|
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: 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 |
$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 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: 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 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 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: 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: 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 52MM 00-8757-052-01
|
Facility
OP
|
$11,318.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,169.04 |
| 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: 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: WEA Trust Commercial |
$6,224.90
|
| Rate for Payer: WPS Commercial |
$8,383.24
|
|
|
SHELL CONTINUUM 54MM 00-8757-054-01
|
Facility
OP
|
$11,318.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,169.04 |
| 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: 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: WEA Trust Commercial |
$6,224.90
|
| Rate for Payer: WPS Commercial |
$8,383.24
|
|
|
SHELL CONTINUUM 54MM 00-8757-054-01
|
Facility
IP
|
$11,318.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967829
|
|
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: 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 56MM KK 00-8757-056-01
|
Facility
OP
|
$11,318.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967831
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,169.04 |
| 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: 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: WEA Trust Commercial |
$6,224.90
|
| Rate for Payer: WPS Commercial |
$8,383.24
|
|
|
SHELL CONTINUUM 56MM KK 00-8757-056-01
|
Facility
IP
|
$11,318.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967831
|
|
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: 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 58MM LL 00-8757-058-01
|
Facility
IP
|
$11,318.00
|
|
| Hospital Charge Code |
2967833
|
|
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: 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 58MM LL 00-8757-058-01
|
Facility
OP
|
$11,318.00
|
|
| Hospital Charge Code |
2967833
|
|
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 60MM 00-8757-060-01
|
Facility
IP
|
$11,318.00
|
|
| Hospital Charge Code |
2967835
|
|
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: 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 60MM 00-8757-060-01
|
Facility
OP
|
$11,318.00
|
|
| Hospital Charge Code |
2967835
|
|
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 MULTI HOLE 54MM 00-8757-054-02
|
Facility
IP
|
$6,649.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4366021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,258.01 |
| Max. Negotiated Rate |
$6,117.08 |
| Rate for Payer: Aetna Commercial |
$5,984.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,523.97
|
| Rate for Payer: Cash Price |
$1,994.70
|
| Rate for Payer: Cigna Commercial |
$6,117.08
|
| Rate for Payer: Health EOS Commercial |
$5,917.61
|
| Rate for Payer: HFN Commercial |
$6,117.08
|
| Rate for Payer: Multiplan Commercial |
$5,319.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,989.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,117.08
|
| Rate for Payer: Quartz Beloit One Network |
$3,258.01
|
| Rate for Payer: Quartz Commercial |
$3,989.40
|
| Rate for Payer: WEA Trust Commercial |
$3,656.95
|
| Rate for Payer: WPS Commercial |
$4,924.91
|
|
|
SHELL CONTINUUM MULTI HOLE 54MM 00-8757-054-02
|
Facility
OP
|
$6,649.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4366021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,861.72 |
| Max. Negotiated Rate |
$6,117.08 |
| Rate for Payer: Aetna Commercial |
$5,984.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,718.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,861.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,321.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,324.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,191.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,523.97
|
| Rate for Payer: Cash Price |
$1,994.70
|
| Rate for Payer: Cigna Commercial |
$6,117.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,720.78
|
| Rate for Payer: Health EOS Commercial |
$5,917.61
|
| Rate for Payer: HFN Commercial |
$6,117.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,986.75
|
| Rate for Payer: Multiplan Commercial |
$5,319.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,989.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,117.08
|
| Rate for Payer: Quartz Beloit One Network |
$3,258.01
|
| Rate for Payer: Quartz Commercial |
$4,321.85
|
| Rate for Payer: Quartz Medicare Advantage |
$3,989.40
|
| Rate for Payer: WEA Trust Commercial |
$3,656.95
|
| Rate for Payer: WPS Commercial |
$4,924.91
|
|
|
SHELL MULTIPOLAR BIPOLAR 46MM 5001-46
|
Facility
OP
|
$5,046.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967817
|
|
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 MULTIPOLAR BIPOLAR 46MM 5001-46
|
Facility
IP
|
$5,046.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967817
|
|
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 TRIDENT 48MM D 502-11-48D
|
Facility
OP
|
$8,866.00
|
|
| Hospital Charge Code |
3127479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,482.48 |
| Max. Negotiated Rate |
$35,464.00 |
| Rate for Payer: Aetna Commercial |
$7,979.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,624.76
