|
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 |
$3,295.80 |
| 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 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 |
$5,767.65 |
| 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 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 |
$3,295.80 |
| 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 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 |
$5,767.65 |
| 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 58MM LL 00-8757-058-01
|
Facility
|
OP
|
$11,318.00
|
|
| Hospital Charge Code |
2967833
|
|
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 58MM LL 00-8757-058-01
|
Facility
|
IP
|
$11,318.00
|
|
| Hospital Charge Code |
2967833
|
|
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 60MM 00-8757-060-01
|
Facility
|
IP
|
$11,318.00
|
|
| Hospital Charge Code |
2967835
|
|
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 60MM 00-8757-060-01
|
Facility
|
OP
|
$11,318.00
|
|
| Hospital Charge Code |
2967835
|
|
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 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 |
$1,936.19 |
| Max. Negotiated Rate |
$6,361.76 |
| Rate for Payer: Aetna Commercial |
$6,223.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,946.87
|
| Rate for Payer: Aetna Managed Medicare |
$1,936.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,494.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,457.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,319.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,664.93
|
| Rate for Payer: Cash Price |
$1,994.70
|
| Rate for Payer: Cigna Commercial |
$6,361.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,869.72
|
| Rate for Payer: Health EOS Commercial |
$6,154.31
|
| Rate for Payer: HFN Commercial |
$6,361.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,186.22
|
| Rate for Payer: Multiplan Commercial |
$5,531.97
|
| Rate for Payer: NAPHCARE Commercial |
$4,148.98
|
| Rate for Payer: Preferred Network Access Commercial |
$6,361.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,388.33
|
| Rate for Payer: Quartz Commercial |
$4,494.72
|
| Rate for Payer: Quartz Medicare Advantage |
$4,148.98
|
| Rate for Payer: The Alliance Commercial |
$3,457.48
|
| Rate for Payer: WEA Trust Commercial |
$3,803.23
|
| Rate for Payer: WPS Commercial |
$5,121.72
|
|
|
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 |
$3,388.33 |
| Max. Negotiated Rate |
$6,361.76 |
| Rate for Payer: Aetna Commercial |
$6,223.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,946.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,664.93
|
| Rate for Payer: Cash Price |
$1,994.70
|
| Rate for Payer: Cigna Commercial |
$6,361.76
|
| Rate for Payer: Health EOS Commercial |
$6,154.31
|
| Rate for Payer: HFN Commercial |
$6,361.76
|
| Rate for Payer: Multiplan Commercial |
$5,531.97
|
| Rate for Payer: Preferred Network Access Commercial |
$6,361.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,388.33
|
| Rate for Payer: Quartz Commercial |
$4,148.98
|
| Rate for Payer: WEA Trust Commercial |
$3,803.23
|
| Rate for Payer: WPS Commercial |
$5,121.72
|
|
|
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 |
$1,469.40 |
| 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 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 |
$2,571.44 |
| 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 TRIDENT 48MM D 502-11-48D
|
Facility
|
OP
|
$8,866.00
|
|
| Hospital Charge Code |
3127479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,581.78 |
| Max. Negotiated Rate |
$8,482.99 |
| Rate for Payer: Aetna Commercial |
$8,298.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,929.75
|
| Rate for Payer: Aetna Managed Medicare |
$2,581.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,993.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,610.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,425.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,886.94
|
| Rate for Payer: Cash Price |
$2,659.80
|
| Rate for Payer: Cigna Commercial |
$8,482.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,160.01
|
| Rate for Payer: Health EOS Commercial |
$8,206.37
|
| Rate for Payer: HFN Commercial |
$8,482.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,915.48
|
| Rate for Payer: Multiplan Commercial |
$7,376.51
|
| Rate for Payer: NAPHCARE Commercial |
$5,532.38
|
