|
STENT VISIPRO 7 X 17 #PXB35-07-17-80
|
Facility
|
OP
|
$9,881.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,877.35 |
| Max. Negotiated Rate |
$9,454.14 |
| Rate for Payer: Aetna Commercial |
$9,248.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,837.57
|
| Rate for Payer: Aetna Managed Medicare |
$2,877.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,679.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,138.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,932.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,446.41
|
| Rate for Payer: Cash Price |
$2,964.30
|
| Rate for Payer: Cigna Commercial |
$9,454.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,750.74
|
| Rate for Payer: Health EOS Commercial |
$9,145.85
|
| Rate for Payer: HFN Commercial |
$9,454.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,707.18
|
| Rate for Payer: Multiplan Commercial |
$8,220.99
|
| Rate for Payer: NAPHCARE Commercial |
$6,165.74
|
| Rate for Payer: Preferred Network Access Commercial |
$9,454.14
|
| Rate for Payer: Quartz Beloit One Network |
$5,035.36
|
| Rate for Payer: Quartz Commercial |
$6,679.56
|
| Rate for Payer: Quartz Medicare Advantage |
$6,165.74
|
| Rate for Payer: The Alliance Commercial |
$5,138.12
|
| Rate for Payer: WEA Trust Commercial |
$5,651.93
|
| Rate for Payer: WPS Commercial |
$7,611.33
|
|
|
STENT VISIPRO 7 X 17 #PXB35-07-17-80
|
Facility
|
IP
|
$9,881.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,035.36 |
| Max. Negotiated Rate |
$9,454.14 |
| Rate for Payer: Aetna Commercial |
$9,248.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,837.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,446.41
|
| Rate for Payer: Cash Price |
$2,964.30
|
| Rate for Payer: Cigna Commercial |
$9,454.14
|
| Rate for Payer: Health EOS Commercial |
$9,145.85
|
| Rate for Payer: HFN Commercial |
$9,454.14
|
| Rate for Payer: Multiplan Commercial |
$8,220.99
|
| Rate for Payer: Preferred Network Access Commercial |
$9,454.14
|
| Rate for Payer: Quartz Beloit One Network |
$5,035.36
|
| Rate for Payer: Quartz Commercial |
$6,165.74
|
| Rate for Payer: WEA Trust Commercial |
$5,651.93
|
| Rate for Payer: WPS Commercial |
$7,611.33
|
|
|
STENT VISPRO 7mm X 27mm #PXB35-07-27-080
|
Facility
|
OP
|
$9,881.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974785
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,877.35 |
| Max. Negotiated Rate |
$9,454.14 |
| Rate for Payer: Aetna Commercial |
$9,248.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,837.57
|
| Rate for Payer: Aetna Managed Medicare |
$2,877.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,679.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,138.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,932.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,446.41
|
| Rate for Payer: Cash Price |
$2,964.30
|
| Rate for Payer: Cigna Commercial |
$9,454.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,750.74
|
| Rate for Payer: Health EOS Commercial |
$9,145.85
|
| Rate for Payer: HFN Commercial |
$9,454.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,707.18
|
| Rate for Payer: Multiplan Commercial |
$8,220.99
|
| Rate for Payer: NAPHCARE Commercial |
$6,165.74
|
| Rate for Payer: Preferred Network Access Commercial |
$9,454.14
|
| Rate for Payer: Quartz Beloit One Network |
$5,035.36
|
| Rate for Payer: Quartz Commercial |
$6,679.56
|
| Rate for Payer: Quartz Medicare Advantage |
$6,165.74
|
| Rate for Payer: The Alliance Commercial |
$5,138.12
|
| Rate for Payer: WEA Trust Commercial |
$5,651.93
|
| Rate for Payer: WPS Commercial |
$7,611.33
|
|
|
STENT VISPRO 7mm X 27mm #PXB35-07-27-080
|
Facility
|
IP
|
$9,881.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2974785
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,035.36 |
| Max. Negotiated Rate |
$9,454.14 |
| Rate for Payer: Aetna Commercial |
$9,248.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,837.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,446.41
|
| Rate for Payer: Cash Price |
$2,964.30
|
| Rate for Payer: Cigna Commercial |
$9,454.14
|
| Rate for Payer: Health EOS Commercial |
$9,145.85
|
| Rate for Payer: HFN Commercial |
$9,454.14
|
| Rate for Payer: Multiplan Commercial |
