|
Apex 3.0mm x 15mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.0mm x 15mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.0mm x 20mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.0mm x 20mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.0mm x 20mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.0mm x 30mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.0mm x 30mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.0mm x 30mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.0mm x 8mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.0mm x 8mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.0mm x 8mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 15mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 15mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 15mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 20mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159016
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 20mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159016
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 20mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159016
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 30mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 30mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 30mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 8mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 8mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 3.5mm x 8mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 4.0mm x 15mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159022
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Apex 4.0mm x 15mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159022
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
