|
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 |
$1,415.23 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,415.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,285.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,527.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,426.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,828.52
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,790.80
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.64
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,285.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,032.64
|
| Rate for Payer: The Alliance Commercial |
$2,527.20
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$1,469.40 |
| Max. Negotiated Rate |
$4,828.01 |
| Rate for Payer: Aetna Commercial |
$4,723.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,513.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,469.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,411.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,623.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,518.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,781.36
|
| Rate for Payer: Cash Price |
$1,513.80
|
| Rate for Payer: Cigna Commercial |
$4,828.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,936.77
|
| Rate for Payer: Health EOS Commercial |
$4,670.58
|
| Rate for Payer: HFN Commercial |
$4,828.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,935.88
|
| Rate for Payer: Multiplan Commercial |
$4,198.27
|
| Rate for Payer: NAPHCARE Commercial |
$3,148.70
|
| Rate for Payer: Preferred Network Access Commercial |
$4,828.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,571.44
|
| Rate for Payer: Quartz Commercial |
$3,411.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,148.70
|
| Rate for Payer: The Alliance Commercial |
$2,623.92
|
| Rate for Payer: WEA Trust Commercial |
$2,886.31
|
| Rate for Payer: WPS Commercial |
$3,886.93
|
|
|
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 |
$2,571.44 |
| Max. Negotiated Rate |
$4,828.01 |
| Rate for Payer: Aetna Commercial |
$4,723.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,513.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,781.36
|
| Rate for Payer: Cash Price |
$1,513.80
|
| Rate for Payer: Cigna Commercial |
$4,828.01
|
| Rate for Payer: Health EOS Commercial |
$4,670.58
|
| Rate for Payer: HFN Commercial |
$4,828.01
|
| Rate for Payer: Multiplan Commercial |
$4,198.27
|
| Rate for Payer: Preferred Network Access Commercial |
$4,828.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,571.44
|
| Rate for Payer: Quartz Commercial |
$3,148.70
|
| Rate for Payer: WEA Trust Commercial |
$2,886.31
|
| Rate for Payer: WPS Commercial |
$3,886.93
|
|
|
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 |
$2,476.66 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,032.64
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$1,415.23 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,415.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,285.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,527.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,426.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,828.52
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,790.80
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.64
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,285.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,032.64
|
| Rate for Payer: The Alliance Commercial |
$2,527.20
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$2,476.66 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,032.64
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$1,415.23 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,415.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,285.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,527.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,426.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,828.52
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,790.80
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.64
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,285.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,032.64
|
| Rate for Payer: The Alliance Commercial |
$2,527.20
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$2,476.66 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,032.64
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$1,415.23 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,415.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,285.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,527.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,426.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,828.52
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,790.80
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.64
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,285.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,032.64
|
| Rate for Payer: The Alliance Commercial |
$2,527.20
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$2,476.66 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,032.64
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$1,415.23 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,415.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,285.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,527.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,426.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,828.52
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,790.80
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.64
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,285.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,032.64
|
| Rate for Payer: The Alliance Commercial |
$2,527.20
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$1,415.23 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,415.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,285.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,527.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,426.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,828.52
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,790.80
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.64
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,285.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,032.64
|
| Rate for Payer: The Alliance Commercial |
$2,527.20
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$2,476.66 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,032.64
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$2,476.66 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,032.64
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$1,415.23 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,415.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,285.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,527.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,426.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,828.52
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,790.80
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.64
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,285.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,032.64
|
| Rate for Payer: The Alliance Commercial |
$2,527.20
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$2,476.66 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,032.64
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$1,415.23 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,415.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,285.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,527.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,426.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,828.52
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,790.80
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.64
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,285.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,032.64
|
| Rate for Payer: The Alliance Commercial |
$2,527.20
