|
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 |
$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 24 M0061752820
|
Facility
|
IP
|
$1,685.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4595303
|
|
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
|
|
|
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 |
$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
|
|
|
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 |
$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 28 M0061752840
|
Facility
|
OP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520048
|
|
Hospital Revenue Code
|
278
|
| 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 28 M0061752840
|
Facility
|
IP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520048
|
|
Hospital Revenue Code
|
278
|
| 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 30 M0061752850
|
Facility
|
OP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520049
|
|
Hospital Revenue Code
|
278
|
| 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 30 M0061752850
|
Facility
|
IP
|
$1,622.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4520049
|
|
Hospital Revenue Code
|
278
|
| 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 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 |
$1,463.57 |
| Max. Negotiated Rate |
$2,747.93 |
| Rate for Payer: Aetna Commercial |
$2,688.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,568.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,583.05
|
| Rate for Payer: Cash Price |
$861.60
|
| Rate for Payer: Cigna Commercial |
$2,747.93
|
| Rate for Payer: Health EOS Commercial |
$2,658.32
|
| Rate for Payer: HFN Commercial |
$2,747.93
|
| Rate for Payer: Multiplan Commercial |
$2,389.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,747.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,463.57
|
| Rate for Payer: Quartz Commercial |
$1,792.13
|
| Rate for Payer: WEA Trust Commercial |
$1,642.78
|
| Rate for Payer: WPS Commercial |
$2,212.30
|
|
|
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 |
$836.33 |
| Max. Negotiated Rate |
$2,747.93 |
| Rate for Payer: Aetna Commercial |
$2,688.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,568.72
|
| Rate for Payer: Aetna Managed Medicare |
$836.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,941.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,493.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,433.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,583.05
|
| Rate for Payer: Cash Price |
$861.60
|
| Rate for Payer: Cigna Commercial |
$2,747.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,671.50
|
| Rate for Payer: Health EOS Commercial |
$2,658.32
|
| Rate for Payer: HFN Commercial |
$2,747.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,240.16
|
| Rate for Payer: Multiplan Commercial |
$2,389.50
|
| Rate for Payer: NAPHCARE Commercial |
$1,792.13
|
| Rate for Payer: Preferred Network Access Commercial |
$2,747.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,463.57
|
| Rate for Payer: Quartz Commercial |
$1,941.47
|
| Rate for Payer: Quartz Medicare Advantage |
$1,792.13
|
| Rate for Payer: The Alliance Commercial |
$1,493.44
|
| Rate for Payer: WEA Trust Commercial |
$1,642.78
|
| Rate for Payer: WPS Commercial |
$2,212.30
|
|
|
Stent-Peripheral Balloon Expandible
|
Facility
|
IP
|
$9,929.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,059.82 |
| Max. Negotiated Rate |
$9,500.07 |
| Rate for Payer: Aetna Commercial |
$9,293.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,880.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,472.86
|
| Rate for Payer: Cash Price |
$2,978.70
|
| Rate for Payer: Cigna Commercial |
$9,500.07
|
| Rate for Payer: Health EOS Commercial |
$9,190.28
|
| Rate for Payer: HFN Commercial |
$9,500.07
|
| Rate for Payer: Multiplan Commercial |
$8,260.93
|
| Rate for Payer: Preferred Network Access Commercial |
$9,500.07
|
| Rate for Payer: Quartz Beloit One Network |
$5,059.82
|
| Rate for Payer: Quartz Commercial |
$6,195.70
|
| Rate for Payer: WEA Trust Commercial |
$5,679.39
|
| Rate for Payer: WPS Commercial |
$7,648.31
|
|
|
Stent-Peripheral Balloon Expandible
|
Facility
|
OP
|
$9,929.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,891.32 |
| Max. Negotiated Rate |
$9,500.07 |
| Rate for Payer: Aetna Commercial |
$9,293.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,880.50
|
| Rate for Payer: Aetna Managed Medicare |
$2,891.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,712.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,163.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,956.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,472.86