$8,220.99
|
| Rate for Payer: Preferred Network Access Commercial |
$9,454.14
|
| Rate for Payer: Quartz Beloit One Network |
$5,035.36
|
| Rate for Payer: Quartz Commercial |
$6,165.74
|
| Rate for Payer: WEA Trust Commercial |
$5,651.93
|
| Rate for Payer: WPS Commercial |
$7,611.33
|
|
|
STENT WALLFLEX 10 X 60MM COVERED M00570370
|
Facility
|
IP
|
$14,941.00
|
|
| Hospital Charge Code |
3455499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,613.93 |
| Max. Negotiated Rate |
$14,295.55 |
| Rate for Payer: Aetna Commercial |
$13,984.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,363.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,235.48
|
| Rate for Payer: Cash Price |
$4,482.30
|
| Rate for Payer: Cigna Commercial |
$14,295.55
|
| Rate for Payer: Health EOS Commercial |
$13,829.39
|
| Rate for Payer: HFN Commercial |
$14,295.55
|
| Rate for Payer: Multiplan Commercial |
$12,430.91
|
| Rate for Payer: Preferred Network Access Commercial |
$14,295.55
|
| Rate for Payer: Quartz Beloit One Network |
$7,613.93
|
| Rate for Payer: Quartz Commercial |
$9,323.18
|
| Rate for Payer: WEA Trust Commercial |
$8,546.25
|
| Rate for Payer: WPS Commercial |
$11,509.05
|
|
|
STENT WALLFLEX 10 X 60MM COVERED M00570370
|
Facility
|
OP
|
$14,941.00
|
|
| Hospital Charge Code |
3455499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,350.82 |
| Max. Negotiated Rate |
$14,295.55 |
| Rate for Payer: Aetna Commercial |
$13,984.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,363.23
|
| Rate for Payer: Aetna Managed Medicare |
$4,350.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,100.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,769.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,458.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,235.48
|
| Rate for Payer: Cash Price |
$4,482.30
|
| Rate for Payer: Cigna Commercial |
$14,295.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,695.66
|
| Rate for Payer: Health EOS Commercial |
$13,829.39
|
| Rate for Payer: HFN Commercial |
$14,295.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,653.98
|
| Rate for Payer: Multiplan Commercial |
$12,430.91
|
| Rate for Payer: NAPHCARE Commercial |
$9,323.18
|
| Rate for Payer: Preferred Network Access Commercial |
$14,295.55
|
| Rate for Payer: Quartz Beloit One Network |
$7,613.93
|
| Rate for Payer: Quartz Commercial |
$10,100.12
|
| Rate for Payer: Quartz Medicare Advantage |
$9,323.18
|
| Rate for Payer: The Alliance Commercial |
$7,769.32
|
| Rate for Payer: WEA Trust Commercial |
$8,546.25
|
| Rate for Payer: WPS Commercial |
$11,509.05
|
|
|
STENT WALLFLEX 10 X 60MM UNCOVERED 7064
|
Facility
|
IP
|
$10,067.00
|
|
| Hospital Charge Code |
3072562
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,130.14 |
| Max. Negotiated Rate |
$9,632.11 |
| Rate for Payer: Aetna Commercial |
$9,422.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,003.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,548.93
|
| Rate for Payer: Cash Price |
$3,020.10
|
| Rate for Payer: Cigna Commercial |
$9,632.11
|
| Rate for Payer: Health EOS Commercial |
$9,318.02
|
| Rate for Payer: HFN Commercial |
$9,632.11
|
| Rate for Payer: Multiplan Commercial |
$8,375.74
|
| Rate for Payer: Preferred Network Access Commercial |
$9,632.11
|
| Rate for Payer: Quartz Beloit One Network |
$5,130.14
|
| Rate for Payer: Quartz Commercial |
$6,281.81
|
| Rate for Payer: WEA Trust Commercial |
$5,758.32
|
| Rate for Payer: WPS Commercial |
$7,754.61
|
|
|
STENT WALLFLEX 10 X 60MM UNCOVERED 7064
|
Facility
|
OP
|
$10,067.00
|
|
| Hospital Charge Code |
3072562
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,931.51 |
| Max. Negotiated Rate |
$9,632.11 |
| Rate for Payer: Aetna Commercial |
$9,422.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,003.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,931.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,805.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,234.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,025.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,548.93
|
| Rate for Payer: Cash Price |
$3,020.10
|
| Rate for Payer: Cigna Commercial |
$9,632.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,858.99