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$2,476.66 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,032.64
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
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 |
$1,415.23 |
| Max. Negotiated Rate |
$4,650.05 |
| Rate for Payer: Aetna Commercial |
$4,548.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,346.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,415.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,285.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,527.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,426.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.83
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,650.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,828.52
|
| Rate for Payer: Health EOS Commercial |
$4,498.42
|
| Rate for Payer: HFN Commercial |
$4,650.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,790.80
|
| Rate for Payer: Multiplan Commercial |
$4,043.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.64
|
| Rate for Payer: Preferred Network Access Commercial |
$4,650.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.66
|
| Rate for Payer: Quartz Commercial |
$3,285.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,032.64
|
| Rate for Payer: The Alliance Commercial |
$2,527.20
|
| Rate for Payer: WEA Trust Commercial |
$2,779.92
|
| Rate for Payer: WPS Commercial |
$3,743.66
|
|
|
SHELL CONTINUUM 48MM GG 00-8757-048-01
|
Facility
|
IP
|
$11,318.00
|
|
| Hospital Charge Code |
2967820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,767.65 |
| Max. Negotiated Rate |
$10,829.06 |
| Rate for Payer: Aetna Commercial |
$10,593.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,122.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,238.48
|
| Rate for Payer: Cash Price |
$3,395.40
|
| Rate for Payer: Cigna Commercial |
$10,829.06
|
| Rate for Payer: Health EOS Commercial |
$10,475.94
|
| Rate for Payer: HFN Commercial |
$10,829.06
|
| Rate for Payer: Multiplan Commercial |
$9,416.58
|
| Rate for Payer: Preferred Network Access Commercial |
$10,829.06
|
| Rate for Payer: Quartz Beloit One Network |
$5,767.65
|
| Rate for Payer: Quartz Commercial |
$7,062.43
|
| Rate for Payer: WEA Trust Commercial |
$6,473.90
|
| Rate for Payer: WPS Commercial |
$8,718.26
|
|
|
SHELL CONTINUUM 48MM GG 00-8757-048-01
|
Facility
|
OP
|
$11,318.00
|
|
| Hospital Charge Code |
2967820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,295.80 |
| Max. Negotiated Rate |
$10,829.06 |
| Rate for Payer: Aetna Commercial |
$10,593.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,122.82
|
| Rate for Payer: Aetna Managed Medicare |
$3,295.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,650.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,885.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,649.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,238.48
|
| Rate for Payer: Cash Price |
$3,395.40
|
| Rate for Payer: Cigna Commercial |
$10,829.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,587.08
|
| Rate for Payer: Health EOS Commercial |
$10,475.94
|
| Rate for Payer: HFN Commercial |
$10,829.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,828.04
|
| Rate for Payer: Multiplan Commercial |
$9,416.58
|
| Rate for Payer: NAPHCARE Commercial |
$7,062.43
|
| Rate for Payer: Preferred Network Access Commercial |
$10,829.06
|
| Rate for Payer: Quartz Beloit One Network |
$5,767.65
|
| Rate for Payer: Quartz Commercial |
$7,650.97
|
| Rate for Payer: Quartz Medicare Advantage |
$7,062.43
|
| Rate for Payer: The Alliance Commercial |
$5,885.36
|
| Rate for Payer: WEA Trust Commercial |
$6,473.90
|
| Rate for Payer: WPS Commercial |
$8,718.26
|
|
|
SHELL CONTINUUM 50MM 00-8757-050-01
|
Facility
|
OP
|
$10,900.00
|
|
| Hospital Charge Code |
2967823
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,174.08 |
| Max. Negotiated Rate |
$10,429.12 |
| Rate for Payer: Aetna Commercial |
$10,202.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,748.96
|
| Rate for Payer: Aetna Managed Medicare |
$3,174.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,368.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,668.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,441.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,008.08
|
| Rate for Payer: Cash Price |
$3,270.00
|
| Rate for Payer: Cigna Commercial |
$10,429.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,343.80
|
| Rate for Payer: Health EOS Commercial |
$10,089.04
|
| Rate for Payer: HFN Commercial |
$10,429.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,502.00
|
| Rate for Payer: Multiplan Commercial |
$9,068.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,801.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,429.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,554.64
|
| Rate for Payer: Quartz Commercial |
$7,368.40
|
| Rate for Payer: Quartz Medicare Advantage |
$6,801.60
|
| Rate for Payer: The Alliance Commercial |
$5,668.00
|
| Rate for Payer: WEA Trust Commercial |
$6,234.80
|
| Rate for Payer: WPS Commercial |
$8,396.27
|
|
|
SHELL CONTINUUM 50MM 00-8757-050-01
|
Facility
|
IP
|
$10,900.00
|
|
| Hospital Charge Code |
2967823
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,554.64 |
| Max. Negotiated Rate |
$10,429.12 |
| Rate for Payer: Aetna Commercial |
$10,202.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,748.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,008.08
|
| Rate for Payer: Cash Price |
$3,270.00
|
| Rate for Payer: Cigna Commercial |
$10,429.12
|
| Rate for Payer: Health EOS Commercial |
$10,089.04
|
| Rate for Payer: HFN Commercial |
$10,429.12
|
| Rate for Payer: Multiplan Commercial |
$9,068.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,429.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,554.64
|
| Rate for Payer: Quartz Commercial |
$6,801.60
|
| Rate for Payer: WEA Trust Commercial |
$6,234.80
|
| Rate for Payer: WPS Commercial |
$8,396.27
|
|
|
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 |
$3,295.80 |
| Max. Negotiated Rate |
$10,829.06 |
| Rate for Payer: Aetna Commercial |
$10,593.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,122.82
|
| Rate for Payer: Aetna Managed Medicare |
$3,295.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,650.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,885.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,649.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,238.48
|
| Rate for Payer: Cash Price |
$3,395.40
|
| Rate for Payer: Cigna Commercial |
$10,829.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,587.08
|
| Rate for Payer: Health EOS Commercial |
$10,475.94
|
| Rate for Payer: HFN Commercial |
$10,829.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,828.04
|
| Rate for Payer: Multiplan Commercial |
$9,416.58
|
| Rate for Payer: NAPHCARE Commercial |
$7,062.43
|
| Rate for Payer: Preferred Network Access Commercial |
$10,829.06
|
| Rate for Payer: Quartz Beloit One Network |
$5,767.65
|
| Rate for Payer: Quartz Commercial |
$7,650.97
|
| Rate for Payer: Quartz Medicare Advantage |
$7,062.43
|
| Rate for Payer: The Alliance Commercial |
$5,885.36
|
| Rate for Payer: WEA Trust Commercial |
$6,473.90
|
| Rate for Payer: WPS Commercial |
$8,718.26
|
|
|
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 |
$5,767.65 |
| Max. Negotiated Rate |
$10,829.06 |
| Rate for Payer: Aetna Commercial |
$10,593.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,122.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,238.48
|
| Rate for Payer: Cash Price |
$3,395.40
|
| Rate for Payer: Cigna Commercial |
$10,829.06
|
| Rate for Payer: Health EOS Commercial |
$10,475.94
|
| Rate for Payer: HFN Commercial |
$10,829.06
|
| Rate for Payer: Multiplan Commercial |
$9,416.58
|
| Rate for Payer: Preferred Network Access Commercial |
$10,829.06
|
| Rate for Payer: Quartz Beloit One Network |
$5,767.65
|
| Rate for Payer: Quartz Commercial |
$7,062.43
|
| Rate for Payer: WEA Trust Commercial |
$6,473.90
|
| Rate for Payer: WPS Commercial |
$8,718.26
|
|
