|
SHELL BIPOLAR 49MM 5001-49
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967821
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 49MM 5001-49
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967821
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 50MM 5001-50
|
Facility
|
IP
|
$5,046.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967822
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,472.54 |
| Max. Negotiated Rate |
$4,642.32 |
| Rate for Payer: Aetna Commercial |
$4,541.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,339.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,674.38
|
| Rate for Payer: Cash Price |
$1,513.80
|
| Rate for Payer: Cigna Commercial |
$4,642.32
|
| Rate for Payer: Health EOS Commercial |
$4,490.94
|
| Rate for Payer: HFN Commercial |
$4,642.32
|
| Rate for Payer: Multiplan Commercial |
$4,036.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,027.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,642.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,472.54
|
| Rate for Payer: Quartz Commercial |
$3,027.60
|
| Rate for Payer: WEA Trust Commercial |
$2,775.30
|
| Rate for Payer: WPS Commercial |
$3,737.57
|
|
|
SHELL BIPOLAR 50MM 5001-50
|
Facility
|
OP
|
$5,046.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967822
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,412.88 |
| Max. Negotiated Rate |
$20,184.00 |
| Rate for Payer: Aetna Commercial |
$4,541.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,339.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,412.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,279.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,523.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,422.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,674.38
|
| Rate for Payer: Cash Price |
$1,513.80
|
| Rate for Payer: Cigna Commercial |
$4,642.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,823.74
|
| Rate for Payer: Health EOS Commercial |
$4,490.94
|
| Rate for Payer: HFN Commercial |
$4,642.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,784.50
|
| Rate for Payer: Multiplan Commercial |
$4,036.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,027.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,642.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,472.54
|
| Rate for Payer: Quartz Commercial |
$3,279.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,027.60
|
| Rate for Payer: The Alliance Commercial |
$20,184.00
|
| Rate for Payer: WEA Trust Commercial |
$2,775.30
|
| Rate for Payer: WPS Commercial |
$3,737.57
|
|
|
SHELL BIPOLAR 51MM 5001-51
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 51MM 5001-51
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 52MM 5001-52
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967825
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 52MM 5001-52
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967825
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 53MM 5001-53
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967827
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 53MM 5001-53
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967827
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 54MM 5001-54
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967828
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 54MM 5001-54
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967828
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 55MM 5001-55
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967830
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 55MM 5001-55
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967830
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 57MM 5001-57
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 57MM 5001-57
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 60MM 5001-60
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967834
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 60MM 5001-60
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967834
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR CUP 58MM 5001-58
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4479197
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR CUP 58MM 5001-58
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4479197
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL CONTINUUM 48MM GG 00-8757-048-01
|
Facility
|
OP
|
$11,318.00
|
|
| Hospital Charge Code |
2967820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,169.04 |
| Max. Negotiated Rate |
$45,272.00 |
| Rate for Payer: Aetna Commercial |
$10,186.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,733.48
|
| Rate for Payer: Aetna Managed Medicare |
$3,169.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,356.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,659.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,432.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,998.54