|
| Rate for Payer: Health EOS Commercial |
$9,318.02
|
| Rate for Payer: HFN Commercial |
$9,632.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,852.26
|
| Rate for Payer: Multiplan Commercial |
$8,375.74
|
| Rate for Payer: NAPHCARE Commercial |
$6,281.81
|
| Rate for Payer: Preferred Network Access Commercial |
$9,632.11
|
| Rate for Payer: Quartz Beloit One Network |
$5,130.14
|
| Rate for Payer: Quartz Commercial |
$6,805.29
|
| Rate for Payer: Quartz Medicare Advantage |
$6,281.81
|
| Rate for Payer: The Alliance Commercial |
$5,234.84
|
| Rate for Payer: WEA Trust Commercial |
$5,758.32
|
| Rate for Payer: WPS Commercial |
$7,754.61
|
|
|
STENT WALLFLEX 10 X 80MM COVERED M00570380
|
Facility
|
IP
|
$14,941.00
|
|
| Hospital Charge Code |
3455498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,613.93 |
| Max. Negotiated Rate |
$14,295.55 |
| Rate for Payer: Aetna Commercial |
$13,984.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,363.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,235.48
|
| Rate for Payer: Cash Price |
$4,482.30
|
| Rate for Payer: Cigna Commercial |
$14,295.55
|
| Rate for Payer: Health EOS Commercial |
$13,829.39
|
| Rate for Payer: HFN Commercial |
$14,295.55
|
| Rate for Payer: Multiplan Commercial |
$12,430.91
|
| Rate for Payer: Preferred Network Access Commercial |
$14,295.55
|
| Rate for Payer: Quartz Beloit One Network |
$7,613.93
|
| Rate for Payer: Quartz Commercial |
$9,323.18
|
| Rate for Payer: WEA Trust Commercial |
$8,546.25
|
| Rate for Payer: WPS Commercial |
$11,509.05
|
|
|
STENT WALLFLEX 10 X 80MM COVERED M00570380
|
Facility
|
OP
|
$14,941.00
|
|
| Hospital Charge Code |
3455498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,350.82 |
| Max. Negotiated Rate |
$14,295.55 |
| Rate for Payer: Aetna Commercial |
$13,984.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,363.23
|
| Rate for Payer: Aetna Managed Medicare |
$4,350.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,100.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,769.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,458.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,235.48
|
| Rate for Payer: Cash Price |
$4,482.30
|
| Rate for Payer: Cigna Commercial |
$14,295.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,695.66
|
| Rate for Payer: Health EOS Commercial |
$13,829.39
|
| Rate for Payer: HFN Commercial |
$14,295.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,653.98
|
| Rate for Payer: Multiplan Commercial |
$12,430.91
|
| Rate for Payer: NAPHCARE Commercial |
$9,323.18
|
| Rate for Payer: Preferred Network Access Commercial |
$14,295.55
|
| Rate for Payer: Quartz Beloit One Network |
$7,613.93
|
| Rate for Payer: Quartz Commercial |
$10,100.12
|
| Rate for Payer: Quartz Medicare Advantage |
$9,323.18
|
| Rate for Payer: The Alliance Commercial |
$7,769.32
|
| Rate for Payer: WEA Trust Commercial |
$8,546.25
|
| Rate for Payer: WPS Commercial |
$11,509.05
|
|
|
STENT WALLFLEX 10 X 80MM UNCOVERED 7065
|
Facility
|
OP
|
$9,030.00
|
|
| Hospital Charge Code |
3072563
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,629.54 |
| Max. Negotiated Rate |
$8,639.90 |
| Rate for Payer: Aetna Commercial |
$8,452.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,076.43
|
| Rate for Payer: Aetna Managed Medicare |
$2,629.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,104.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,695.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,507.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,977.34
|
| Rate for Payer: Cash Price |
$2,709.00
|
| Rate for Payer: Cigna Commercial |
$8,639.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,255.46
|
| Rate for Payer: Health EOS Commercial |
$8,358.17
|
| Rate for Payer: HFN Commercial |
$8,639.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,043.40
|
| Rate for Payer: Multiplan Commercial |
$7,512.96
|
| Rate for Payer: NAPHCARE Commercial |
$5,634.72
|
| Rate for Payer: Preferred Network Access Commercial |
$8,639.90
|
| Rate for Payer: Quartz Beloit One Network |
$4,601.69
|
| Rate for Payer: Quartz Commercial |
$6,104.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5,634.72
|
