rate for Payer: Aetna Commercial |
$1,577.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,507.06
|
| Rate for Payer: Aetna Managed Medicare |
$490.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,139.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$876.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$841.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.77
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,612.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$980.67
|
| Rate for Payer: Health EOS Commercial |
$1,559.64
|
| Rate for Payer: HFN Commercial |
$1,612.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,314.30
|
| Rate for Payer: Multiplan Commercial |
$1,401.92
|
| Rate for Payer: NAPHCARE Commercial |
$1,051.44
|
| Rate for Payer: Preferred Network Access Commercial |
$1,612.21
|
| Rate for Payer: Quartz Beloit One Network |
$858.68
|
| Rate for Payer: Quartz Commercial |
$1,139.06
|
| Rate for Payer: Quartz Medicare Advantage |
$1,051.44
|
| Rate for Payer: The Alliance Commercial |
$876.20
|
| Rate for Payer: WEA Trust Commercial |
$963.82
|
| Rate for Payer: WPS Commercial |
$1,297.96
|
|
|
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 |
$858.68 |
| Max. Negotiated Rate |
$1,612.21 |
| Rate for Payer: Aetna Commercial |
$1,577.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,507.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.77
|
| Rate for Payer: Cash Price |
$505.50
|
| Rate for Payer: Cigna Commercial |
$1,612.21
|
| Rate for Payer: Health EOS Commercial |
$1,559.64
|
| Rate for Payer: HFN Commercial |
$1,612.21
|
| Rate for Payer: Multiplan Commercial |
$1,401.92
|
| Rate for Payer: Preferred Network Access Commercial |
$1,612.21
|
| Rate for Payer: Quartz Beloit One Network |
$858.68
|
| Rate for Payer: Quartz Commercial |
$1,051.44
|
| Rate for Payer: WEA Trust Commercial |
$963.82
|
| Rate for Payer: WPS Commercial |
$1,297.96
|
|
