|
SHELL BIPOLAR 43 MM 5001-43
|
Facility
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967813
|
|
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: 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 44MM 5001-44
|
Facility
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967814
|
|
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: 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 44MM 5001-44
|
Facility
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967814
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| 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: 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: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 45MM 5001-45
|
Facility
IP
|
$5,046.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967816
|
|
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: 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 45MM 5001-45
|
Facility
OP
|
$5,046.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967816
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,412.88 |
| 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: 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: WEA Trust Commercial |
$2,775.30
|
| Rate for Payer: WPS Commercial |
$3,737.57
|
|
|
SHELL BIPOLAR 47MM 5001-47
|
Facility
OP
|
$5,046.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967818
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,412.88 |
| 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: 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: WEA Trust Commercial |
$2,775.30
|
| Rate for Payer: WPS Commercial |
$3,737.57
|
|
|
SHELL BIPOLAR 47MM 5001-47
|
Facility
IP
|
$5,046.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967818
|
|
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: 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 48MM 5001-48
|
Facility
IP
|
$5,046.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967819
|
|
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: 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 48MM 5001-48
|
Facility
OP
|
$5,046.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967819
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,412.88 |
| 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: 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: WEA Trust Commercial |
$2,775.30
|
| Rate for Payer: WPS Commercial |
$3,737.57
|
|
|
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: 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 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 |
$4,471.20 |
| 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: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
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 |
$4,642.32 |
| 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: WEA Trust Commercial |
$2,775.30
|
| Rate for Payer: WPS Commercial |
$3,737.57
|
|
|
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: 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 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: 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 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 |
$4,471.20 |
| 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: 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: 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 |
$4,471.20 |
| 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: 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: 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 |
$4,471.20 |
| 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: 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: 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 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 |
$4,471.20 |
| 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: 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 |
$4,471.20 |
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| 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 Medicare Advantage |
$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
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: 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 |
$4,471.20 |
| 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: 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: 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
|
|