| Rate for Payer: The Alliance Commercial |
$4,695.60
|
| Rate for Payer: WEA Trust Commercial |
$5,165.16
|
| Rate for Payer: WPS Commercial |
$6,955.81
|
|
|
STENT WALLFLEX 10 X 80MM UNCOVERED 7065
|
Facility
|
IP
|
$9,030.00
|
|
| Hospital Charge Code |
3072563
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,601.69 |
| Max. Negotiated Rate |
$8,639.90 |
| Rate for Payer: Aetna Commercial |
$8,452.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,076.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,977.34
|
| Rate for Payer: Cash Price |
$2,709.00
|
| Rate for Payer: Cigna Commercial |
$8,639.90
|
| Rate for Payer: Health EOS Commercial |
$8,358.17
|
| Rate for Payer: HFN Commercial |
$8,639.90
|
| Rate for Payer: Multiplan Commercial |
$7,512.96
|
| Rate for Payer: Preferred Network Access Commercial |
$8,639.90
|
| Rate for Payer: Quartz Beloit One Network |
$4,601.69
|
| Rate for Payer: Quartz Commercial |
$5,634.72
|
| Rate for Payer: WEA Trust Commercial |
$5,165.16
|
| Rate for Payer: WPS Commercial |
$6,955.81
|
|
|
STENT WALLFLEX 18 X 23CM FULLY COVERED M00516700
|
Facility
|
OP
|
$12,447.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
5432732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,624.57 |
| Max. Negotiated Rate |
$11,909.29 |
| Rate for Payer: Aetna Commercial |
$11,650.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,132.60
|
| Rate for Payer: Aetna Managed Medicare |
$3,624.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,414.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,472.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,213.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,860.79
|
| Rate for Payer: Cash Price |
$3,734.10
|
| Rate for Payer: Cigna Commercial |
$11,909.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,244.15
|
| Rate for Payer: Health EOS Commercial |
$11,520.94
|
| Rate for Payer: HFN Commercial |
$11,909.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,708.66
|
| Rate for Payer: Multiplan Commercial |
$10,355.90
|
| Rate for Payer: NAPHCARE Commercial |
$7,766.93
|
| Rate for Payer: Preferred Network Access Commercial |
$11,909.29
|
| Rate for Payer: Quartz Beloit One Network |
$6,342.99
|
| Rate for Payer: Quartz Commercial |
$8,414.17
|
| Rate for Payer: Quartz Medicare Advantage |
$7,766.93
|
| Rate for Payer: The Alliance Commercial |
$6,472.44
|
| Rate for Payer: WEA Trust Commercial |
$7,119.68
|
| Rate for Payer: WPS Commercial |
$9,587.92
|
|
|
STENT WALLFLEX 18 X 23CM FULLY COVERED M00516700
|
Facility
|
IP
|
$12,447.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
5432732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,342.99 |
| Max. Negotiated Rate |
$11,909.29 |
| Rate for Payer: Aetna Commercial |
$11,650.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,132.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,860.79
|
| Rate for Payer: Cash Price |
$3,734.10
|
| Rate for Payer: Cigna Commercial |
$11,909.29
|
| Rate for Payer: Health EOS Commercial |
$11,520.94
|
| Rate for Payer: HFN Commercial |
$11,909.29
|
| Rate for Payer: Multiplan Commercial |
$10,355.90
|
| Rate for Payer: Preferred Network Access Commercial |
$11,909.29
|
| Rate for Payer: Quartz Beloit One Network |
$6,342.99
|
| Rate for Payer: Quartz Commercial |
$7,766.93
|
| Rate for Payer: WEA Trust Commercial |
$7,119.68
|
| Rate for Payer: WPS Commercial |
$9,587.92
|
|
|
STENT WALLFLEX 18 X 23CM PARTIAL COVERED 1690
|
Facility
|
IP
|
$13,118.00
|
|
| Hospital Charge Code |
3072560
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,684.93 |
| Max. Negotiated Rate |
$12,551.30 |
| Rate for Payer: Aetna Commercial |
$12,278.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,732.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,230.64
|
| Rate for Payer: Cash Price |
$3,935.40
|
| Rate for Payer: Cigna Commercial |
$12,551.30
|
| Rate for Payer: Health EOS Commercial |
$12,142.02
|
| Rate for Payer: HFN Commercial |
$12,551.30
|
| Rate for Payer: Multiplan Commercial |
$10,914.18
|
| Rate for Payer: Preferred Network Access Commercial |
$12,551.30
|
| Rate for Payer: Quartz Beloit One Network |
$6,684.93
|
| Rate for Payer: Quartz Commercial |
$8,185.63
|
| Rate for Payer: WEA Trust Commercial |