| Rate for Payer: Preferred Network Access Commercial |
$8,482.99
|
| Rate for Payer: Quartz Beloit One Network |
$4,518.11
|
| Rate for Payer: Quartz Commercial |
$5,993.42
|
| Rate for Payer: Quartz Medicare Advantage |
$5,532.38
|
| Rate for Payer: The Alliance Commercial |
$4,610.32
|
| Rate for Payer: WEA Trust Commercial |
$5,071.35
|
| Rate for Payer: WPS Commercial |
$6,829.48
|
|
|
SHELL TRIDENT 48MM D 502-11-48D
|
Facility
|
IP
|
$8,866.00
|
|
| Hospital Charge Code |
3127479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,518.11 |
| Max. Negotiated Rate |
$8,482.99 |
| Rate for Payer: Aetna Commercial |
$8,298.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,929.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,886.94
|
| Rate for Payer: Cash Price |
$2,659.80
|
| Rate for Payer: Cigna Commercial |
$8,482.99
|
| Rate for Payer: Health EOS Commercial |
$8,206.37
|
| Rate for Payer: HFN Commercial |
$8,482.99
|
| Rate for Payer: Multiplan Commercial |
$7,376.51
|
| Rate for Payer: Preferred Network Access Commercial |
$8,482.99
|
| Rate for Payer: Quartz Beloit One Network |
$4,518.11
|
| Rate for Payer: Quartz Commercial |
$5,532.38
|
| Rate for Payer: WEA Trust Commercial |
$5,071.35
|
| Rate for Payer: WPS Commercial |
$6,829.48
|
|
|
SHELL TRIDENT 50MM D 502-11-50D
|
Facility
|
IP
|
$8,538.00
|
|
| Hospital Charge Code |
3365514
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,350.96 |
| Max. Negotiated Rate |
$8,169.16 |
| Rate for Payer: Aetna Commercial |
$7,991.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,636.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,706.15
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$8,169.16
|
| Rate for Payer: Health EOS Commercial |
$7,902.77
|
| Rate for Payer: HFN Commercial |
$8,169.16
|
| Rate for Payer: Multiplan Commercial |
$7,103.62
|
| Rate for Payer: Preferred Network Access Commercial |
$8,169.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,350.96
|
| Rate for Payer: Quartz Commercial |
$5,327.71
|
| Rate for Payer: WEA Trust Commercial |
$4,883.74
|
| Rate for Payer: WPS Commercial |
$6,576.82
|
|
|
SHELL TRIDENT 50MM D 502-11-50D
|
Facility
|
OP
|
$8,538.00
|
|
| Hospital Charge Code |
3365514
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,486.27 |
| Max. Negotiated Rate |
$8,169.16 |
| Rate for Payer: Aetna Commercial |
$7,991.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,636.39
|
| Rate for Payer: Aetna Managed Medicare |
$2,486.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,771.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,439.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,262.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,706.15
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$8,169.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,969.12
|
| Rate for Payer: Health EOS Commercial |
$7,902.77
|
| Rate for Payer: HFN Commercial |
$8,169.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,659.64
|
| Rate for Payer: Multiplan Commercial |
$7,103.62
|
| Rate for Payer: NAPHCARE Commercial |
$5,327.71
|
| Rate for Payer: Preferred Network Access Commercial |
$8,169.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,350.96
|
| Rate for Payer: Quartz Commercial |
$5,771.69
|
| Rate for Payer: Quartz Medicare Advantage |
$5,327.71
|
| Rate for Payer: The Alliance Commercial |
$4,439.76
|
| Rate for Payer: WEA Trust Commercial |
$4,883.74
|
| Rate for Payer: WPS Commercial |
$6,576.82
|
|
|
SHELL TRIDENT 52MM E 502-11-52E
|
Facility
|
IP
|
$8,538.00
|
|
| Hospital Charge Code |
3365518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,350.96 |
| Max. Negotiated Rate |
$8,169.16 |
| Rate for Payer: Aetna Commercial |
$7,991.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,636.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,706.15
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$8,169.16
|
| Rate for Payer: Health EOS Commercial |
$7,902.77
|
| Rate for Payer: HFN Commercial |
$8,169.16
|
| Rate for Payer: Multiplan Commercial |
$7,103.62
|
| Rate for Payer: Preferred Network Access Commercial |
$8,169.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,350.96
|
| Rate for Payer: Quartz Commercial |
$5,327.71
|
| Rate for Payer: WEA Trust Commercial |
$4,883.74
|
| Rate for Payer: WPS Commercial |
$6,576.82
|
|
|
SHELL TRIDENT 52MM E 502-11-52E
|
Facility
|
OP
|
$8,538.00
|
|
| Hospital Charge Code |