|
| Rate for Payer: Cash Price |
$2,978.70
|
| Rate for Payer: Cigna Commercial |
$9,500.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,778.68
|
| Rate for Payer: Health EOS Commercial |
$9,190.28
|
| Rate for Payer: HFN Commercial |
$9,500.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,744.62
|
| Rate for Payer: Multiplan Commercial |
$8,260.93
|
| Rate for Payer: NAPHCARE Commercial |
$6,195.70
|
| Rate for Payer: Preferred Network Access Commercial |
$9,500.07
|
| Rate for Payer: Quartz Beloit One Network |
$5,059.82
|
| Rate for Payer: Quartz Commercial |
$6,712.00
|
| Rate for Payer: Quartz Medicare Advantage |
$6,195.70
|
| Rate for Payer: The Alliance Commercial |
$5,163.08
|
| Rate for Payer: WEA Trust Commercial |
$5,679.39
|
| Rate for Payer: WPS Commercial |
$7,648.31
|
|
|
Stent-Peripheral Self Expanding
|
Facility
|
OP
|
$9,929.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001131
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,891.32 |
| Max. Negotiated Rate |
$9,500.07 |
| Rate for Payer: Aetna Commercial |
$9,293.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,880.50
|
| Rate for Payer: Aetna Managed Medicare |
$2,891.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,712.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,163.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,956.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,472.86
|
| Rate for Payer: Cash Price |
$2,978.70
|
| Rate for Payer: Cigna Commercial |
$9,500.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,778.68
|
| Rate for Payer: Health EOS Commercial |
$9,190.28
|
| Rate for Payer: HFN Commercial |
$9,500.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,744.62
|
| Rate for Payer: Multiplan Commercial |
$8,260.93
|
| Rate for Payer: NAPHCARE Commercial |
$6,195.70
|
| Rate for Payer: Preferred Network Access Commercial |
$9,500.07
|
| Rate for Payer: Quartz Beloit One Network |
$5,059.82
|
| Rate for Payer: Quartz Commercial |
$6,712.00
|
| Rate for Payer: Quartz Medicare Advantage |
$6,195.70
|
| Rate for Payer: The Alliance Commercial |
$5,163.08
|
| Rate for Payer: WEA Trust Commercial |
$5,679.39
|
| Rate for Payer: WPS Commercial |
$7,648.31
|
|
|
Stent-Peripheral Self Expanding
|
Facility
|
IP
|
$9,929.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4001131
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,059.82 |
| Max. Negotiated Rate |
$9,500.07 |
| Rate for Payer: Aetna Commercial |
$9,293.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,880.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,472.86
|
| Rate for Payer: Cash Price |
$2,978.70
|
| Rate for Payer: Cigna Commercial |
$9,500.07
|
| Rate for Payer: Health EOS Commercial |
$9,190.28
|
| Rate for Payer: HFN Commercial |
$9,500.07
|
| Rate for Payer: Multiplan Commercial |
$8,260.93
|
| Rate for Payer: Preferred Network Access Commercial |
$9,500.07
|
| Rate for Payer: Quartz Beloit One Network |
$5,059.82
|
| Rate for Payer: Quartz Commercial |
$6,195.70
|
| Rate for Payer: WEA Trust Commercial |
$5,679.39
|
| Rate for Payer: WPS Commercial |
$7,648.31
|
|
|
STENT PLACEMENT
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960389
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
STENT PLACEMENT
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960389
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
STENT POLARIS LOOP 8 X 24 M0061552520
|
Facility
|
OP
|
$2,362.00
|
|
| Hospital Charge Code |
4519302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$687.81 |
| Max. Negotiated Rate |
$2,259.96 |
| Rate for Payer: Aetna Commercial |
$2,210.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,112.57
|
| Rate for Payer: Aetna Managed Medicare |
$687.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,596.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,228.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,179.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,301.93
|
| Rate for Payer: Cash Price |
$708.60
|
| Rate for Payer: Cigna Commercial |
$2,259.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,374.68
|
| Rate for Payer: Health EOS Commercial |
$2,186.27
|
| Rate for Payer: HFN Commercial |
$2,259.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,842.36
|
| Rate for Payer: Multiplan Commercial |
$1,965.18
|
| Rate for Payer: NAPHCARE Commercial |
$1,473.89
|
| Rate for Payer: Preferred Network Access Commercial |
$2,259.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,203.68
|
| Rate for Payer: Quartz Commercial |