$7,503.50
|
| Rate for Payer: WPS Commercial |
$10,104.80
|
|
|
STENT WALLFLEX 18 X 23CM PARTIAL COVERED 1690
|
Facility
|
OP
|
$13,118.00
|
|
| Hospital Charge Code |
3072560
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,819.96 |
| Max. Negotiated Rate |
$12,551.30 |
| Rate for Payer: Aetna Commercial |
$12,278.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,732.74
|
| Rate for Payer: Aetna Managed Medicare |
$3,819.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,867.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,821.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,548.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,230.64
|
| Rate for Payer: Cash Price |
$3,935.40
|
| Rate for Payer: Cigna Commercial |
$12,551.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,634.68
|
| Rate for Payer: Health EOS Commercial |
$12,142.02
|
| Rate for Payer: HFN Commercial |
$12,551.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,232.04
|
| Rate for Payer: Multiplan Commercial |
$10,914.18
|
| Rate for Payer: NAPHCARE Commercial |
$8,185.63
|
| Rate for Payer: Preferred Network Access Commercial |
$12,551.30
|
| Rate for Payer: Quartz Beloit One Network |
$6,684.93
|
| Rate for Payer: Quartz Commercial |
$8,867.77
|
| Rate for Payer: Quartz Medicare Advantage |
$8,185.63
|
| Rate for Payer: The Alliance Commercial |
$6,821.36
|
| Rate for Payer: WEA Trust Commercial |
$7,503.50
|
| Rate for Payer: WPS Commercial |
$10,104.80
|
|
|
STENT WALLFLEX COLONIC 22 X 27MM 9CM 6511
|
Facility
|
IP
|
$14,613.00
|
|
| Hospital Charge Code |
3072502
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,446.78 |
| Max. Negotiated Rate |
$13,981.72 |
| Rate for Payer: Aetna Commercial |
$13,677.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,069.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,054.69
|
| Rate for Payer: Cash Price |
$4,383.90
|
| Rate for Payer: Cigna Commercial |
$13,981.72
|
| Rate for Payer: Health EOS Commercial |
$13,525.79
|
| Rate for Payer: HFN Commercial |
$13,981.72
|
| Rate for Payer: Multiplan Commercial |
$12,158.02
|
| Rate for Payer: Preferred Network Access Commercial |
$13,981.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,446.78
|
| Rate for Payer: Quartz Commercial |
$9,118.51
|
| Rate for Payer: WEA Trust Commercial |
$8,358.64
|
| Rate for Payer: WPS Commercial |
$11,256.39
|
|
|
STENT WALLFLEX COLONIC 22 X 27MM 9CM 6511
|
Facility
|
OP
|
$14,613.00
|
|
| Hospital Charge Code |
3072502
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,255.31 |
| Max. Negotiated Rate |
$13,981.72 |
| Rate for Payer: Aetna Commercial |
$13,677.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,069.87
|
| Rate for Payer: Aetna Managed Medicare |
$4,255.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,878.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,598.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,294.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,054.69
|
| Rate for Payer: Cash Price |
$4,383.90
|
| Rate for Payer: Cigna Commercial |
$13,981.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,504.77
|
| Rate for Payer: Health EOS Commercial |
$13,525.79
|
| Rate for Payer: HFN Commercial |
$13,981.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,398.14
|
| Rate for Payer: Multiplan Commercial |
$12,158.02
|
| Rate for Payer: NAPHCARE Commercial |
$9,118.51
|
| Rate for Payer: Preferred Network Access Commercial |
$13,981.72
|
| Rate for Payer: Quartz Beloit One Network |
$7,446.78
|
| Rate for Payer: Quartz Commercial |
$9,878.39
|
| Rate for Payer: Quartz Medicare Advantage |
$9,118.51
|
| Rate for Payer: The Alliance Commercial |
$7,598.76
|
| Rate for Payer: WEA Trust Commercial |
$8,358.64
|
| Rate for Payer: WPS Commercial |
$11,256.39
|
|
|
STER-DRAPE SMALL 24 X 14 DYNJSD1040
|
Facility
|
OP
|
$102.00
|
|
| Hospital Charge Code |
2963304
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$97.59 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Aetna Managed Medicare |
$29.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.22
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.36
|
| Rate for Payer: Health EOS Commercial |
$94.41
|
| Rate for Payer: HFN Commercial |