3365518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,486.27 |
| Max. Negotiated Rate |
$8,169.16 |
| Rate for Payer: Aetna Commercial |
$7,991.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,636.39
|
| Rate for Payer: Aetna Managed Medicare |
$2,486.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,771.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,439.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,262.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,706.15
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$8,169.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,969.12
|
| Rate for Payer: Health EOS Commercial |
$7,902.77
|
| Rate for Payer: HFN Commercial |
$8,169.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,659.64
|
| Rate for Payer: Multiplan Commercial |
$7,103.62
|
| Rate for Payer: NAPHCARE Commercial |
$5,327.71
|
| Rate for Payer: Preferred Network Access Commercial |
$8,169.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,350.96
|
| Rate for Payer: Quartz Commercial |
$5,771.69
|
| Rate for Payer: Quartz Medicare Advantage |
$5,327.71
|
| Rate for Payer: The Alliance Commercial |
$4,439.76
|
| Rate for Payer: WEA Trust Commercial |
$4,883.74
|
| Rate for Payer: WPS Commercial |
$6,576.82
|
|
|
SHELL TRIDENT 568MM F 509-02-58F
|
Facility
|
IP
|
$8,538.00
|
|
| Hospital Charge Code |
4263460
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,350.96 |
| Max. Negotiated Rate |
$8,169.16 |
| Rate for Payer: Aetna Commercial |
$7,991.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,636.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,706.15
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$8,169.16
|
| Rate for Payer: Health EOS Commercial |
$7,902.77
|
| Rate for Payer: HFN Commercial |
$8,169.16
|
| Rate for Payer: Multiplan Commercial |
$7,103.62
|
| Rate for Payer: Preferred Network Access Commercial |
$8,169.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,350.96
|
| Rate for Payer: Quartz Commercial |
$5,327.71
|
| Rate for Payer: WEA Trust Commercial |
$4,883.74
|
| Rate for Payer: WPS Commercial |
$6,576.82
|
|
|
SHELL TRIDENT 568MM F 509-02-58F
|
Facility
|
OP
|
$8,538.00
|
|
| Hospital Charge Code |
4263460
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,486.27 |
| Max. Negotiated Rate |
$8,169.16 |
| Rate for Payer: Aetna Commercial |
$7,991.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,636.39
|
| Rate for Payer: Aetna Managed Medicare |
$2,486.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,771.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,439.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,262.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,706.15
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$8,169.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,969.12
|
| Rate for Payer: Health EOS Commercial |
$7,902.77
|
| Rate for Payer: HFN Commercial |
$8,169.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,659.64
|
| Rate for Payer: Multiplan Commercial |
$7,103.62
|
| Rate for Payer: NAPHCARE Commercial |
$5,327.71
|
| Rate for Payer: Preferred Network Access Commercial |
$8,169.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,350.96
|
| Rate for Payer: Quartz Commercial |
$5,771.69
|
| Rate for Payer: Quartz Medicare Advantage |
$5,327.71
|
| Rate for Payer: The Alliance Commercial |
$4,439.76
|
| Rate for Payer: WEA Trust Commercial |
$4,883.74
|
| Rate for Payer: WPS Commercial |
$6,576.82
|
|
|
SHELL TRIDENT 56MM F 502-11-56F
|
Facility
|
IP
|
$8,538.00
|
|
| Hospital Charge Code |
3297463
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,350.96 |
| Max. Negotiated Rate |
$8,169.16 |
| Rate for Payer: Aetna Commercial |
$7,991.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,636.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,706.15
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$8,169.16
|
| Rate for Payer: Health EOS Commercial |
$7,902.77
|
| Rate for Payer: HFN Commercial |
$8,169.16
|
| Rate for Payer: Multiplan Commercial |
$7,103.62
|
| Rate for Payer: Preferred Network Access Commercial |
$8,169.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,350.96
|
| Rate for Payer: Quartz Commercial |
$5,327.71
|
| Rate for Payer: WEA Trust Commercial |
$4,883.74
|
| Rate for Payer: WPS Commercial |
$6,576.82
|
|
|
SHELL TRIDENT 56MM F 502-11-56F
|
Facility
|
OP
|
$8,538.00