$1,596.71
|
| Rate for Payer: Quartz Medicare Advantage |
$1,473.89
|
| Rate for Payer: The Alliance Commercial |
$1,228.24
|
| Rate for Payer: WEA Trust Commercial |
$1,351.06
|
| Rate for Payer: WPS Commercial |
$1,819.45
|
|
|
STENT POLARIS LOOP 8 X 24 M0061552520
|
Facility
|
IP
|
$2,362.00
|
|
| Hospital Charge Code |
4519302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,203.68 |
| Max. Negotiated Rate |
$2,259.96 |
| Rate for Payer: Aetna Commercial |
$2,210.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,112.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,301.93
|
| Rate for Payer: Cash Price |
$708.60
|
| Rate for Payer: Cigna Commercial |
$2,259.96
|
| Rate for Payer: Health EOS Commercial |
$2,186.27
|
| Rate for Payer: HFN Commercial |
$2,259.96
|
| Rate for Payer: Multiplan Commercial |
$1,965.18
|
| Rate for Payer: Preferred Network Access Commercial |
$2,259.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,203.68
|
| Rate for Payer: Quartz Commercial |
$1,473.89
|
| Rate for Payer: WEA Trust Commercial |
$1,351.06
|
| Rate for Payer: WPS Commercial |
$1,819.45
|
|
|
STENT POLARIS ULTRA 6 X 20 M0061921300
|
Facility
|
IP
|
$2,121.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4594911
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,080.86 |
| Max. Negotiated Rate |
$2,029.37 |
| Rate for Payer: Aetna Commercial |
$1,985.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,897.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,169.10
|
| Rate for Payer: Cash Price |
$636.30
|
| Rate for Payer: Cigna Commercial |
$2,029.37
|
| Rate for Payer: Health EOS Commercial |
$1,963.20
|
| Rate for Payer: HFN Commercial |
$2,029.37
|
| Rate for Payer: Multiplan Commercial |
$1,764.67
|
| Rate for Payer: Preferred Network Access Commercial |
$2,029.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,080.86
|
| Rate for Payer: Quartz Commercial |
$1,323.50
|
| Rate for Payer: WEA Trust Commercial |
$1,213.21
|
| Rate for Payer: WPS Commercial |
$1,633.81
|
|
|
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 |
$617.64 |
| Max. Negotiated Rate |
$2,029.37 |
| Rate for Payer: Aetna Commercial |
$1,985.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,897.02
|
| Rate for Payer: Aetna Managed Medicare |
$617.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,433.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,102.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,058.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,169.10
|
| Rate for Payer: Cash Price |
$636.30
|
| Rate for Payer: Cigna Commercial |
$2,029.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,234.42
|
| Rate for Payer: Health EOS Commercial |
$1,963.20
|
| Rate for Payer: HFN Commercial |
$2,029.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,654.38
|
| Rate for Payer: Multiplan Commercial |
$1,764.67
|
| Rate for Payer: NAPHCARE Commercial |
$1,323.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,029.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,080.86
|
| Rate for Payer: Quartz Commercial |
$1,433.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,323.50
|
| Rate for Payer: The Alliance Commercial |
$1,102.92
|
| Rate for Payer: WEA Trust Commercial |
$1,213.21
|
| Rate for Payer: WPS Commercial |
$1,633.81
|
|
|
STENT POLARIS ULTRA 6 X 22 M0061921310
|
Facility
|
OP
|
$2,121.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4594912
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$2,029.37 |
| Rate for Payer: Aetna Commercial |
$1,985.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,897.02
|
| Rate for Payer: Aetna Managed Medicare |
$617.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,433.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,102.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,058.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,169.10
|
| Rate for Payer: Cash Price |
$636.30
|
| Rate for Payer: Cigna Commercial |
$2,029.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,234.42
|
| Rate for Payer: Health EOS Commercial |
$1,963.20
|
| Rate for Payer: HFN Commercial |
$2,029.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,654.38
|
| Rate for Payer: Multiplan Commercial |
$1,764.67
|
| Rate for Payer: NAPHCARE Commercial |
$1,323.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,029.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,080.86
|
| Rate for Payer: Quartz Commercial |
$1,433.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,323.50
|
| Rate for Payer: The Alliance Commercial |
$1,102.92
|
| Rate for Payer: WEA Trust Commercial |
