|
ART SURFACE PSN VE CR 3-9 CD 10MM RT 42-5220-004-10
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 3-9 CD 10MM RT 42-5220-004-10
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 3-9 CD 13MM RT 42-5220-004-13
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641019
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 3-9 CD 13MM RT 42-5220-004-13
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641019
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 3-9 CD 14MM RT 42-5220-004-14
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641020
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 3-9 CD 14MM RT 42-5220-004-14
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641020
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 3-9 CD 16MM RT 42-5220-004-16
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 3-9 CD 16MM RT 42-5220-004-16
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 3-9 CD 18MM RT 42-5220-004-18
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 3-9 CD 18MM RT 42-5220-004-18
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 11MM LT 42-5120-006-11
|
Facility
|
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,554.12 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,554.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,929.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,560.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,378.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,104.72
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,841.38
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: NAPHCARE Commercial |
$5,473.10
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,929.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,473.10
|
| Rate for Payer: The Alliance Commercial |
$4,560.92
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
ART SURFACE PSN VE CR 7-12 GH 11MM LT 42-5120-006-11
|
Facility
|
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,469.70 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,473.10
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
ART SURFACE PSN VE CR 7-12 GH 13MM LT 42-5120-006-13
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 13MM LT 42-5120-006-13
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 14MM LT 42-5120-006-14
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 14MM LT 42-5120-006-14
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 16MM LT 42-5120-006-16
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 16MM LT 42-5120-006-16
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 18MM LT 42-5120-006-18
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641016
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 18MM LT 42-5120-006-18
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641016
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ART SURFACE PSN VE MC 6-7 EF 11MM RT 42-5221-007-11
|
Facility
|
OP
|
$6,213.39
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246160
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,809.34 |
| Max. Negotiated Rate |
$5,944.97 |
| Rate for Payer: Aetna Commercial |
$5,815.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,557.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,809.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,200.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,230.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,101.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,424.82
|
| Rate for Payer: Cash Price |
$1,864.02
|
| Rate for Payer: Cigna Commercial |
$5,944.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,616.19
|
| Rate for Payer: Health EOS Commercial |
$5,751.11
|
| Rate for Payer: HFN Commercial |
$5,944.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,846.44
|
| Rate for Payer: Multiplan Commercial |
$5,169.54
|
| Rate for Payer: NAPHCARE Commercial |
$3,877.16
|
| Rate for Payer: Preferred Network Access Commercial |
$5,944.97
|
| Rate for Payer: Quartz Beloit One Network |
$3,166.34
|
| Rate for Payer: Quartz Commercial |
$4,200.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,877.16
|
| Rate for Payer: The Alliance Commercial |
$3,230.96
|
| Rate for Payer: WEA Trust Commercial |
$3,554.06
|
| Rate for Payer: WPS Commercial |
$4,786.17
|
|
|
ART SURFACE PSN VE MC 6-7 EF 11MM RT 42-5221-007-11
|
Facility
|
IP
|
$6,213.39
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246160
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,166.34 |
| Max. Negotiated Rate |
$5,944.97 |
| Rate for Payer: Aetna Commercial |
$5,815.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,557.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,424.82
|
| Rate for Payer: Cash Price |
$1,864.02
|
| Rate for Payer: Cigna Commercial |
$5,944.97
|
| Rate for Payer: Health EOS Commercial |
$5,751.11
|
| Rate for Payer: HFN Commercial |
$5,944.97
|
| Rate for Payer: Multiplan Commercial |
$5,169.54
|
| Rate for Payer: Preferred Network Access Commercial |
$5,944.97
|
| Rate for Payer: Quartz Beloit One Network |
$3,166.34
|
| Rate for Payer: Quartz Commercial |
$3,877.16
|
| Rate for Payer: WEA Trust Commercial |
$3,554.06
|
| Rate for Payer: WPS Commercial |
$4,786.17
|
|
|
ART SURFACE PSN VE MC 8-11 GH 11MM LT 42-5121-009-11
|
Facility
|
IP
|
$6,213.39
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248152
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,166.34 |
| Max. Negotiated Rate |
$5,944.97 |
| Rate for Payer: Aetna Commercial |
$5,815.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,557.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,424.82
|
| Rate for Payer: Cash Price |
$1,864.02
|
| Rate for Payer: Cigna Commercial |
$5,944.97
|
| Rate for Payer: Health EOS Commercial |
$5,751.11
|
| Rate for Payer: HFN Commercial |
$5,944.97
|
| Rate for Payer: Multiplan Commercial |
$5,169.54
|
| Rate for Payer: Preferred Network Access Commercial |
$5,944.97
|
| Rate for Payer: Quartz Beloit One Network |
$3,166.34
|
| Rate for Payer: Quartz Commercial |
$3,877.16
|
| Rate for Payer: WEA Trust Commercial |
$3,554.06
|
| Rate for Payer: WPS Commercial |
$4,786.17
|
|
|
ART SURFACE PSN VE MC 8-11 GH 11MM LT 42-5121-009-11
|
Facility
|
OP
|
$6,213.39
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248152
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,809.34 |
| Max. Negotiated Rate |
$5,944.97 |
| Rate for Payer: Aetna Commercial |
$5,815.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,557.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,809.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,200.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,230.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,101.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,424.82
|
| Rate for Payer: Cash Price |
$1,864.02
|
| Rate for Payer: Cigna Commercial |
$5,944.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,616.19
|
| Rate for Payer: Health EOS Commercial |
$5,751.11
|
| Rate for Payer: HFN Commercial |
$5,944.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,846.44
|
| Rate for Payer: Multiplan Commercial |
$5,169.54
|
| Rate for Payer: NAPHCARE Commercial |
$3,877.16
|
| Rate for Payer: Preferred Network Access Commercial |
$5,944.97
|
| Rate for Payer: Quartz Beloit One Network |
$3,166.34
|
| Rate for Payer: Quartz Commercial |
$4,200.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,877.16
|
| Rate for Payer: The Alliance Commercial |
$3,230.96
|
| Rate for Payer: WEA Trust Commercial |
$3,554.06
|
| Rate for Payer: WPS Commercial |
$4,786.17
|
|
|
ASCA IgA
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2770814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$71.84 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