$97.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.56
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: NAPHCARE Commercial |
$63.65
|
| Rate for Payer: Preferred Network Access Commercial |
$97.59
|
| Rate for Payer: Quartz Beloit One Network |
$51.98
|
| Rate for Payer: Quartz Commercial |
$68.95
|
| Rate for Payer: Quartz Medicare Advantage |
$63.65
|
| Rate for Payer: The Alliance Commercial |
$53.04
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: WPS Commercial |
$78.57
|
|
|
STER-DRAPE SMALL 24 X 14 DYNJSD1040
|
Facility
|
IP
|
$102.00
|
|
| Hospital Charge Code |
2963304
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.98 |
| Max. Negotiated Rate |
$97.59 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.22
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: Health EOS Commercial |
$94.41
|
| Rate for Payer: HFN Commercial |
$97.59
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: Preferred Network Access Commercial |
$97.59
|
| Rate for Payer: Quartz Beloit One Network |
$51.98
|
| Rate for Payer: Quartz Commercial |
$63.65
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: WPS Commercial |
$78.57
|
|
|
Stereotactic Body Radiation Delivery 77373
|
Professional
|
Both
|
$6,691.00
|
|
|
Service Code
|
CPT 77373
|
| Hospital Charge Code |
5430723
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$969.40 |
| Max. Negotiated Rate |
$6,610.71 |
| Rate for Payer: Aetna Commercial |
$6,610.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,984.43
|
| Rate for Payer: Aetna Managed Medicare |
$969.40
|
| Rate for Payer: Anthem Medicare Advantage |
$969.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$969.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$969.40
|
| Rate for Payer: Cash Price |
$2,007.30
|
| Rate for Payer: Cash Price |
$2,007.30
|
| Rate for Payer: Cash Price |
$2,007.30
|
| Rate for Payer: Cigna Commercial |
$6,610.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,479.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$969.40
|
| Rate for Payer: Health EOS Commercial |
$6,332.36
|
| Rate for Payer: HFN Commercial |
$6,610.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,035.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4,035.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$969.40
|
| Rate for Payer: Multiplan Commercial |
$5,566.91
|
| Rate for Payer: NAPHCARE Commercial |
$1,454.11
|
| Rate for Payer: Preferred Network Access Commercial |
$6,610.71
|
| Rate for Payer: Quartz Beloit One Network |
$3,061.80
|
| Rate for Payer: Quartz Commercial |
$3,966.42
|
| Rate for Payer: Quartz Medicare Advantage |
$969.40
|
| Rate for Payer: The Alliance Commercial |
$3,683.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$969.40
|
| Rate for Payer: WEA Trust Commercial |
$3,827.25
|
| Rate for Payer: WPS Commercial |
$4,847.02
|
|
|
Stereotactic Body Radiation Management 77435
|
Professional
|
Both
|
$8,637.00
|
|
|
Service Code
|
CPT 77435
|
| Hospital Charge Code |
5432657
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$635.04 |
| Max. Negotiated Rate |
$8,533.36 |
| Rate for Payer: Aetna Commercial |
$8,533.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,724.93
|
| Rate for Payer: Aetna Managed Medicare |
$635.04
|
| Rate for Payer: Anthem Medicare Advantage |
$635.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$635.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$635.04
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cigna Commercial |
$8,533.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,491.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$635.04
|
| Rate for Payer: Health EOS Commercial |
$8,174.06
|
| Rate for Payer: HFN Commercial |
$8,533.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,254.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,254.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$635.04
|
| Rate for Payer: Multiplan Commercial |
$7,185.98
|
| Rate for Payer: NAPHCARE Commercial |
$952.57
|
| Rate for Payer: Preferred Network Access Commercial |
$8,533.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,952.29
|
| Rate for Payer: Quartz Commercial |
$5,120.01
|
| Rate for Payer: Quartz Medicare Advantage |
$635.04
|