|
| Rate for Payer: Cash Price |
$3,395.40
|
| Rate for Payer: Cigna Commercial |
$10,412.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,333.55
|
| Rate for Payer: Health EOS Commercial |
$10,073.02
|
| Rate for Payer: HFN Commercial |
$10,412.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,488.50
|
| Rate for Payer: Multiplan Commercial |
$9,054.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,790.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,412.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,545.82
|
| Rate for Payer: Quartz Commercial |
$7,356.70
|
| Rate for Payer: Quartz Medicare Advantage |
$6,790.80
|
| Rate for Payer: The Alliance Commercial |
$45,272.00
|
| Rate for Payer: WEA Trust Commercial |
$6,224.90
|
| Rate for Payer: WPS Commercial |
$8,383.24
|
|
|
SHELL CONTINUUM 48MM GG 00-8757-048-01
|
Facility
|
IP
|
$11,318.00
|
|
| Hospital Charge Code |
2967820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,545.82 |
| Max. Negotiated Rate |
$10,412.56 |
| Rate for Payer: Aetna Commercial |
$10,186.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,733.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,998.54
|
| Rate for Payer: Cash Price |
$3,395.40
|
| Rate for Payer: Cigna Commercial |
$10,412.56
|
| Rate for Payer: Health EOS Commercial |
$10,073.02
|
| Rate for Payer: HFN Commercial |
$10,412.56
|
| Rate for Payer: Multiplan Commercial |
$9,054.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,790.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,412.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,545.82
|
| Rate for Payer: Quartz Commercial |
$6,790.80
|
| Rate for Payer: WEA Trust Commercial |
$6,224.90
|
| Rate for Payer: WPS Commercial |
$8,383.24
|
|
|
SHELL CONTINUUM 50MM 00-8757-050-01
|
Facility
|
OP
|
$10,900.00
|
|
| Hospital Charge Code |
2967823
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,052.00 |
| Max. Negotiated Rate |
$43,600.00 |
| Rate for Payer: Aetna Commercial |
$9,810.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,374.00
|
| Rate for Payer: Aetna Managed Medicare |
$3,052.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,085.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,450.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,232.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,777.00
|
| Rate for Payer: Cash Price |
$3,270.00
|
| Rate for Payer: Cigna Commercial |
$10,028.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,099.64
|
| Rate for Payer: Health EOS Commercial |
$9,701.00
|
| Rate for Payer: HFN Commercial |
$10,028.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,175.00
|
| Rate for Payer: Multiplan Commercial |
$8,720.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,540.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,028.00
|
| Rate for Payer: Quartz Beloit One Network |
$5,341.00
|
| Rate for Payer: Quartz Commercial |
$7,085.00
|
| Rate for Payer: Quartz Medicare Advantage |
$6,540.00
|
| Rate for Payer: The Alliance Commercial |
$43,600.00
|
| Rate for Payer: WEA Trust Commercial |
$5,995.00
|
| Rate for Payer: WPS Commercial |
$8,073.63
|
|
|
SHELL CONTINUUM 50MM 00-8757-050-01
|
Facility
|
IP
|
$10,900.00
|
|
| Hospital Charge Code |
2967823
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,341.00 |
| Max. Negotiated Rate |
$10,028.00 |
| Rate for Payer: Aetna Commercial |
$9,810.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,374.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,777.00
|
| Rate for Payer: Cash Price |
$3,270.00
|
| Rate for Payer: Cigna Commercial |
$10,028.00
|
| Rate for Payer: Health EOS Commercial |
$9,701.00
|
| Rate for Payer: HFN Commercial |
$10,028.00
|
| Rate for Payer: Multiplan Commercial |
$8,720.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,540.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,028.00
|
| Rate for Payer: Quartz Beloit One Network |
$5,341.00
|
| Rate for Payer: Quartz Commercial |
$6,540.00
|
| Rate for Payer: WEA Trust Commercial |
$5,995.00
|
| Rate for Payer: WPS Commercial |
$8,073.63
|
|
|
SHELL CONTINUUM 52MM 00-8757-052-01
|
Facility
|
IP
|
$11,318.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,545.82 |
| Max. Negotiated Rate |
$10,412.56 |
| Rate for Payer: Aetna Commercial |
$10,186.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,733.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,998.54
|
| Rate for Payer: Cash Price |
$3,395.40
|
| Rate for Payer: Cigna Commercial |
$10,412.56
|
| Rate for Payer: Health EOS Commercial |
$10,073.02
|
| Rate for Payer: HFN Commercial |
$10,412.56
|
| Rate for Payer: Multiplan Commercial |
$9,054.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,790.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,412.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,545.82
|
| Rate for Payer: Quartz Commercial |
$6,790.80
|
| Rate for Payer: WEA Trust Commercial |
$6,224.90
|
| Rate for Payer: WPS Commercial |
$8,383.24
|
|