|
| Rate for Payer: Aetna Managed Medicare |
$2,482.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,762.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,433.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,255.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,698.98
|
| Rate for Payer: Cash Price |
$2,659.80
|
| Rate for Payer: Cigna Commercial |
$8,156.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,961.41
|
| Rate for Payer: Health EOS Commercial |
$7,890.74
|
| Rate for Payer: HFN Commercial |
$8,156.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,649.50
|
| Rate for Payer: Multiplan Commercial |
$7,092.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,319.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,156.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,344.34
|
| Rate for Payer: Quartz Commercial |
$5,762.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,319.60
|
| Rate for Payer: The Alliance Commercial |
$35,464.00
|
| Rate for Payer: WEA Trust Commercial |
$4,876.30
|
| Rate for Payer: WPS Commercial |
$6,567.05
|
|
|
SHELL TRIDENT 48MM D 502-11-48D
|
Facility
IP
|
$8,866.00
|
|
| Hospital Charge Code |
3127479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,344.34 |
| Max. Negotiated Rate |
$8,156.72 |
| Rate for Payer: Aetna Commercial |
$7,979.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,698.98
|
| Rate for Payer: Cash Price |
$2,659.80
|
| Rate for Payer: Cigna Commercial |
$8,156.72
|
| Rate for Payer: Health EOS Commercial |
$7,890.74
|
| Rate for Payer: HFN Commercial |
$8,156.72
|
| Rate for Payer: Multiplan Commercial |
$7,092.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,319.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,156.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,344.34
|
| Rate for Payer: Quartz Commercial |
$5,319.60
|
| Rate for Payer: WEA Trust Commercial |
$4,876.30
|
| Rate for Payer: WPS Commercial |
$6,567.05
|
|
|
SHELL TRIDENT 50MM D 502-11-50D
|
Facility
IP
|
$8,538.00
|
|
| Hospital Charge Code |
3365514
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,183.62 |
| Max. Negotiated Rate |
$7,854.96 |
| Rate for Payer: Aetna Commercial |
$7,684.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,525.14
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$7,854.96
|
| Rate for Payer: Health EOS Commercial |
$7,598.82
|
| Rate for Payer: HFN Commercial |
$7,854.96
|
| Rate for Payer: Multiplan Commercial |
$6,830.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,122.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,854.96
|
| Rate for Payer: Quartz Beloit One Network |
$4,183.62
|
| Rate for Payer: Quartz Commercial |
$5,122.80
|
| Rate for Payer: WEA Trust Commercial |
$4,695.90
|
| Rate for Payer: WPS Commercial |
$6,324.10
|
|
|
SHELL TRIDENT 50MM D 502-11-50D
|
Facility
OP
|
$8,538.00
|
|
| Hospital Charge Code |
3365514
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.64 |
| Max. Negotiated Rate |
$34,152.00 |
| Rate for Payer: Aetna Commercial |
$7,684.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,342.68
|
| Rate for Payer: Aetna Managed Medicare |
$2,390.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,549.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,269.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,098.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,525.14
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$7,854.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,777.86
|
| Rate for Payer: Health EOS Commercial |
$7,598.82
|
| Rate for Payer: HFN Commercial |
$7,854.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,403.50
|
| Rate for Payer: Multiplan Commercial |
$6,830.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,122.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,854.96
|
| Rate for Payer: Quartz Beloit One Network |
$4,183.62
|
| Rate for Payer: Quartz Commercial |
$5,549.70
|
| Rate for Payer: Quartz Medicare Advantage |
$5,122.80
|
| Rate for Payer: The Alliance Commercial |
$34,152.00
|
| Rate for Payer: WEA Trust Commercial |
$4,695.90
|
| Rate for Payer: WPS Commercial |
$6,324.10
|
|
|
SHELL TRIDENT 52MM E 502-11-52E
|
Facility
OP
|
$8,538.00
|
|
| Hospital Charge Code |
3365518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.64 |
| Max. Negotiated Rate |
$34,152.00 |
| Rate for Payer: Aetna Commercial |
$7,684.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,342.68
|
| Rate for Payer: Aetna Managed Medicare |
$2,390.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,549.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,269.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,098.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,525.14
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$7,854.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,777.86
|
| Rate for Payer: Health EOS Commercial |
$7,598.82
|
| Rate for Payer: HFN Commercial |
$7,854.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,403.50
|
| Rate for Payer: Multiplan Commercial |
$6,830.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,122.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,854.96
|
| Rate for Payer: Quartz Beloit One Network |
$4,183.62
|
| Rate for Payer: Quartz Commercial |
$5,549.70
|
| Rate for Payer: Quartz Medicare Advantage |
$5,122.80
|
| Rate for Payer: The Alliance Commercial |
$34,152.00
|
| Rate for Payer: WEA Trust Commercial |
$4,695.90
|
| Rate for Payer: WPS Commercial |
$6,324.10
|
|