|
|
| Hospital Charge Code |
3297463
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,486.27 |
| Max. Negotiated Rate |
$8,169.16 |
| Rate for Payer: Aetna Commercial |
$7,991.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,636.39
|
| Rate for Payer: Aetna Managed Medicare |
$2,486.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,771.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,439.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,262.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,706.15
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$8,169.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,969.12
|
| Rate for Payer: Health EOS Commercial |
$7,902.77
|
| Rate for Payer: HFN Commercial |
$8,169.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,659.64
|
| Rate for Payer: Multiplan Commercial |
$7,103.62
|
| Rate for Payer: NAPHCARE Commercial |
$5,327.71
|
| Rate for Payer: Preferred Network Access Commercial |
$8,169.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,350.96
|
| Rate for Payer: Quartz Commercial |
$5,771.69
|
| Rate for Payer: Quartz Medicare Advantage |
$5,327.71
|
| Rate for Payer: The Alliance Commercial |
$4,439.76
|
| Rate for Payer: WEA Trust Commercial |
$4,883.74
|
| Rate for Payer: WPS Commercial |
$6,576.82
|
|
|
SHELL TRIDENT 60MM F 509-02-60F
|
Facility
|
OP
|
$8,538.00
|
|
| Hospital Charge Code |
4491009
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,486.27 |
| Max. Negotiated Rate |
$8,169.16 |
| Rate for Payer: Aetna Commercial |
$7,991.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,636.39
|
| Rate for Payer: Aetna Managed Medicare |
$2,486.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,771.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,439.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,262.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,706.15
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$8,169.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,969.12
|
| Rate for Payer: Health EOS Commercial |
$7,902.77
|
| Rate for Payer: HFN Commercial |
$8,169.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,659.64
|
| Rate for Payer: Multiplan Commercial |
$7,103.62
|
| Rate for Payer: NAPHCARE Commercial |
$5,327.71
|
| Rate for Payer: Preferred Network Access Commercial |
$8,169.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,350.96
|
| Rate for Payer: Quartz Commercial |
$5,771.69
|
| Rate for Payer: Quartz Medicare Advantage |
$5,327.71
|
| Rate for Payer: The Alliance Commercial |
$4,439.76
|
| Rate for Payer: WEA Trust Commercial |
$4,883.74
|
| Rate for Payer: WPS Commercial |
$6,576.82
|
|
|
SHELL TRIDENT 60MM F 509-02-60F
|
Facility
|
IP
|
$8,538.00
|
|
| Hospital Charge Code |
4491009
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,350.96 |
| Max. Negotiated Rate |
$8,169.16 |
| Rate for Payer: Aetna Commercial |
$7,991.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,636.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,706.15
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$8,169.16
|
| Rate for Payer: Health EOS Commercial |
$7,902.77
|
| Rate for Payer: HFN Commercial |
$8,169.16
|
| Rate for Payer: Multiplan Commercial |
$7,103.62
|
| Rate for Payer: Preferred Network Access Commercial |
$8,169.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,350.96
|
| Rate for Payer: Quartz Commercial |
$5,327.71
|
| Rate for Payer: WEA Trust Commercial |
$4,883.74
|
| Rate for Payer: WPS Commercial |
$6,576.82
|
|
|
SHELL TRITANIUM CLUSTER HOLE 50MM D 502-03-50D
|
Facility
|
IP
|
$8,538.00
|
|
| Hospital Charge Code |
3397502
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,350.96 |
| Max. Negotiated Rate |
$8,169.16 |
| Rate for Payer: Aetna Commercial |
$7,991.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,636.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,706.15
|
| Rate for Payer: Cash Price |
$2,561.40
|
| Rate for Payer: Cigna Commercial |
$8,169.16
|
| Rate for Payer: Health EOS Commercial |
$7,902.77
|
| Rate for Payer: HFN Commercial |
$8,169.16
|
| Rate for Payer: Multiplan Commercial |
$7,103.62
|
| Rate for Payer: Preferred Network Access Commercial |
$8,169.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,350.96
|
| Rate for Payer: Quartz Commercial |
$5,327.71
|
| Rate for Payer: WEA Trust Commercial |
$4,883.74
|
| Rate for Payer: WPS Commercial |
$6,576.82
|
|