$1,213.21
|
| Rate for Payer: WPS Commercial |
$1,633.81
|
|
|
STENT POLARIS ULTRA 6 X 22 M0061921310
|
Facility
|
IP
|
$2,121.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4594912
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,080.86 |
| Max. Negotiated Rate |
$2,029.37 |
| Rate for Payer: Aetna Commercial |
$1,985.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,897.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,169.10
|
| Rate for Payer: Cash Price |
$636.30
|
| Rate for Payer: Cigna Commercial |
$2,029.37
|
| Rate for Payer: Health EOS Commercial |
$1,963.20
|
| Rate for Payer: HFN Commercial |
$2,029.37
|
| Rate for Payer: Multiplan Commercial |
$1,764.67
|
| Rate for Payer: Preferred Network Access Commercial |
$2,029.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,080.86
|
| Rate for Payer: Quartz Commercial |
$1,323.50
|
| Rate for Payer: WEA Trust Commercial |
$1,213.21
|
| Rate for Payer: WPS Commercial |
$1,633.81
|
|
|
STENT POLARIS ULTRA 6 X 24 M0061921320
|
Facility
|
OP
|
$2,121.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4594913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$2,029.37 |
| Rate for Payer: Aetna Commercial |
$1,985.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,897.02
|
| Rate for Payer: Aetna Managed Medicare |
$617.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,433.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,102.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,058.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,169.10
|
| Rate for Payer: Cash Price |
$636.30
|
| Rate for Payer: Cigna Commercial |
$2,029.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,234.42
|
| Rate for Payer: Health EOS Commercial |
$1,963.20
|
| Rate for Payer: HFN Commercial |
$2,029.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,654.38
|
| Rate for Payer: Multiplan Commercial |
$1,764.67
|
| Rate for Payer: NAPHCARE Commercial |
$1,323.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,029.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,080.86
|
| Rate for Payer: Quartz Commercial |
$1,433.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,323.50
|
| Rate for Payer: The Alliance Commercial |
$1,102.92
|
| Rate for Payer: WEA Trust Commercial |
$1,213.21
|
| Rate for Payer: WPS Commercial |
$1,633.81
|
|
|
STENT POLARIS ULTRA 6 X 24 M0061921320
|
Facility
|
IP
|
$2,121.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4594913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,080.86 |
| Max. Negotiated Rate |
$2,029.37 |
| Rate for Payer: Aetna Commercial |
$1,985.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,897.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,169.10
|
| Rate for Payer: Cash Price |
$636.30
|
| Rate for Payer: Cigna Commercial |
$2,029.37
|
| Rate for Payer: Health EOS Commercial |
$1,963.20
|
| Rate for Payer: HFN Commercial |
$2,029.37
|
| Rate for Payer: Multiplan Commercial |
$1,764.67
|
| Rate for Payer: Preferred Network Access Commercial |
$2,029.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,080.86
|
| Rate for Payer: Quartz Commercial |
$1,323.50
|
| Rate for Payer: WEA Trust Commercial |
$1,213.21
|
| Rate for Payer: WPS Commercial |
$1,633.81
|
|
|
STENT POLARIS ULTRA 6 X 26 M0061921330
|
Facility
|
OP
|
$2,121.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
4594914
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$2,029.37 |
| Rate for Payer: Aetna Commercial |
$1,985.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,897.02
|
| Rate for Payer: Aetna Managed Medicare |
$617.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,433.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,102.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,058.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,169.10
|
| Rate for Payer: Cash Price |
$636.30
|
| Rate for Payer: Cigna Commercial |
$2,029.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,234.42
|
| Rate for Payer: Health EOS Commercial |
$1,963.20
|
| Rate for Payer: HFN Commercial |
$2,029.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,654.38
|
| Rate for Payer: Multiplan Commercial |
$1,764.67
|
| Rate for Payer: NAPHCARE Commercial |
$1,323.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,029.37
|
| Rate for Payer: Quartz Beloit One Network |
$1,080.86
|
| Rate for Payer: Quartz Commercial |
$1,433.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,323.50
|
| Rate for Payer: The Alliance Commercial |
$1,102.92
|
| Rate for Payer: WEA Trust Commercial |
$1,213.21
|
| Rate for Payer: WPS Commercial |
$1,633.81
|
|