| Rate for Payer: The Alliance Commercial |
$2,413.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$635.04
|
| Rate for Payer: WEA Trust Commercial |
$4,940.36
|
| Rate for Payer: WPS Commercial |
$3,175.22
|
|
|
Stereotactic Body Radiation Therapy
|
Facility
|
OP
|
$12,381.00
|
|
|
Service Code
|
CPT 77373
|
| Hospital Charge Code |
3970755
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,881.72 |
| Max. Negotiated Rate |
$11,846.14 |
| Rate for Payer: Aetna Commercial |
$11,588.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,073.57
|
| Rate for Payer: Aetna Managed Medicare |
$1,881.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,878.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,502.65
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,227.52
|
| Rate for Payer: Anthem Medicare Advantage |
$1,881.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,824.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,881.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,881.72
|
| Rate for Payer: Cash Price |
$3,714.30
|
| Rate for Payer: Cash Price |
$3,714.30
|
| Rate for Payer: Cigna Commercial |
$11,846.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,881.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,205.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,881.72
|
| Rate for Payer: Health EOS Commercial |
$11,459.85
|
| Rate for Payer: HFN Commercial |
$11,846.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,000.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,881.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,881.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,881.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,881.72
|
| Rate for Payer: Multiplan Commercial |
$10,300.99
|
| Rate for Payer: NAPHCARE Commercial |
$2,822.59
|
| Rate for Payer: Preferred Network Access Commercial |
$11,846.14
|
| Rate for Payer: Quartz Beloit One Network |
$6,309.36
|
| Rate for Payer: Quartz Commercial |
$8,369.56
|
| Rate for Payer: Quartz Medicare Advantage |
$1,881.72
|
| Rate for Payer: The Alliance Commercial |
$7,526.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,881.72
|
| Rate for Payer: United Healthcare PPO |
$7,725.74
|
| Rate for Payer: WEA Trust Commercial |
$7,081.93
|
| Rate for Payer: Wellcare Medicare |
$1,881.72
|
| Rate for Payer: WPS Commercial |
$9,537.08
|
|
|
Stereotactic Body Radiation Therapy
|
Facility
|
IP
|
$12,381.00
|
|
|
Service Code
|
CPT 77373
|
| Hospital Charge Code |
3970755
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$6,309.36 |
| Max. Negotiated Rate |
$11,846.14 |
| Rate for Payer: Aetna Commercial |
$11,588.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,073.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,824.41
|
| Rate for Payer: Cash Price |
$3,714.30
|
| Rate for Payer: Cigna Commercial |
$11,846.14
|
| Rate for Payer: Health EOS Commercial |
$11,459.85
|
| Rate for Payer: HFN Commercial |
$11,846.14
|
| Rate for Payer: Multiplan Commercial |
$10,300.99
|
| Rate for Payer: Preferred Network Access Commercial |
$11,846.14
|
| Rate for Payer: Quartz Beloit One Network |
$6,309.36
|
| Rate for Payer: Quartz Commercial |
$7,725.74
|
| Rate for Payer: WEA Trust Commercial |
$7,081.93
|
| Rate for Payer: WPS Commercial |
$9,537.08
|
|
|
Stereotactic Cranial Linear Radiation Therapy
|
Facility
|
IP
|
$18,484.00
|
|
|
Service Code
|
CPT 77372
|
| Hospital Charge Code |
5586206
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$9,419.45 |
| Max. Negotiated Rate |
$17,685.49 |
| Rate for Payer: Aetna Commercial |
$17,301.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,532.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,188.38
|
| Rate for Payer: Cash Price |
$5,545.20
|
| Rate for Payer: Cigna Commercial |
$17,685.49
|
| Rate for Payer: Health EOS Commercial |
$17,108.79
|
| Rate for Payer: HFN Commercial |
$17,685.49
|
| Rate for Payer: Multiplan Commercial |
$15,378.69
|
| Rate for Payer: Preferred Network Access Commercial |
$17,685.49
|
| Rate for Payer: Quartz Beloit One Network |
$9,419.45
|
| Rate for Payer: Quartz Commercial |
$11,534.02
|
| Rate for Payer: WEA Trust Commercial |
$10,572.85
|
| Rate for Payer: WPS Commercial |
$14,238.23
|
|
